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A prisoner who killed a dad-of-three took his own life after claiming he was being bullied by inmates.
Wesley Rowlands was serving a life sentence at high-security HMP Garth in Lancashire when he was found dead in his cell in October 2016.
In the months prior, he is suspected of taking an overdose and was repeatedly moved over safety concerns.
Rowlands was jailed after beating his friend David Lavender to death on a pub crawl after he objected to him urinating on a landlady’s dog.
Mr Lavender, 37, protested to Rowlands, who then brutally attacked him in a park in Chester in May 2012, the Liverpool Echo reports.
At HMP Liverpool in 2015, Rowlands attacked a prison officer with a homemade blade and was handed an extra two years in jail.
After a seven-month stint in a secure hospital he was moved to HMP Garth, a specialist jail where many of the inmates are serving indeterminate and life sentences, in November 2015.
A Prisons and Probation Ombudsman report found Rowlands' troubles developed over the following 11 months.
In March 2016, he was moved from A Wing to C Wing after telling staff he was in debt and being threatened by other prisoners.
Over the next fortnight Rowlands was moved again, before telling a prison officer on April 13 he did not feel safe going to the workshop because he was being bullied.
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The following day he suffered a broken nose in what he said was a "play fight".
Staff suspected Rowlands had been attacked but he refused to take further action and the findings of an inquiry into the incident were "inconclusive".
He was found collapsed in his cell on September 5, with another inmate saying he thought he had taken an overdose of medication prescribed for issues including paranoid schizophrenia.
Other prisoners claimed Rowlands had made comments about “leaving soon” and he was observed by officers regularly during the night.
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The following day he denied he had attempted to self-harm and appeared “happy and chirpy”.
Rowlands was said to be in "good spirits" on the night of October 13, but was found dead in his cell the next morning.
Two notes were found alongside him, with the PPO reporting: "He wrote that he was having difficulty coming to terms with the offences he had committed and asked for forgiveness from his friends and family.
"He also thanked prison and healthcare staff for the support they had given him.
"After his death, officers found a number of handwritten notes, including names and prison numbers of other prisoners with various amounts of money written against each name."
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In a series of findings published this week, the PPO report concluded: "We are concerned that officers did not adequately explore Mr Rowlands’ risk factors after he took an overdose the month before he died. We have also identified some frailties in ACCT (suicide and self-harm procedures) monitoring.
"Despite Mr Rowlands reporting that he was intimidated by a prisoner, we found that he was not adequately supported, the alleged perpetrator was not appropriately challenged and the incident was not investigated as it should have been according to the prison’s violence reduction strategy."
HMP Garth said staff would be briefed on relevant guidelines, claims of bullying or violence would be investigated and the support systems in place at the time would be reviewed.
A Prison Service spokesman said: “Our thoughts remain with the family and friends of Mr Rowlands. Since his death four years ago, we have improved staff training and implemented a scheme to ensure the most vulnerable receive one-to-one support.”
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