A man found hanging in his cell at Westgate prison nearly eight years ago did not plan to take his own life, a jury has ruled.

The jury of 11 returned a majority verdict, with one juror dissenting, for the inquest into the sudden death of the inmate, Kevin Leroy Gladstone Butterfield.

Mr Butterfield, 41, was being held on remand at the jail on a firearms-related charge in October 2015 when a prison officer discovered him unconscious in his maximum security cell.

Mr Butterfield was hanging by the neck from a noose, made from the laces of his sneakers, which he had attached to the hinge at the back of the cell door.

The jury, which began hearing evidence on Tuesday, found yesterday that Mr Butterfield deliberately tied it tightly around his neck and suspended himself.

However, they concluded that he “did not intend to take his own life and did not expect the outcome to be fatal”.

His death was determined to be misadventure rather than suicide.

The inquest heard that psychiatrists had found Mr Butterfield, who had a history of self-harm and substance abuse, displayed parasuicide ― meaning he had made attempts that resembled suicide, but lacked a genuine intent of taking his own life.

Magistrate Craig Attridge, acting as coroner, summarised the evidence before sending the jury out.

Mr Attridge directed the 11 jurors to reach a conclusion on the facts of Mr Butterfield’s death, without attributing liability or blame.

Mr Butterfield had been arrested, along with his wife, on October 1, 2015, and taken into custody at the Hamilton Police Station.

The court heard earlier that a firearm had been discovered at his residence. Mr Butterfield claimed the weapon was not his.

When assessed, he told police he had never suffered from mental health problems.

On October 2, while still in custody, Mr Butterfield was further arrested for separate matters that were not specified in court.

He remained in Hamilton Police Station while his wife was bailed and released.

The jury heard that Mr Butterfield because upset after learning he would not be released and told police he could not remain in his cell because it made him want to harm himself.

A doctor examined him and found him fit to remain in detention.

Mr Butterfield had symptoms described as mild depression, with previous thoughts of suicide, but there was no evidence of significant psychological disorder.

Shortly afterwards, police found him lying in his cell with a T-shirt tied around his neck, but conscious and breathing.

Mr Butterfield began banging his head on the cell wall after they removed the garment and handcuffed him.

He was taken to the Mid-Atlantic Wellness Institute. He informed doctors that he had recently used heroin ― but did not have thoughts of suicide or self-harm at present.

Doctors concluded his behaviour at the police station was staged and Mr Butterfield apologised to officers when he was returned.

He was formally charged in Magistrates’ Court on October 5 and remanded to Westgate when he could not make $15,000 in bail.

On October 6, he was found in his cell bleeding from a razor wound to his wrist.

Doctors at King Edward VII Memorial Hospital treated what was described as a superficial laceration.

He was placed on suicide watch in the segregated unit back at Westgate but the frequency of observation was gradually relaxed.

The jury heard that inmates on suicide watch would have their usual clothing taken away, leaving them dressed only in a smock.

In addition, their cells would be stripped of anything potentially of danger, with an officer keeping watch and checking every 15 minutes.

After spending sufficient time on suicide watch, Mr Butterfield was put on a half-hourly and then hourly observation schedule. His regular prison clothing, including sneakers, was returned to him.

On October 7, Mr Butterfield asked to speak by telephone to his wife, held at the Co-Ed facility.

The jury heard he appeared “shocked” when she declined the call.

During his four days at Westgate, Mr Butterfield also expressed anxiety that his children would be taken from him.

On October 8, the inmate was in his cell at maximum security.

Evidence from prison staff described Mr Butterfield as appearing normal.

On the topic of suicide, he told nursing staff: “I am not that type of person. That’s not me ― I have a lot to live for.”

On that day, Mr Butterfield spoke to an officer familiar to him from his previous times at Westgate.

He asked the officer what he was doing and was told the officer was going to fetch a newspaper for another inmate.

Mr Butterfield told him: “When you get back, come see me.”

The officer responded, meaning Mr Butterfield would have known he intended to return.

It was ten to 15 minutes before the officer returned with the newspaper and discovered the inmate hanging.

With Mr Butterfield’s body against the door, it took two staff to force the door open.

Mr Attridge highlighted the inmate’s history of parasuicide and suggested the jury should consider why someone genuinely intent on taking their own life would want to know if the officer was returning.

He added: “In my view, that is incredibly cogent evidence.”

He also pointed out that the difficulty opening the cell door suggested Mr Butterfield had been alone inside, because any other person would likely have struggled to get back out of the cell.

Once inside, officers placed a chair under Mr Butterfield’s feet and struggled to get him down, while another officer had to use a key to cut through the shoelaces.

An on-call doctor pronounced Mr Butterfield dead just over an hour later, giving the cause as “asphyxia due to hanging”.

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