Slovakian-born Ondrej Suha, 19, was found hanged in his cell, hours after receiving a letter from the Home Office telling him he was liable to be deported to Slovakia following his sentence.
He was taken from Brinsford young offender institution to New Cross Hospital in Wolverhampton, but died on Christmas day.
An inquest jury found that the young man, who was given a 14-month custodial sentence after pleading guilty to burglary and assault, killed himself because he was told he could be deported.
It also found there had been significant failures in prison staff training, communication and coordination in dealing with the incident, as well as a lack of measures taken to prevent it.
Prison medical records show that after the teenager was found no one began cardiopulmonary resuscitation until a nurse arrived seven minutes later.
The control room officer also delayed calling an ambulance, in breach of national rules, the inquest found.
Prior to his death, Mr Suha had been discovered with ligatures around his neck on two occasions and had told staff he wanted to kill himself, the inquest heard. He had also witnessed his cellmate try to hang himself four days earlier.
While Mr Suha had initially been placed on a suicide prevention and self-harm regime upon arrival at the prison, this was cancelled the following day by a prison officer who later said he wasn’t aware that the prisoner had tied two separate ligatures.
The prison officer who delivered the Home Office papers to Mr Suha before he was locked in his cell for the night on 21 December told the hearing that he would have preferred to do this during the core prison day.
Mr Suha’s sister, Andrea Suhova, said following the inquest: “Our family has been devastated by losing Ondrej. Knowing that more could have been done to protect him has only made our pain worse. Ondrej grew up in the UK and thought of himself as British through and through.
“We will never understand why the prison thought it was appropriate to give him that letter, knowing full well it was informing him he might be deported, before locking him away for the night. He had only recently tried to harm himself and told staff that he wanted to die.
“It is now so important that the prison service, and HMYOI Brinsford in particular, learns from Ondrej’s death so that other young people are safe and other families don’t have to experience the same pain as us.”
An investigation into Mr Suha’s death by the Prison and Probation Ombudsman (PPO) stated that the suicide and self-harm prevention regime put in place on 30 November and cancelled the following day was “poorly managed and did little to support [Mr Suha]”, adding that it “underestimated his risk so soon after his self-harm”.
The PPO added that it had “a number of concerns about the emergency response on the night of 21 December”, including alleged confusion among officers about where to find the key and reports that the prison nurse did not have the necessary keys to attend the scene of the emergency, leading to further delay.
“The failures in this case are depressingly familiar from other prison deaths. Whether because of poor training, understaffing or simple lack of care HMYOI Brinsford failed to keep Ondrej safe,” Mr Silverman said.
“This inquest has also heard worrying evidence that the prison service considers it is appropriate to allow prisons to operate with only one member of CPR trained staff on duty at any one time. Ondrej’s family now look to the head of the National Offender Management Service (NOMS) to act on the concerns of the Coroner regarding this policy.
“Our society needs to ask itself how many more prisoners must die before prison safety is made a priority.”
Deborah Coles, head of charity Inquest, which provides advice and support around contentious deaths, meanwhile told The Independent: “This is a desperately sad case. There was a complete disregard for the vulnerability of Ondrej Suha, not least given the delivery of such significant news before night time lockup.
“This left the 19 year old isolated and alone after being told he faced deportation from his home. The jury found failings in both the protection of a prisoner at risk of suicide, and in the emergency response; issues we hear time and time again.
“It is clear that NOMS is not acting on serious health and safety concerns in prisons across the country, and staff are ill-equipped to care for vulnerable prisoners.”
A Prison Service spokesperson said: “This was a tragic case and our thoughts are with the family and friends of Ondrej Suha. HMYOI Brinsford has already put in place a number of measures to better support the safety of offenders in custody. We will now carefully consider the findings of the inquest.”