A prisoner who reported hearing voices from a "pig man" telling him to harm himself took his own life at a jail where his mental health care was described as "not of the required standard".
"The clinical reviewer concluded that the mental health care Mr Chadwick received at Altcourse was not of the required standard and therefore not equivalent to that which he could have expected to receive in the community." Ms McAllister wrote: "An alert was sent to the prison’s mental health team from the court which said that Mr Chadwick had been experiencing- auditory hallucinations from a ‘pig man’ telling him to self-harm. A follow up review was scheduled for the mental health team to see Mr Chadwick within 48 hours. Mr Chadwick was not seen until 25 July."
Mr Chadwick appeared to have taken a turn for the worse over the next five days, telling his sister in a phone call he was contemplating suicide and making accusations that he had been "mocked" by a member of staff.