Prison guard cleared of involuntary homicide over 2016 inmate suicide

A 66-year-old former Correctional Officer has been acquitted of negligently causing the death of an inmate who was found dead in his cell at the Forensic Ward of Mount Carmel Hospital in 2016.

The inmate, Richard Paxton, was found to have hung himself. Correctional Officers, assisted by a doctor working at the facility, had administered CPR but were too late to save him.

Paxton was being held at Mount Carmel in preventive custody at the time of his death.

An internal inquiry held by the Ministry for Home Affairs at the time had concluded that there were no administrative shortcomings, but did find shortcomings by some employees.

The Correctional Officer on duty that morning was Philip Zammit, who was subsequently charged with involuntary homicide. Zammit had been in charge of monitoring CCTV cameras.

Handing down judgement in this case, Magistrate Kevan Azzopardi noted that there were blindspots in the CCTV coverage of Paxton’s cell, and that the 4-inch monitors connected to them provided a black and white picture that was unclear. This had been the subject of several complaints made by the staff, but the facility’s management had not committed to addressing the problem.

“The court is perplexed as to how a person who had already attempted suicide was not only placed in a cell which was not fully covered by the CCTV camera, but was [also] placed in a cell with a door having a large enough hole in it to be used by a person with suicidal tendencies to in fact commit suicide,” Magistrate Kevan Azzopardi said.

The positioning and angle of the CCTV cameras were subsequently changed, as were the monitors, noted the court, which went on to observe that it “was truly a shame that this tragedy had to happen for the authorities concerned to address the CCTV problem, despite the same authorities having known about this problem for a long time… and apparently having done nothing concrete to address it.”

The magistrate also noted that although the hole in the door had been filled in, he had seen an identical hole in at least one other cell door. The court recommended that a risk assessment be immediately carried out to identify and address the dangers in the division in question.

“Therefore the defendant Philip Zammit certainly should not be held responsible for this shortcoming,” said the magistrate. Neither was Zammit responsible for carrying out searches in Paxton’s cell, which had failed to find the fishing line eventually used by the inmate to hang himself.

Zammit had told investigators that his job was to maintain security, prevent inmates from escaping and maintain good order in the ward. Asked directly whether he had been entrusted with keeping the inmate under constant watch, he said that this was the nurses’ job.

This account was corroborated by other witnesses, including the psychiatric consultant who had been treating Paxton, the deputy chairman at Mount Carmel at the time, as well as a nurse who told the court that “level one” care meant “standing guard constantly [watching] the monitors.”

Prison major Frankie Borg had testified that for the most part, Zammit would be detailed as an orderly, manning the phones and managing visitors during the day. On night-shifts, his job was to provide assistance to staff as required or handle new admissions from prison. It was not the first time that Correctional Officers at the Forensic ward encountered incidents of self-harm and that two Correctional Officers were needed to search inmates.

“Constant watch is something which the nurse has to deal with, not the warder… the psychiatrist ordered constant watch and there would be a nurse with him 24 hours a day. For the nurse to move away, another nurse must replace her.”

The evidence all pointed to the nursing staff being responsible for keeping constant watch on Paxton while Zammit’s responsibility was security and maintaining order in the Forensic Unit, said the magistrate.

It was also shown that Correctional Officers did not have the power to simply open a cell, but had to be asked to do so by a nurse or doctor. The moment the duty nurse had asked Zammit to open Paxton’s cell, the defendant had done so “immediately and in the shortest possible time,” said the court.

Ruling that the prosecution had failed to prove negligence, imprudence or carelessness on the part of Zammit, the court declared him not guilty.

Lawyers Arthur Azzopardi and Jacob Magri assisted Zammit.