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The coroner conducting the  inquest into the death of Andrew Barclay who died at HMP Norwich in 2003 has criticised the establishment for having “serious failings and fundamental flaws” in procedures in April 2003.

William Armstrong said the response to discovering Andrew hanging was “uncoordinated, undirected and inappropriate” and that the lack of staff training was totally unacceptable.

While acknowledging that improvements had been made at the prison, Armstrong went on to say that far too many people were dying in custody and that it was important that deaths in prison were independently investigated and lessons were learned.

Co-director of INQUEST Deborah Coles said: “Yet again an inquest into a death in prison has resulted in highly critical comments from the coroner and jury about the failure by the Prison Service to protect the right to life of a prisoner in its care.

“INQUEST is concerned that there are no effective mechanisms to ensure that lessons are learned across the prison estate following a death in custody.”