Coroner Khamisi Tokunbo will write a report into the suicide of a mentally-ill Westgate inmate, in a bid to prevent anything similar happening again.

The jury hearing the inquest into the death of prisoner Lorenzo Robinson delivered a verdict of suffocation due to suicide by hanging yesterday.

The jurors were not allowed by law to make any comments or recommendations, or attribute any blame over the death of 28-year-old Mr. Robinson.

Their role was simply to determine how, when and where he died.

However, Mr. Tokunbo told them afterwards that under the Coroner's rules, a Coroner who believes that action should be taken to prevent the recurrence of similar fatalities may report the matter to whoever has power to take such action.

"I'm now announcing that I will be reporting the matter to the person or authority that can take action," he said, although he did not specify what he will report or to whom.

Asked by about this by The Royal Gazette after the case, and whether his recommendations will be made public, Mr. Tokunbo replied: "I have to figure that out."

News of his report was welcomed by those concerned about the Robinson case, but they also repeated calls for action on the part of Government and even a full public inquiry into the wider issues raised (see separate story.)

Mr. Robinson was sent to Westgate indefinitely after being acquitted on grounds of insanity of attempting to stab a tourist to death on Front Street.

Experts said during his trial in 2004 that he was highly dangerous and required long-term detention and treatment in a secure forensic psychiatric facility, which Bermuda does not have.

Mr. Robinson also obtained a ruling from Chief Justice Richard Ground four months before his suicide that his condition required him to be treated in such a unit, and that a designated "hospital cell" he was being kept in at Westgate was no such thing.

The Chief Justice asked for Mr. Robinson's care to be reconsidered, including the possibility of sending him overseas.

However, he remained in Westgate, locked in a punishment cell for 23-and-a-half hours per day, until he took his own life on July 13 2008.

He was not on suicide watch which meant he would have 15-minute checks and no access to bedclothes despite having made multiple prior attempts on his own life in Westgate, and despite there being a special CCTV-monitored room for at-risk inmates.

The jury of nine women and eleven men unanimously found that Mr. Robinson died through suffocation due to suicide by hanging after it was suggested to them by the Coroner that other possible verdicts such as death by unlawful means or by accident were not relevant. However, he urged them to only come to that conclusion if they were sure of it beyond reasonable doubt.

The inquest heard evidence earlier this week that Mr. Robinson may have been bullied and put in fear of his life by other inmates and prison officers, although this was strenuously denied by the individuals in question and the Police found no evidence to press criminal charges.

Several of his fellow inmates and one officer claim they reported concerns about his welfare on the day he hanged himself to the officer on duty. However, the prison officer in question, Melton Taylor, denied earlier this week that he had been alerted to any problems related to Mr. Robinson and stressed that he had checked on him every half-hour.

Mr. Robinson was found hanging from the ceiling of his cell, having made a noose out of bed linen that he'd torn up and plaited. He suspended it to the ceiling using batteries wedged into grooves in the ceiling.

The inquest heard that batteries are illegal items inside the segregation wing of Westgate, as are plaited sheets, which are used by prisoners as "fishing lines" to transport contraband between cells.

Principal Officer Phillip Downie told the inquest that it was normal practice for Mr. Robinson to use batteries to suspend a line to the ceiling to do pull ups in his cell. Coroner Mr. Tokunbo commented when he was summing up the evidence yesterday: "I found that disturbing."

Saul Froomkin QC, representing Mr. Robinson's mother Dedona Grant, also raised concerns over a policy that meant the officers on duty did not have access to the cell keys in the segregation section at night. He questioned whether Mr. Robinson's life could have been saved if access had been gained to his cell more quickly after he failed to respond to knocks.

In an interview after the hearing, Commissioner of Corrections Edward Lamb extended his condolences to the family before stating: "In terms of the specifics of the case, I don't know fully what's transpired here. All I've seen is what's been reported in the newspaper. It would be imprudent for me to comment.

"Of course it's a very unfortunate circumstance and there are no winners. I'm hoping that I can get the transcripts of the whole inquest as I would like to digest the proceedings. Regrettably the service may have come out unfairly portrayed in a negative light in some circumstances.

"Of course the results were regrettable. I can assure the public that our officers performed their duties in a very diligent and professional manner. I would like to voice my support for my officers. My officers and staff had to manage a difficult situation under very trying circumstances. I am confident they will have done their level best to manage this particular situation."

He added: "We've improved arrangements between us and MAWI (the Mid-Atlantic Wellness Institute) such that they will provide us with a higher level of psychiatric services. That's in place, with prisoners being treated in prison. It's not a forensic psychiatric unit, but suffice to say we have increased the psychiatric services."

Quizzed over the illegal contraband that assisted Mr. Robinson in taking his life, he said: "We have constant searches throughout the cells but as one can imagine, in jails worldwide, inmates can be quite creative and ingenious in hiding contraband."

He confirmed that an internal report has been completed into Mr. Robinson's case.

"No disciplinary action has been taken. None was deemed to be necessary," he said. "There was some immediate action in terms of some alterations to the actual structure inside the segregation unit, the physical structure. We've taken precautions to prevent similar occurrences in the unit in terms of what our inmates can do to harm themselves in a similar fashion."