AN inquest into the death of a man in Winchester Prison has heard of delays to emergency calls, confusion over record-keeping and questions over his confinement to a single cell despite his attempt to kill himself once before.
Prison officers raised the alarm after finding Sheldon Woodford hanged in his single cell on March 9, last year.
He was pronounced dead in hospital three days later.
But a similar incident happened less than two weeks before, the inquest heard.
Mark Jones, custodial manager at the prison where 24-year-old Woodford was serving time for robbery, told the jury how he and fellow officers fought to save him when he tried to take his life not once but twice.
Tom Stoate, representing Alex Tasker - Woodford's fiancée, told the hearing Ms Tasker was thankful to prison staff who had "quite literally brought Sheldon back from the dead" on February 24.
"I think it's clear from the evidence you feel pretty strongly about this case. It's obviously affected you fairly deeply," he said.
Mr Jones responded: "Any loss of life is a tragedy and we, as a group, try our hardest [to avoid it]."
Tuesday's inquest was told precautionary measures to keep prisoners safe often included them being held in two-man cells.
Mr Stoate asked: "Would Sheldon have died if he had been in one of those safer cells?"
Mr Jones responded: "If somebody is determined to commit suicide they will do it.
"Personally I was gobsmacked. I felt very said that it happened again. Personally I would have liked to see him in a shared cell."
Mr Stoate also asked Mr Jones about one of Sheldon's case reviews in which he wrote 'night orderly officer check: recent case reviews are not signed and make little sense. Undue confusion caused'. Mr Jones confirmed it was unclear whether Sheldon was being checked three times a night or three times per hour.
Mr Stoate also drew attention to Mr Jones's subsequent interview with the Ombudsman during which he claimed in the 18 months prior to the incident the prison had experienced 'severe shortages' in staff numbers.
"We have been running reduced staff levels for quite a while. Logistically I didn't have enough staff to cover all the jobs," he said, adding that he was concerned about the response time from medical staff to his outgoing emergency message.
Share article "I felt the response time from the urgent message going out on the radio - and I know they can be on the other side of the prison - I would've liked them to have been there a bit quicker. To me, in that cell with Sheldon, it did take quite a while."