Keith Andrew Turner was jailed for three years and nine months in March 2019, after he subjected a vulnerable woman to months of violent and psychological abuse.
He died in custody on January 9, 2020 at HMP Humber, in Everthorpe, East Yorkshire and at an inquest, held from September 16 to 23 this year the jury concluded that Turner died by suicide.
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An independent investigation by the Prisons and Probation Ombudsman into the death of 50-year-old Turner was conducted in 2020, but could only be published after the outcome of the inquest.
It found that there were many missed opportunities for the mental health team to give him support.
Report author Sue McAllister said: “On the morning of Mr Turner’s death, around an hour before he was found, his wife called the prison’s switchboard and asked if someone could check on her husband because she had not heard from him that morning.
“I am concerned that the switchboard operator did not refer Mr Turner’s wife to the Safer Custody hotline. This was a missed opportunity for someone to check on Mr Turner.
“I am also concerned that there was a delay in sending an emergency ambulance to treat Mr Turner, as prison staff initially gave insufficient information to the ambulance service for them to treat the call as an emergency.”
She recommended that the governor and the head of healthcare should ensure that all staff have a clear understanding of their responsibilities to manage prisoners at risk of suicide and self-harm in line with national guidelines and, in particular, understand:
• the need to record, share and consider all relevant information about risk, and start ACCT procedures when indicated; and
• the need to consider risk factors rather than simply relying on what the prisoner says or how he presents. The head of healthcare should share a copy of this report with senior nurse A and nurse B and discuss the Ombudsman’s findings with them.
The Press reported back in 2019 how Turner, formerly of Acomb, who was also ordered to pay his victim £10,000 compensation, had abused a 30-year-old York woman between December 2015 and July 2017.
It included Turner kicking and being violent towards the woman.
When she finally found the courage to go to the police, Turner made her give evidence at his trial for eight hours before changing his plea to guilty.
At the time, the victim Karen (not her real name) told The Press Turner had taken advantage of her low self-esteem to groom her, and she had only managed to escape after seeking help.
It was the second time Turner was locked-up for abusive behaviour towards his partners, having previously been jailed in 2012.
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