Coroner urges seven-day mental health services at HMP Haverigg after inmate found dead on release day

A 62-year-old inmate was found dead in his cell at HMP Haverigg in Millom, Cumbria, during a routine check on 13 March last year, coroner Robert Cohen told an inquest that concluded the death was suicide and called for seven-day mental health provision.

Jury findings said Nigel John Keenan experienced heightened stress and worry ahead of his planned release, largely due to difficulties securing suitable housing because he was a registered sex offender, and that this probably contributed to his death.

Keenan had been sentenced in June 2022 to five and a half years for offences including engaging in sexual activity with a child. His plan to live with his partner fell through and other options were ruled unsuitable before arrangements to live with his brother were confirmed eight days before release.

The inquest heard Keenan reported suicidal thoughts a month before he was due for release. Health care staff assessed him as not being at immediate risk; he met with staff several times but was not placed under formal mental health monitoring.

Coroner Cohen raised concerns about the prison’s mental health staffing, saying it was surprising that dedicated mental health teams did not operate at weekends. He warned that at Haverigg, a Category D open prison, there are insufficient staff to place prisoners on constant watch, meaning those needing close observation must be transferred to a closed prison.

The coroner said this arrangement risks encouraging prisoners in crisis to minimise their difficulties to avoid transfers, and highlighted the lack of weekend mental health input as “counterproductive” because weekend care would be provided only by prison staff until Monday.

In response, NHS England told the coroner its North West Region Health and Justice team said there was a seven-day service at HMP Haverigg with an on-call arrangement at weekends and a core Monday-to-Friday service. NHS England acknowledged confusion about weekend operations but said the issue had been resolved.

NHS England added a review of prison healthcare services is under way and is due to be finalised in summer 2026, and that any lessons from the case would inform that review. The coroner set out his concerns in a prevention of future deaths report to prompt action.