A prisoner who was serving a life sentence for murder died after hanging himself while on hourly observations.

Aleksandras Zuravliovas, who attacked an Italian waiter in Maidstone, was three years into his minimum of 21-year jail term when he was discovered in his cell at Sheppey's HMP Swaleside in Eastchurch on June 3, 2017.

The inquest, which lasted four days, heard how the Lithuanian was under an Assessment, Care in Custody and Teamwork (ACCT) review.

ACCTs allow prison staff to map how an offender, who is at risk of suicide or self-harm, can be cared for in prison.

He was put on hourly observations meaning officers had to check in on him once every hour.

The court heard how the 30-year-old had been found with makeshift booze on May 10, 2017, days before he celebrated his birthday on May 18.

This resulted in him being disciplined and having privileges taken away.

Four days later officers were called to Zuravliovas' cell when his call button was pressed.

They found he had cut his arms.

He explained he had been missing his family and he was also worried about the length of his sentence.

An ACCT review was opened and he told a prison nurse he would not self-harm again.

The next day an assessment was held where he talked more about his worries, he could not get hold of his ex-girlfriend - who visited him about once a month - and he had been put on basic privileges without a radio.

Staff agreed to try to contact her and would try to find him a radio for his cell.

On May 24, he was reviewed again and the ACCT was closed on May 30 after he seemed "happy".

But fresh concerns were raised when he barricaded himself in his cell and threatened to cut himself if anyone went near him.

Staff managed to get inside and another ACCT review was opened.

He was placed on hourly observations and was referred to a drugs and alcohol rehabilitation service after spice - a synthetic cannabinoid - was found.

He was also questioned about a drugs debt list which he refused to talk about.

On June 3 a document said he was observed through the afternoon until 7pm by former prison officer, Sam Skinner.

But in evidence Mr Skinner said he did not check him at 7pm - leaving a gap of at least one hour and 39 minutes where he was locked in his cell and not monitored.

The prison officer had documented concerns from another prisoner about Zuravliovas seeming "out of character".

The hearing was told Mr Skinner had been dismissed following disciplinary action.

Zuravliovas was found hanging in his cell at 7.39pm by prison officer Claire Wallis.

The alarm was raised and backup arrived to give him CPR while they waited 40 minutes for paramedics who declared him dead at 8.29pm.

A toxicology report said he had no traces of the most common drugs in his system - although it did not test for all substances.

The jury returned a conclusion of death by suicide with the cause being suspension.

Assistant coroner Katrina Hepburn said she was satisfied the prison had put steps in place to boost the support offered to offenders on ACCTs.

She added: "I'm satisfied duty governors are now reviewing 20% of all ACCTs and that referrals are being made to mental health services.

"Any concerns I did have, I'm now satisfied have been dealt with. I'm not compelled to make any direction to prevent further deaths."

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