A prisoner who bled to death from a self-inflicted wound died by misadventure, an inquest has ruled.
Kenneth Martin died in Norwich jail on July 31, 2018, more than two months after arriving on May 18.
A four-day jury inquest at Norfolk Coroner's Court heard Mr Martin was well known by prison staff and nurses as a prolific self harmer, and so was placed on the prison's mental health assessment programme known as ACT.
During his time in prison, Mr Martin had self harmed at least eight times and was taken to hospital for treatment on some of those occasions.
He was reviewed as part of ACT by prison officers and nurses on 12 occasions and the number of hourly observations he received depended on his wellbeing - they varied from four times per hour to 11 times a day at the time of his death.
The inquest heard Mr Martin would often self harm "if certain needs were not met and as a means to achieve a certain outcome."
On one occasion he self harmed for not being paid for his cleaning job and on another occasion in frustration over the lack of vape capsules.
He was prescribed a blood-thinning drug due to his high risk of blood clots, but as a known self harmer the decision to prescribe this medication was "between the devil and the deep blue sea", said prison doctor Allison Oguru.
Dr Oguru said the risk of deep vein thrombosis if the drug was stopped was greater than the risk from self harm.
Evidence was heard that on the morning of his death, Mr Martin showed no signs of concern and had tea with another prisoner and shared a vape with an inmate in his cell.
At 12.50pm, an officer responded to Mr Martin's cell bell - an electronic emergency system.
He told the officer he had cut himself, but as his cell was dark from the drawn curtains and clothes covering the emergency lighting the officer could not see how severe the blood loss was.
After nurses arrived at his cell and found Mr Martin bleeding profusely into a bucket, officers called in code red which triggered a response from the medical team and a call to emergency services.
The ambulance service arrived at 1.26pm but Mr Martin was pronounced dead at the scene.
On Thursday, after an hour of deliberations, the jury concluded Mr Martin died by misadventure.
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