Last year 78 men, women and teenagers killed themselves in prison in England and Wales. Half of them were on remand awaiting trial, or sentencing.
This was the case with Wesley McGoldrick, who was caught shoplifting cheese and milk from a London branch of Sainsbury's on Saturday 16 April 2005.
When he admitted also carrying a knife, the 24-year-old was arrested, charged and, after a weekend in a police station, remanded into custody at Brixton Prison.
By the Tuesday afternoon, less than a day after his arrival at the jail, he was dead, having used bed sheets to hang himself from the bars of his cell window.
He was the 21st person to kill himself in prison in England and Wales that year. Another 57 were to follow.
The Prison Service says it is "completely committed to reducing the number of such tragic incidents" but a combination of circumstances make this a difficult task.
Gina Webb and her son Wesley McGoldrick
He was a real person and was my son but while they're in prison they're nothing, they're just a number
Gina Webb, Wesley McGoldrick's mother
The set of factors that surrounded Wesley's death are "sadly all too common" according to Deborah Coles, co-director of Inquest, a pressure group which provides support to families in deaths in custody cases.
He was a young male who had recently been remanded into a local prison - features which "are well known to the prison authorities for being over-represented for the number of people dying," she said.
Almost a third of suicides occur within the first week of someone arriving in custody and one in seven is within 48 hours.
Remand prisoners are likely to be placed in a local jail, many of which are overcrowded and may lack the staff or resources to provide intensive support for new inmates.
'Found dead'
The first Wesley's mother, Gina Webb, knew of her son's death was when her daughter turned up on her doorstep in the early hours of the morning, flanked by two police officers and sobbing hysterically.
The only information the officers had was that Wesley had been "found dead" - at that point neither Gina nor the police knew he was in jail.
"I had nothing to go on, just that one statement thrown in my face," she said.
"'Where did it happen? How did it happen? Was it an accident? Was he murdered?' It didn't matter what I asked, the answer was 'Sorry, we don't know'."
It was another day before she found out what had happened and a further day before she could identify the body.
'Signs of paranoia'
Once a keen athlete and footballer, Wesley had drifted into homelessness in his early 20s.
He had taken catering work with live-in positions but couldn't settle and the nature of his work meant that if he lost a job he also lost his home. His mother says she begged him to come back to the family home in Ruislip, Middlesex, but he would not.
PRISON SUICIDES 2005
78 deaths in England and Wales
8 deaths in Scotland (2004/05)
37% on remand awaiting trial
12 were under 21 years of age
Youngest was 16
Four were women
80% were in local prisons
131 people resuscitated after acts of self harm
Source: Howard League
Full list of the 78 who died
He was sleeping rough at the time of his arrest and Gina suspects he "wanted to get caught so he would have a roof over his head for the weekend".
Evidence heard at the inquest into Wesley's death indicated he had mental health issues. Gina believes her son's crime and his last desperate act were "a cry for help".
Officers at Kennington police station, where he was taken on his arrest, were sufficiently concerned about his state of mind to call a doctor who noted "signs of increasing paranoia".
However, the doctor's note was not seen by anyone at Brixton prison, the inquest heard.
Brixton prison gates
An investigation recommended changes in procedure at Brixton
Staff there said they judged Wesley's mental state based on conversations with him and the answers he gave to a medical questionnaire.
Neither gave any cause for alarm, they said, even though he admitted self harming previously.
Under the prison's own procedures this meant he should have been referred for a mental health assessment but this did not happen and he was not placed on suicide watch.
An investigation by the prison ombudsman recommended that mental health assessment training at Brixton was tightened up.
The governor of the prison, John Podmore, said "all prisoners undergo a comprehensive screening process" which "examines all aspects of mental and physical health as well as drug and alcohol issues".
He added: "We are working hard... to provide the highest standards of care for prisoners and continually looking to see how that provision can be improved.
"Tragedies such as the death of Mr McGoldrick cause us to look even harder particularly in the light of reports emanating from these events... our sympathies once again go to the family of Mr McGoldrick."
Fall in suicide rate
Suicide and self harm is recognised as one of the toughest challenges facing the prison service.
The 2004-05 annual report from HM Chief Inspector of Prisons observed: "The pressure of population, the reactive culture in some prisons and the vulnerability of many of those in prison, will continue to make it difficult for prisons properly to protect those in their care."
But some headway does appear to be being made: the total number of suicides fell last year from 95 in 2004 to 78, a welcome drop after three years of record levels of self-inflicted deaths.
Bar chart showing prison suicides in England and Wales 1995-2005
It comes as prisons are beginning to implement a new system known as ACCT - assessment, care in custody and teamwork - which replaces the old suicide watch forms and is designed to be more focussed on the individual.
In addition, a new health screening process has been set up that is designed to detect mental health issues on arrival into custody.
Many jails now have several "safer cells" designed to be as free from potential ligature points as possible.
And the majority of prisons also run Listener schemes in which Samaritans-trained prisoners provide 24-hour confidential support to other inmates.
Prevention measures
A Home Office spokesman said "Every death in custody is a terrible tragedy for the families left behind and also has a profound effect on staff and other prisoners.
"The government takes the issue of suicide in prisons very seriously and, in the face of population pressures, suicide prevention efforts have continued with unprecedented energy and commitment."
But Gina Webb is still angry at a system which she believes failed Wesley.
"He was a real person and was my son - they all belong to somebody, they're somebody's husband or somebody's son. But while they're in prison they're nothing, they're just a number," she said.
"What ever reason they're in there for, they're in there. The state has a duty to care for the people they're supposedly looking after and quite frankly they haven't done it."
Dead in prison
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