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A much-loved son died in jail following multiple failures across all levels of the prison regime, a jury has ruled. Aaron Taylor was 'failed by nurses, doctors, prison officers and the governor' at HMP Garth who neglected to perform proper role call checks and forged documents. All parties failed to offer appropriate care to Aaron Taylor and protect him during his eight months at the jail. The 32-year-old had been regularly self-harming and had said that he wanted to die but staff failed to take steps to prevent self-harm and suicide, jurors at an inquest into his death have concluded. Over the last eight days, the jury at County Hall in Preston has heard evidence from staff at all levels within Garth Prison. The inquest heard that prison officers had failed to carry out role call checks, key workers weren't aware how often they should meet with prisoners and documentation was 'forged' to suggest checks had been carried out, Lancs Live reports . The inquest comes after Aaron was found hanging in his cell on the Echo wing at Garth at around 8.05am on August 28, 2023. Prison officers started CPR but Aaron was clearly dead and his death was confirmed by paramedics. The jury said that mistakes were made by prison staff and healthcare workers from the most junior prison officer to the governor. In their conclusion the jury said that included a nurse, mental health nurse, GP, prison officers, senior prison officers, prison offender manager and the governor. Join the Manchester Evening News WhatsApp group HERE Jurors concluded that "inadequate preventative steps and assessments, lack of documentation, inability to adhere to policies and procedures and a lack of professional curiosity" from prison staff and healthcare workers employed by Greater Manchester Mental Health NHS Foundation Trust all contributed to Mr Taylor's death. Aaron's mum Maria, who has sat in court throughout the inquest, had raised concerns about the lack of support offered to her son. The inquest heard she had flagged these up as soon as Aaron was transferred to HMP Garth in January 2023 and during the course of the following eight months. Aaron, from Preston, Lancashire, was not subject to an Assessment, Care in Custody and Teamwork (ACCT) plan at the time of his death, despite recently inflicting a serious injury on himself and his history of self-harm. An ACCT would have meant that Aaron was offered additional mental health support and checked more frequently. The prison's governor, Lee Macmillan, told the jury that the jail was "still struggling" to recover from the Covid pandemic and significant levels of staff sickness continue to prevent inmates from receiving regular sessions with their key worker. The inquest heard that prisoners should have one, 45-minute weekly session, but are currently only having one a month. The inquest ended today with the jury concluding that "multiple failures" contributed to Aaron's tragic death. In their lengthy conclusion, the jury said: "With the evidence provided by the pathologist, CCTV footage from August the 27th and August the 28th, combined with witness statements from the prison officer who found Aaron Lee Taylor at 8.05am on the 28th of August 2023, Mr Aaron Lee Taylor died between 7.30pm on the 27th of August 2023 and 6am on the 28th of August 2023 in a cell on the premises of HMP Garth, 1 Moss Lane, Ulnes Walton, Leyland. "Mr Aaron Taylor died of hanging. Taking into account the three letters that Mr Taylor wrote, the pre-planning and the method in which Mr Taylor died leads us to conclude Mr Taylor did take steps intending to take his own life. "There were multiple failures in the measures taken to prevent self-harm and suicide. From the evidence that has been presented in court, multiple opportunities were missed by multiple professionals - nurse, GP, prison officers, mental health nurse, prison offender manager, governor and senior prison officer - to support or offer suitable or appropriate care and resources for Mr Taylor. "Inadequate preventative steps and assessments, lack of documentation, inability to adhere to policies and procedures and a lack of professional curiosity as stated by an operations manager from [Greater Manchester Mental Health NHS Foundation Trust], who undertook an external investigation, all contributed to Mr Taylor's death. "Witness testimony demonstrated that the relevant observations had not been carried out on the 28th of August 2023. With the evidence and testimony of the pathologist and the uncertainty surrounding time of death we cannot say that these observations, or lack of, contributed to Mr Taylor's death. "As highlighted by the external investigation carried out by [Greater Manchester Mental Health NHS Foundation Trust] there were multiple serious failures to provide minimal or adequate mental health interventions for Mr Taylor. "These serious failures and inadequacies possibly contributed to Mr Taylor's death." Lancashire's Senior Coroner, Chris Long, has indicated that he will be sending a Report to Prevent Future Deaths to the Ministry of Justice and PPG Healthcare, who are responsible for healthcare at HMP Garth, to require them to provide evidence detailing how they intend to make improvements.
