A bisexual murderer who hanged himself in a Lambeth jail was not given a statutory mental health assessment to see if he was at risk of self-harm, an inquest heard.
A number of procedural failings took place at Brixton Prison prior to the death of Roderick McDonald, who was found hanging by his bed sheet from his cell bars five days after entering the jail, Southwark Coroners' Court heard this week.
McDonald, 51, was not referred for a mental health examination necessary for all murder and manslaughter suspects despite seeing both a GP, nurse and prison officer on the day he entered the prison, the jury was told.
Inadequate staff numbers also meant prison officers were "too busy" to check on the Scotsman - on hourly watch because he was a high-risk prisoner - for at least two hours before he was found dead at noon in his cell on February 27, 2007, the court heard.
McDonald was in custody after being charged with the murder of his alleged male lover, Brazilian Acioli-Pariz Junior, 29.
He was found brutally beaten and stabbed to death in a central London hotel room on February 14, 2007.
A note from McDonald was found by his body in the cell apologising to Junior's parents saying "he loved him so very much".
McDonald was dubbed the "Kinky Killer" after being jailed for 12 years for the murder of his wife, Elizabeth, in 1993, after she refused to have a threesome with his male lover.
He absconded from an open prison in Scotland in 2005.
Ruth Houston, who carried out an investigation for the Prisons and Probation Ombudsman (PPO), said the procedural failures were not "substantive" in contributing to McDonald’s death.
She said specialist mental health workers could have spotted signs he was suicidal that may have been missed by a busy nurse, but there was no guarantee a referral would have meant he was seen before he was found hanging in his cell.
The PPO investigator said prison officer sickness on the day McDonald died meant there was a lower staff-to-prisoner ratio than there should have been, meaning prison officers had been "too busy" to carry out the one hour checks on McDonald in his cell they were tasked with.
The jury heard McDonald could have tried to already kill himself in the prison by taking an overdose of paracetemol.
The jury returned a verdict of suicide on Tuesday.
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