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‘No one told us Kelvin had self-harmed. If we’d known we’d have tried to help’

<span>Photograph: Christopher Thomond/The Guardian</span>
Photograph: Christopher Thomond/The Guardian

Speakman and his four siblings spent most of his childhood in Wigan, in and out of foster and care homes. His mental ill health was exacerbated by drug and alcohol addiction.

In 2007, he was given an indeterminate sentence, called an imprisonment for public protection order, with a recommendation to serve a minimum of two years. IPPs – introduced in 2005 and scrapped in 2012 – were sentences designed to hold prisoners deemed to be a danger to the public until the parole board decided they were no longer a risk. But, like thousands of other prisoners, Speakman was held for much longer, and, was still in jail nine years on. In 2015, he was transferred to HMP Hewell in Worcestershire.

Despite repeated episodes of self-harm and numerous suicide attempts, he was never transferred to a secure mental health unit – even though consultant psychiatrists had twice recommended it. In April 2016, Speakman was found in his cell, having hanged himself. Although the initial resuscitation was successful, he died on 9 May. A postmortem recorded the cause of death as pneumonia, due to brain injury from his suicide attempt.

We knew he was frustrated at his lack of progress, but he always put on a brave face for us

The subsequent inquest found multiple failings, particularly in the assessment, care in custody and teamwork process for prisoners at risk of self-harm or suicide. Worcestershire senior coroner Geraint Williams issued a report to prevent further deaths notice saying that “deaths at Hewell subsequent to Mr Speakman’s demonstrate clearly that the same failings exist and are perpetuated”. And a report by the prisons and probation ombudsman found that although managing Speakman’s safety was a significant challenge, enhanced case review procedures were not used consistently and he did not have the required mental health assessments to safeguard against his continued segregation.

Lee Dobson, Speakman’s older brother (Dobson adopted his wife’s surname when he married), had become a father figure to his sibling. The battle for answers, let alone justice, has taken a huge toll. In early 2019, Dobson collapsed in his kitchen with a burst stomach ulcer, resulting in emergency surgery to remove his stomach and part of his bowel. Although it has permanently changed his life, Dobson says his illness has helped him get answers about his brother’s death. “Had I not been so ill, I wouldn’t have qualified for legal aid,” he says.

A spokeswoman for the Ministry of Justice says that, since Speakman’s death, HMP Hewell has improved its training for staff managing vulnerable offenders and a member of the senior team now reviews all ACCT cases on a daily basis.

For Dobson, it is not knowing what his brother was going through that is hardest to cope with. He and his wife visited him in prison many times and he phoned them regularly, but they were unaware he had repeatedly self-harmed. The first they knew was when police arrived at their house the day after Speakman was taken to hospital. “We knew he was frustrated at his lack of progress, but he always put on a brave face for us,” he says. “If we had known, we could have at least tried to talk him through his hard times. Instead, he died without help from us, or the system.”

• In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org or jo@samaritans.ie. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is 13 11 14. Other international helplines can be found at befrienders.org.