Sutton man's death in HMP Nottingham was 'difficult to prevent' due to staffing levels
An inquest jury has found that a Sutton man suffered from "inadequate care and support" before he was found hanged in prison.
But it said that the "vast majority" of Nottingham Prison staff worked in the best interests of Shane Stroughton, who was 29 when he became the first of five inmates to die in a month.
He had been given 30 months custody under the terms of an open-ended penalty no longer available to courts.
Although the sentence for assault was imposed in 2008, he was returned to custody nine years later after breaking a curfew in a Hucknall hostel.
In its conclusions, the jury said they regarded Shane's death as "very difficult to prevent due to the staffing levels of prison officers and care staff with their workloads."
The jury findings referred to "inadequate care and support from mental health services" and failure to respond to family worries.
The jury also pinpointed a shortage of staff trained in assessing prisoners like Mr Stroughton who were put on care plans. He was also under "constant supervision."
After being arrested on July 3, 2017, he was taken to Mansfield Police Station, where he put a t-shirt around his neck.
Officers filled in a "suicide self-harm warning."
This went to the prison where he was put under close review and "constant supervision."
Two days later, he said he "felt like hanging himself."
Observations were stepped up but an hour later he had to be cut down after making a ligature.
"He said it didn't matter what level of observation he was on, he would kill himself," said assistant coroner Ivan Cartwright, who referred to the jury's "narrative" conclusion.
He had "a close bond" with his brother Liam, who died in 2012, writing about him on his cell wall.
On July 17, he said that he was "feeling better and had no thoughts of killing himself."
By the end of the month, the cover was ended and supervision was reduced.
But his brother and grandfather outlined concerns after a visit on August 26. His mother phoned the prison's "safer custody line."
When told he would be freed shortly, he was "neither elated nor in a low mood" but said he did not want to return to the Hucknall unit.
He was found hanged in his cell on September 13.
Nick Armstrong, who represented his family, said that he knew the inmate who hanged himself the day before. He was on the same wing, worked as a cleaner and died later in hospital.
"That's a pretty bleak sequence of events," said Mr Armstrong.
Since the five deaths, the wing no longer handles people who have just been brought into the prison.
Prison officer Nicholas Turner told the hearing: "The wing is calmer. You have your busy days."