Kevin Dermott

1. 1. misdiagnosed serious mental health condition

   “The seriousness of the deceased's condition was realised whilst the deceased was at HMP Durham although probably initially misdiagnosed”

2. 2. urine soaked cell without proper hygiene

   “During a hypomanic episode which lasted a number of weeks the deceased was for a time left in a urine soaked cell, drinking and washing from the cell toilet at a time when he needed specialist hospital treatment”

3. 3. lack of psychiatric referral and care planning

   “At HMP Durham a psychiatric referral for the purpose of compiling a care plan, including a plan for therapeutic medication was never completed and he was transferred to HMP Haverigg without any steps being taken to plan health care for the future, take action to avoid a recurrence of his illness or identify and deal with a relapse should one occur”

4. 4. inadequate mental health staffing

   “At HMP Haverigg there was inadequate mental health cover with at times only one mental 1 health nurse and no provision for psychiatric referral”

5. 5. unsuitable psychiatric facilities

   “A lack of suitable psychiatric care facilities at HMP Kirkham (among other things) led to a transfer to HMP Risley, where due to inadequacies of care planning and communication deficits which had been a feature of the deceased's care whilst in prison, the fact that the deceased was relapsing into depression was not recognised”

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