The Prisons & Probation Ombudsman has published the following self-inflicted death in custody reports in the last seven days.

Mr Robert McLoughlin was found hanging in his cell at HMP Leeds on 20 February, and died in hospital five days later, on 25 February, never having regained consciousness. He was 32 years old. I offer my condolences to Mr McLoughlin’s family and friends. Although Mr McLoughlin was subject to Prison Service suicide and self-harm monitoring procedures at the time of his death, I am concerned that the prison did not properly address or mitigate his risk factors. Had the suicide and self-harm monitoring procedures operated more effectively, staff might have made more informed decisions about how best to support him. I am concerned that I have repeatedly criticised the management of suicide and self-harm at Leeds and note that the Chief Inspector of Prisons has raised similar concerns. It is essential that the lessons from Mr McLoughlin’s tragic death are quickly and effectively acted upon.

Full report.

Mr Mark Doyle was found hanged in his cell on 22 March 2017 at HMP Pentonville and died in hospital six days later. Mr Doyle was 45 years old. We offer our condolences to Mr Doyle’s family and friends. The investigation into Mr Doyle’s death found deficiencies in the management of the ACCT process, specifically in assessing risk and delivering appropriate levels of observations. Control room staff did not immediately call an ambulance when the emergency was raised. Faulty cell bells were not reported and were not checked daily as required. We are troubled that mental health staff did not consider all available information in considering Mr Doyle’s referral. There have been six self-inflicted deaths at Pentonville since 2016. We are very concerned to repeat in this report recommendations that have been made in previous investigations into deaths at Pentonville. Given these concerns, the Prisons Group Director for London and Thames Valley should commission a review on the operation and management of the ACCT process at HMP Pentonville. As part of this review, he should, in particular, assure himself that HMP Pentonville has effectively implemented all PPO recommendations following self-inflicted deaths at the prison in the last five years and provide a report to me outlining progress within 3 months of receiving this report.

Full report.

Mr Jack Denison died of sepsis and pneumonia at hospital on 31 May 2016, while a prisoner at HMP Wymott. He was 86 years old. I offer my condolences to Mr Denison’s family and friends. Mr Denison was a frail man with several health conditions which healthcare staff managed well. I am satisfied that his care in prison was equivalent to that he could have expected to receive in the community and healthcare staff could not have prevented his death. Although it did not affect the cause of death, I am concerned that poor communication between HMP Garth and Wymott resulted in Mr Denison missing vital hospital appointments. There was no medical input to the security risk assessment when Mr Denison was taken to hospital and managers gave insufficient consideration to the impact of his health on his level of risk. It is also a concern that Mr Denison’s next of kin details were not updated when he arrived at Wymott.

Full report.

Mr Gary Lines was found hanged in his cell at HMP Northumberland on 18 September 2015. He was 44 years old. I offer my condolences to Mr Lines’ family and friends. Prison staff had begun suicide and self-harm prevention procedures when Mr Lines harmed himself on 13 September, but case reviews were not multidisciplinary and healthcare staff were not involved. No one checked Mr Lines’ community prescription from the time he arrived in prison on 8 August and he was not prescribed antidepressants, which he said he needed to help drive off suicidal thoughts, until the day before he died. While I consider it would have been difficult to predict that Mr Lines was at high and imminent risk of suicide, I am concerned that a lack of effective information sharing and consideration of his risk factors led to his risk being underestimated and a low level of observations. On the morning he was found hanged, I am not satisfied that staff checked Mr Lines’ wellbeing effectively.

Full report.

Mr John Duffey was found hanged in his cell at HMP Liverpool on 16 July 2016. He was 44 years old. I offer my condolences to Mr Duffey’s family and friends. Mr Duffey was a military veteran with a diagnosis of post-traumatic stress disorder and depression. He had a long history of illicit drug use and alcohol abuse. The investigation found deficiencies in the operation of suicide and self-harm prevention procedures at the prison. I am concerned that this is not the first time that I have found suicide and self-harm prevention procedures to be inadequate at Liverpool. However, I do not consider that staff at Liverpool could have predicted that Mr Duffey intended to take his own life when he did and, therefore, could not have prevented his actions. Fellow prisoners said that Mr Duffey was a regular user of ‘Spice’, a new psychoactive substance, that he was being bullied and was in debt for drugs, but the investigation found no evidence to corroborate these claims. Nevertheless, I note the ease with which Mr Duffey appeared to have been able to acquire illicit drugs at Liverpool and the prison needs to increase its efforts to combat the risks posed to prison safety particularly by new psychoactive substances.

Full report.

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