Aaron Taylor made mistakes. And he had been imprisoned for those mistakes. But Aaron wasn't just a prisoner, he was a son who was very much loved by his mum Maria.
The love a parent has for their child is unconditional; innate; instinctive. And Maria, aware of her son's vulnerabilities and mental health problems, repeatedly told the Probation Service and prison staff that Aaron had said he would kill himself in jail after he was recalled to HMP Preston in January 2023.
Maria's pleas for specialist support for her son continued, but were "ignored", as Aaron's mental health deteriorated. And, overnight on Sunday August 27 in 2023, Maria's biggest fears became a reality when Aaron took his own life in Cell 134 at Garth Prison. He was just 32.
Stuck to the wall of Aaron's cell was a note he had written to his mum. In it he described the "daily torture" he was facing. Aaron wrote that he "can't take anymore heartache". Aaron told his mum, in the note, that he "loves her to pieces" but felt that taking his own life was his "best option".
The last time Aaron had been seen alive was at 7.28pm on August 27 when prison officer Kevin Reid briefly opened the observation hatch of Cell 134 and saw him sitting on his bed with his back to the door. Mr Reid was due to conduct a role call of Echo wing between 5am and 6am the following morning but failed to do so.
In evidence, after being warned that he was not obliged to answer any questions which could result in him incriminating himself, Mr Reid admitted he had not checked the cells that morning. Prison records revealed that a signature had been added to the relevant log but Mr Reid, who blamed his marital problems for failing to carry out his duties, insisted it was not his writing. He was later sacked.
Prison staff were aware that Aaron had a long history of self-harming and suicidal ideation. Just a few weeks before he died, Aaron had inflicted an injury on himself which was so severe he was hospitalised.
If prison staff believe that an inmate is an immediate risk to themselves they can place the prisoner on what is known as an ACCT - an Assessment, Care in Custody and Teamwork (ACCT) plan which allows for additional welfare checks and mental health support. But despite Aaron's recent self-harming and threats to kill himself, he wasn't put on an ACCT prior to his death.
Inmates at HMP Garth, near Leyland, are assigned a key worker - a member of prison staff who acts as their first port of call if they have any concerns, questions or needs. Key worker sessions are supposed to be held every week but up until earlier this year they were only taking place monthly.
During an inquest which concluded this week, with the jury ruling that "multiple failures" contributed to Aaron's death, and despite more than two years having passed since he took his own life, one key worker at Garth Prison didn't know the answer when they were asked how often sessions should take place.
The testimony of prison officer Shaun Bradley provided what was perhaps the most frank evidence during the inquest. Officer Bradley, who described Aaron as something of a model prisoner, bravely spoke out against colleagues who had "disrespected" Aaron and believed that he should have been checked more frequently given his history of self-harming.
The prison's governor, Lee Macmillan, told the jury that the jail is "still struggling" with high levels of sickness which started during the Covid pandemic.
Bosses at PPG Healthcare, which provides healthcare services at the prison, have been trying to recruit psychologists to provide specialist mental health care to inmates since April of this year. Nobody have been appointed while the waiting lists for support, which last for months, continue to grow.
For eight days the jury of 11 people have listened diligently to the evidence presented to them. Some jurors who used the opportunity to ask questions of witnesses were clear that what had happened to Aaron was unacceptable.
The jury concluded that "multiple failures" and "inadequate care" at Garth Prison contributed to Aaron's death. And, after the jurors returned their conclusion, Lancashire's Senior Coroner Chris Long voiced his own concerns.
While he acknowledged that "lessons have been learned in the wake of Aaron's death the coroner also said that "it shouldn't take for someone to die" to ensure that correct prison service policies and processes are followed. The Ministry of Justice and PPG Healthcare have 56 days within which to respond to the coroner's Report to Prevent Future Deaths.
Overcoming the ongoing issues at HMP Garth which contributed to Aaron's tragic death will take place alongside efforts to address much wider problems at the Lancashire prison. Bosses are already under pressure to deal with concerns raised during the most recent prison inspection.
Garth, which houses up to around 800 prisoners, was described by inspectors as a "troubled prison" which "will continue to be a jail of real concern" without additional support from the regional team and Prison Service.
As well as facing scrutiny from His Majesty's Inspectorate of Prison the role of Lancashire's Senior Coroner Chris Long, who oversaw the inquest into Aaron's death, will not end just because the eight-day hearing has concluded.
"As a local coroner, as a local judge, I'm not going anywhere and don't plan to and if the situation reoccurs when I've been given reassurance I may make very different decisions in the future," the coroner warned in his final comments.