Serious failures within the prison system contributed to the death of a schizophrenic murder suspect, an inquest jury concluded.

Father-of-two Adrian Johnson, 27, was found hanged in his cell on Thursday, May 13, 2010, in the segregation unit of Belmarsh Prison, Thamesmead.

Mr Johnson, a former warehouseman, was charged with stabbing to death 49-year-old Robert Anthony Lewis and with assaulting Colin Buckfield at a shared home for vulnerable adults in Cheam Road, Sutton, on May 4.

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The scene in 2010

In giving a narrative verdict on Friday, December 6, the jury ruled Mr Johnson died by an act of accidental hanging - partly because of serious failures within the prison system.

Mr Johnson died after the frequency of his observations by officers was downgraded - despite a previous attempt to hang himself just days before in HMP High Down.

The jury concluded the decision to downgrade observations and move Mr Johnson to a non-gated cell, before securing an overdue mental health assessment, amounted to neglect.

Their verdict also highlighted issues including staff being unaware of the existence or whereabouts of his clinical records and failing to highlight his urgent need for a mental health assessment.

The jury noted staff failed to take appropriate heed of Mr Johnson’s exceptional dependency on nicotine which triggered his previous self-harm attempt High Down.

Mr Johnson’s family issued a statement after the verdict thanking the coroner Dr Andrew Harris, the jury and staff for their support.

They said: "We are pleased to note the changes that have already been implemented as a result of matters arising at the time and hope that the conclusions and recommendations, not only from this coroner's inquest but also the various other investigations into this matter, will continue to effect positive changes within government organisations and institutions in order to help prevent any further deaths of vulnerable people in their care."

'Belmarsh have a few other things to answer to'

The brother of Adrian Johnson's victim said he would have liked to have seen justice for his brother Robert Lewis.

David Lewis, 50, from Wallington, said he felt the jury came to an odd conclusion and could not understand how it was accidental hanging.

Mr Lewis, a layout manager for Superdrug, was in the office when the police arrived to tell him his brother had been murdered in 2010.

He said: "Obviously Belmarsh have got a few things to answer to.

"[My family] have not really spoken about it. Obviously Robert passed away three years ago and we lost my mum this year. She went into hospital just after Christmas in about February and she died on May 14.

"She would liked to have known what the outcome was. We would have liked to have seen justice for Robert. It was very much a shock.

"The police came to tell me Robert had been murdered and they said Adrian Johnson had owned up to it when the police first got there.

"So although we have known we also just wanted justice for that murder - everybody does that loses a son or a brother.

"We would like to have known why he did it. We will never know what happened that night for him to do what he did.

"There’s a lot of unanswered questions - why it happened and who else was there. Both us and Mr Johnson’s family know nothing about what happened that night."

In April this year an NHS report into the attack which happened at shared accommodation, in Cheam Road, Sutton, revealed that the risk Mr Johnson posed to others was not disclosed to the organisation which housed him.

It revealed information about Mr Johnson’s risk to himself and others, his self harm, paranoia and illegal drug use were not disclosed on his housing application.

The report made 11 recommendations into how to prevent a similar event in the future.