A PRISON has pledged to improve after a man found dead just days after being jailed for drink driving was not flagged as a suicide risk - with numerous staff denying they were told he had tried to harm himself.

Johanathan Rancijh, 39, from Birmingham, was found hanged in cell 126 at HMP Bullingdon in Upper Arncott, Bicester on April 17, 2018.

The father-of-three entered the prison on April 12, 2018 after he was sentenced for erratic drink-driving on the M40 while four times over the legal alcohol limit.

Evidence was heard throughout his inquest - which started on Monday and ended yesterday - under senior coroner for Oxfordshire, Darren Salter.

ALSO READ: Inquest into death of Johanathan Rancijh who was found dead at HMP Bullingdon

Witnesses, including prison staff and an inmate who shared a cell with Mr Rancijh spoke before the jury.

It heard that there were three incidents on April 16 involving Mr Rancijh that happened in the prison before his death.

The first involved Mr Rancijh having an anxiety attack in his cell. The prison ‘bank paramedic’ Daniel Swain – who was on his first shift at the prison – was called to attend to him.

Upon arrival Mr Rancijh was shouting and was ‘confrontational’ towards him, and also showing signs of paranoia, but he quickly calmed down once Mr Swain instructed him to sit down.

He told the jury: “I didn’t have any concerns that anything further would have happened that night.”

Mr Swain said Mr Rancijh had experienced a panic attack and did not open an Assessment, Care in Custody and Teamwork (ACCT) document - which is set up by any member of staff at the prison who has identified a prisoner as being at risk of suicide or self-harm.

He said in court that he had had little training about it and was not aware he could open one himself.

The second incident happened later that day at around 8.30pm when Sean Musson – who shared the same cell with Mr Rancijh – was woken by Mr Rancijh who had a ligature around his neck.

After checking Mr Rancijh was okay, Mr Musson rang the bell and banged the door to get officer Michelle Rose’s attention.

In his witness statement, Mr Musson said he told Ms Rose about the ligature, but she denied this in court, saying Mr Rancijh had simply had another anxiety attack.

ALSO READ: Man jailed for erratic drink-driving while on busy motorway

She added: “It appeared Johanathan was having some sort of anxiety attack. He kept talking about the window. He was concerned people would come into the cell. The cell mate was concerned he was going to keep him awake. Other than that, I couldn’t see any major issues.”

Mr Rose also did not open an ACCT.

In the final incident, Mr Musson told the coroner that Mr Rancijh had been shouting and spitting at him later that evening and so he called for an officer, Oana Cirpan.

Ms Cirpan attended and Mr Musson told her about the ligature from earlier on.

She told him to step away from the door to see inside but she did not see anything. She said: “I didn’t believe that he was telling the truth, but that he came up with it as a reason to be separated [from Mr Rancijh].”

The officer notified custodial manager Stephen Woodus, however he too denies being told about the ligature.

Ms Cirpan said she recorded the ligature in the wing observation book but did not open an ACCT document.

Concerned about Mr Rancijh's mental health, Mr Woodus moved him to a cell in healthcare as he thought it would be ‘beneficial’ as it was ‘quieter’ and allows for ‘one-to-one time’.

As they walked to the cell, Mr Woodus told the jury, Mr Rancijh was 'happy and content'.

Mr Woodus told prison officer Fera to ‘sporadically check on him’, which he clarified as ‘a couple times a shift’.

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Officer Fera was not told about what had happened and said Mr Rancijh appeared very happy as he was put into the cell.

However, the jury learned that Mr Rancijh was found hanged in the cell the following day at 7am.

Coroner Salter agreed with the jury's conclusion that there was a 'system failure' and a lack of effective communication between prison staff and healthcare staff during handover about previous incidents.

He said: "There should have been more comprehensive handover to health care and Fera. It's a difficult issue to resolve about Cirpan and Woodus' statements but despite this there seemed to be a failure to effectively escalate information about the ligature from Sean.

"It was documented but not escalated further which would have resulted in an ACCT document being opened."

The prison has since updated its operational policy whereby prison staff and health care staff must communicate about any issues that have arisen amongst prisoners during handover.

Previously, it was up to prison staff to judge whether a prisoner should be taken to health care, now a nurse will attend to the prisoner first and jointly decide whether or not they need to be taken to health care.

Furthermore, now all new staff, temporary staff and permanent staff will have induction training and all staff have had refresher training on ACCT.

Support is available to anyone in emotional distress, struggling to cope, or at risk of suicide at Samaritans by calling 123 116.