Andrew Peebles, 39, who was 13 years into a life sentence for murder, could have been saved if medics at Wymott Prison, near Leyland, had properly assessed him.
After a two-and-a-half week hearing in Preston, a jury ruled there had been “a gross failure to provide basic health care” by mental health nurses at the prison. Peebles, of Blackpool, died because of “neglect”.
Coroner Dr James Adeley, who is to relay his concerns about the case in writing to the Lancashire Care NHS Foundation Trust, added: “There was a lack of dialogue, a lack of providing treatment and a lack of action being taken to prevent his death.”
The inquest was told Peebles, who stabbed a man in the neck during a gang attack in Oldham in 2000, had been transferred to Wymott only two months earlier.
During the next few weeks his mental condition deteriorated, but he was not given a full psychiatric assessment – something which might have resulted in treatment and could have saved his life.
He began to self-harm and was suffering from psychotic episodes in which he believed he was going to be murdered by other prisoners. He started sleeping under his bed because he felt safer there and believed his family had been murdered by his fellow inmates.
Psychiatrist Dr Dinesh Maganty, called as an expert, said that had Peebles been appropriately treated, either in jail or at a hospital, he would probably have made a full recovery.
But the signs were not acted on and he was found hanged when prison officers unlocked his cell one morning.
The jury in their conclusions said: “At the time of his death he was suffering from an acute psychosis and had lost touch with reality.
“The assessment of his mental health was inappropriate. There were several occasions when a mental health nurse missed an opportunity to carry out an assessment. As a result no diagnosis was made and no treatment given. The lack of action by mental health nurses caused his death.”
A spokesperson at Lancashire Care NHS Foundation Trust, which employs the mental health staff at Wymott Prison, said: “We would like to offer our sincere condolences to Andrew’s family for their loss.
“We respect the conclusion of the jury and accept responsibility for the shortcomings in the care provided to Andrew for which we are extremely sorry.
“It is almost three years since Andrew died at HMP Wymott and since then, the Trust has taken significant steps to improve the provision of mental health services within the prison.”