The mental state of a prisoner who was found hanging in his cell was never fully assessed, it was revealed yesterday Jurors gave their verdict at the end of a five-day inquest into the death of 33-year-old Richard Carter, from Haworth.

Mr Carter, a single man, was found hanging by torn bed sheets in his cell and left "in situ" for four hours, breaking jail orders, the Leeds inquest also heard.

His body was discovered on August 26, 2004, during a routine morning roll call, he had not been checked on during the night despite telling prison staff he would put up a fight if they tried to carry out a planned transfer from Armley Jail to Lyndholme Prison the next day.

He was worried about moving to Lyndholme, where he had been before, because accommodation can be shared by up to six prisoners.

The narrative verdict stated: "Richard stated quite clearly on several occasions to both healthcare and prison staff that he did not want to be moved to Her Majesty's Prison, Lindholme.

"His concerns were with the accommodation at that establishment, that being of a dormitory-style regime with possibly up to six people sharing a dormitory.

"He said he had a problem handling the spurs."

It added: "Minimal time was spent with Richard and it appears that a full assessment of his mental state was never undertaken."

The jurors heard from the governor on duty at the time that if Mr Carter had single cell status at Armley that criteria would have been followed at Lyndholme. This information was never passed on to Mr Carter, the inquest was told.

Nick Stannage, representing Mr Carter's family, said: "In his mother's view, there are concerns that this was an avoidable death and that the minimum of information given to Richard about the transfer would have put his mind at rest."

Mr Carter, who was passed fit for transfer and rubber-stamped not depressed or suicidal, despite being on anti-depressants, left two notes, one of which was for his family.

In the letter to his family he described how he wished he had told healthcare staff and prison officers "the truth" earlier about his depression and panic attacks, but he had been afraid he would be locked up in a mental hospital.

He wrote: "I couldn't let you know what I was going through, not the done thing when you're a man."

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