Staff at a Surrey prison failed to get medical attention for a prisoner who was reportedly found “naked on all fours, and barking like a dog” before he took his own life.

Haydar Jefferies, 51, died in hospital on March 5, 2023, after trying to kill himself in his cell at HMP Coldingley, Woking, a few days earlier. 

An inquest jury found scores of failures contributed to Mr Jefferies’ death, amounting to neglect. Mr Jefferies’ mental health drastically deteriorated while he was waiting for parole and it was left untreated by staff responsible for his care, according to his family’s lawyers. The 51-year-old pub manager attempted suicide the day before his long-awaited parole hearing. 

After being found guilty of an assault offence in 2006, Mr Jefferies served seven years of an Imprisonment for Public Protection (IPP) sentence, given to people considered ‘dangerous’ but the offence did not merit a life sentence.

Nearly ten years after his crime, Mr Jefferies was then recalled and sent back to prison in January 2022 on his IPP sentence. The allegation against Mr Jefferies was reportedly not backed up and the police decided no further action would be taken, within three months after being sent back to prison. 

But due to the nature of the IPP sentence and the delays in the Parole Board decision-making, Mr Jefferies was forced to stay at the prison despite all charges being dropped nine months prior.

A Ministry of Justice spokesperson said: “Our thoughts remain with Haydar Jeffries’ friends and family. As with all deaths in custody, the Prison and Probation Ombudsman are investigating and we will respond to their report in due course.”

By the end of February 2023, Mr Jefferies was acutely psychotic, found by officers in his cell flushing his head down the toilet, naked on all fours, and barking like a dog. 

Despite custodial staff noting major concerns over his mental health, they allegedly failed to seek any medical attention or even notify health care providers, according to the family’s lawyers Hodge Jones & Allen. Custodial staff allegedly failed to place him on constant supervision and/or take him to an external place of safety. 

The jury duly found that Mr Jefferies’ IPP status and the delays in his parole hearing materially contributed to the development of his subsequent psychosis, Hodge Jones & Allen solicitors said.

Between his initial release and recall, Mr Jefferies had tried to rebuild his life, setting up his own pub and B&B with his husband, who sadly passed away in 2021.

Zhora Jefferies, Haydar’s mother, said: “After creating a wonderful life in the community, it is devastating to have witnessed how Haydar’s life was completely destroyed by the nature of his IPP sentence and the extensive delays he experienced when waiting to be released from prison.

“We had to watch our beloved son, brother and father succumb to the fear and paranoia that he was suffering with in the final weeks of his life. We, and Haydar himself, were all crying out for help and it was falling on deaf ears.

“Nothing can be done to bring Haydar back but our biggest hope is that lessons can be learned from his experience. Haydar brought so much love to our family and we will always be grateful for the time we had with him.”

A few months into Mr Jefferies’ recall to HMP Bullingdon, in early 2022, it was confirmed the allegations against him were no longer being pursued. But he remained in prison for another year, waiting for authorised release by the Parole Board. An application to determine his release on papers was declined, and various delays led to his parole hearing being rescheduled to March 2023. 

Mr Jefferies was then transferred to HMP Coldingley on December 28, 2022. By February 12, 2023, he asked to be segregated for his own safety. The jury reportedly heard evidence from a consultant psychiatrist that after being segregated, Mr Jefferies’ mental health steeply deteriorated. 

By around February 18, 2023, he was suffering from a severe psychotic illness which required timely psychiatric assessment, treatment and transfer to a prison with a healthcare wing. 

The jury heard that, during his subsequent 10 days in segregation, Haydar made multiple concerning comments to both prison officers and his family symptomatic of his deteriorating ill-health. It included his intensifying delusional beliefs that prison officers were colluding with prisoners to sexually abuse and kill him, and that they were pumping gas into his cell. 

Mr Jefferies’ family made numerous phone calls to the prison with serious concerns over his welfare. But none of the calls were appropriately documented in prison records or passed onto the Mental Health Team. 

The jury concluded there was a “systematic failure on behalf of the Ministry of Justice” that there was no policy for recording and sharing information from concerned family members, according to Hodge Jones & Partners. 

Cormac McDonough, a civil liberties solicitor at Hodge Jones & Allen, who represented the family at the inquest said: “It is extremely rare for a jury to reach a finding of neglect in this context, which demonstrates how fundamentally failed Haydar was while under the care of prison staff at HMP Coldingley.

“It was evident that Haydar was suffering due to the unjust circumstances of his IPP recall and that this contributed to his deteriorating mental state. Staff at the prison failed entirely to recognise his deterioration and to take appropriate steps to keep him safe. His family made repeated attempts to get Haydar the help he patently needed, after receiving multiple distressing phone calls, but no action was taken.”