HMP Woodhill: Prison failings led to inmate's death
Multiple failures by prison staff led to the death of a vulnerable inmate, an inquest has ruled.
Ryan Harvey, 23, took his own life while on remand at HMP Woodhill in Milton Keynes in May 2015.
A jury found that staff failing to remove a ligature from his cell after they discovered it around his neck contributed to his death.
The prison said it had improved procedures since Mr Harvey's death.
Mr Harvey was found hanging in his cell on 3 May 2015 and died in hospital five days later.
Staff at Woodhill had first found him with a ligature around his neck on 2 May and again saw him with one at around 20:35 BST on 3 May.
He was found hanging in his cell at 21:58 that day.
Mr Harvey had arrived at Woodhill as a remand prisoner on 22 April 2015.
He had been charged with arson and burglary after allegedly setting fire to his mother's house.
He had learning disability, as well as a history of drug and alcohol abuse, and was designated as a "vulnerable adult".
The inquest, held in Milton Keynes, heard how mental health staff at HMP Woodhill were "firefighting" to look after about 800 inmates.
Recording a conclusion of suicide, jurors said a number of "systematic failures and consistently missed opportunities in sharing critical information" about Mr Harvey contributed to his death.
Addressing Mr Harvey's mother in court, Tom Osborne, senior coroner for Milton Keynes, said: "As a result of Ryan's death, there has been a great deal of action taken - and still being taken - by the new governor [at Woodhill]."