A grieving family have said they've paid the "ultimate price" after a jury concluded there were a string of failings in the care of a beloved man who died after being found injured in prison. The jury at Essex Coroners' Court concluded today (April 24) that there was a "serious failure" in training prison and healthcare staff at HMP Chelmsford at the time of inmate Daniel Weighman's death.
Mr Weighman, 38, from Rochford, had been recalled to HMP Chelmsford in October 2022 for breaching his licence conditions. On January 3, 2023, he was found unresponsive in his cell and rushed to Broomfield Hospital where he sadly died. A jury examined the care Mr Weighman received in prison and the circumstances of his death at a week-long inquest in coroners' court.
The court previously heard that Mr Weighman had self-harmed on January 1, 2023, and then again on January 3, where he was placed under an ACCT (a safety plan for prisoners at risk of self-harm), which included hourly observations in his cell. Despite this, at around 6.30pm - just hours later - he was found injured in his cell and died in hospital from his wounds.
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Mr Weighman was described as a "loving and kind" person, a beloved father and brother, who "lit up the room" when he walked in. The court heard he had previously been diagnosed with schizophrenia and had battled issues with alcohol before going to prison
Where to get help if you're struggling
You don't have to suffer in silence if you're struggling with your mental health. Here are some groups you can contact when you need help:
The Silver Line: Free confidential helpline providing information, friendship and advice to older people: 0800 4 70 80 90
Samaritans: Phone 116 123, 24 hours a day, or email jo@samaritans.org, in confidence
Childline: Phone 0800 1111. Calls are free and won't show up on your bill
PAPYRUS: A voluntary organisation supporting suicidal teens and young adults. Phone 0800 068 4141
Students Against Depression: A website for students who are depressed, have low mood, or are suicidal. Click here to visit
Bullying UK: A website for both children and adults affected by bullying. Click here
Campaign Against Living Miserably (CALM): For young men who are feeling unhappy. Has a website here and a helpline: 0800 58 58 58
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'Serious failure' in staff training at all levels
In their conclusions shared to the court today, the jury said healthcare staff had failed to assess the risk of Mr Weighman attempting self-harm and suicide, with staff lacking in "adequate understanding of their duties under the ACCT process". They said there was a "serious failure" of inappropriate ACCT training for healthcare and prison staff "at all levels".
The jury also said the healthcare staff's communications were "inadequate" about the risks concerning Mr Weighman's wellbeing. Regarding the fateful incident on January 3, the jury said the staff response had been "adequate initially", but there were "deficiencies" with the ACCT, and staff not following best practices, with "untrained staff not having sufficient knowledge of the ACCT procedure".
Finally, the jury highlighted that the hourly observation levels on January 3 were "inappropriate" and Mr Weighman was not supported enough during the previous incident on January 1. Following the conclusions, Area Coroner Sean Horstead stated he would be writing a prevention of future deaths report to the governor of HMP Chelmsford due to the "serious" concerns raised.
He said: "[There are] far too many people now that have not had adequate training in what is a critical aspect of care management and treatment of people whose liberty has been taken away. They rely on healthcare staff being appropriately trained. The findings of the jury reference serious failings in that respect." Coroner Horstead said half the staff identified during the inquest "didn't have that training", and that it was a "very significant concern".
'Our Danny was failed repeatedly by the prison'
In a statement following the conclusion, Chloe Weighman, Mr Weighman's sister, said: "Danny, at his core, was a kind and loving person, and while he made a few mistakes in his life, he never deserved this. HMP Chelmsford has taken Danny from us. If Danny was given the support he so desperately asked for, we would not be where we are today.
"He was repeatedly failed by the prison and healthcare service, who failed to carry out their basic responsibilities towards him, and we have paid the ultimate price for those failures."
Gimhani Eriyagolla, a solicitor from Hodge, Jones & Allen who represented Mr Weighman's family, said: "We welcome today’s conclusion, and are yet unsurprised by these continued failures of HMP Chelmsford and CRG. Too many people have now died because of their careless and slapdash approach to the well-being and health of the men they are charged with looking after.
"If nothing else, we hope that Daniel’s case goes on to raise national awareness of the need for our prisons to make sure more lives aren’t needlessly lost through easily avoided errors. Urgent action is needed to improve and expand the mental health services within our prison system. We need to make sure those in our prison system receive the crucial support they desperately need and are entitled to."
The Ministry of Justice was contacted for comment.
