A prisoner was found dead in his cell on the day he was due to be released from jail, an inquest has heard.
Nigel John Keenan, known as John, was found by prison staff at Haverigg in Millom, Cumbria, in the early hours of 13 March 2025.
An inquest at Workington Coroners Court, scheduled to take place over five days, is being held in front of a jury of six women and five men. Coroner Robert Cohen told jurors this was necessary because Keenan's death had happened in custody.
He said: "It's very important we have a completely independent and fearless investigation to ensure that nothing went wrong."
The inquest heard Keenan, 62, was a registered sex offender and had been sentenced to five and a half years in prison in June 2022 for offences including engaging in sexual activity with a child.
Cohen told jurors they should "completely disregard any opinions about any offences he committed."
'Gone downhill'
The inquest heard Keenan had been stressed in the lead up to his release due to difficulties in arranging housing for him and the "abrupt" ending of his relationship with his partner.
In a note found in his cell, addressed to a governor at the prison, Keenan said his mind had been "broken for two months".
He raised concerns over how his release had been managed, including threats to tell his partner's ex-husband that she was in a relationship with a sex offender.
He said his health had "gone downhill" and he had recently been in a diabetic coma.
The inquest heard that, during an appointment in February to monitor his type two diabetes, Keenan told Haverigg's advanced clinical practitioner Ryan Tallentire that he had had thoughts of harming himself.
Tallentire told the court Keenan was "adamant" this were due to an antidepressant he had been prescribed as part of treatment for leg pain.
Tallentire said he arranged an appointment with a GP that same day and Keenan was prescribed a different drug.
He said Keenan seemed "jovial", not different to how he presented normally and no-one, including the GP, raised concerns about his mental health.
Keenan had been suffering with high blood sugar and at an appointment on 11 March Tallentire asked him about potential stresses which are known to trigger the condition.
Tallentire said Keenan spoke of feeling stressed coming up to the day of release, having "trouble with his personal offender manager" and the end of his relationship.
The coroner asked: "Was this not a moment to ask the question 'are you going to harm yourself'?"
Tallentire said he could not recall if he had asked that question, but said he had not made a note of it.
Asked if he thought about a referral for mental health support, Tallentire said: "We were really close to release at this point, a mental health referral likely wouldn't have been actioned prior to his release."
The inquest continues.
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