The verdict given at the inquest into the death of Gerard Kavanagh at HMP Garth, Preston, has left his family with continued concerns over his treatment, and that he was allowed to have enough medication in his possession to kill himself.
The inquest jury last week [20th November] found that Kavanagh, who was serving a life sentence for murder, took his own life through an overdose.
They did not consider that a lack of medication review or the actual prescription and amount of the medication provided contributed to his death.
Mr Kavanagh, who had no criminal record prior to his arrest in 1990, always maintained his innocence. He died in his cell at HMP Garth on 20th September 2002. The family’s solicitor Mike Pemberton, a human rights specialist at North West law firm Stephensons, said: “In the year leading up to his death, he suffered a number of catastrophic personal tragedies which he struggled to cope with. These included the death of his mother, death of his sister, failure of his long running appeal and transfer to another prison establishment.
“In June 2002, he was placed on self harm suicide watch and prescribed the anti-depressant drug Dothiepin by a prison doctor, being given a weeks worth of tablets every week until his death in September. The date of his death was the anniversary of his arrest for the crime which led to his life sentence - a crime he consistently maintained his innocence of.”
The Kavanagh family raised issues at the inquest which included Mr Kavanagh being in possession of 14 tablets, despite the prison knowing that he had attempted to hang himself on previous occasions and self harm, with no medical review for over 3 months. The jury heard from an expert toxicologist Professor Forest that Dothiepin was a lethal cardiotoxic poison in overdose, and 14 tablets would be enough to kill a person.
Mike Pemberton continues: “Despite their disappointment at the verdict, the family hope that lessons will be learned by the prison service following Mr Kavanaghs’ death. They obtained some solace from the coroner’s intention to make recommendations to the prison service which may prevent further deaths in custody of this type.”
The coroners’ recommendations included:
- Better follow up procedures involving medication reviews and counselling, or other therapeutic recommendations.
- Better cross reference and notation between inmate medical records and self harm documents
- More details to be noted in medical records in relation to medical reviews of a prisoner prior to transfer to another establishment.