Discharged: Dead – When Truth Falls Through The Trap Door


By Mark Leech FRSA. Editor: The Prisons Handbook

I remember it all like it was yesterday – and I doubt I will ever forget.

The 23rd May 1985 was a bitterly cold day in Dartmoor prison as the howling wind whistled off the local Tors and I found myself once again shivering as I walked alone Midnight Express style around a small caged exercise yard in the E.Hall punishment block of a prison built to hold Napoleonic prisoners of war 200 years before.

I was serving 56 days’ solitary confinement, completely my own fault, having just spent two weeks protesting about the change in parole policy by the then Home Secretary Leon Brittan, on the roof of Long Lartin Maximum Security prison in Evesham.

In the cage next to me was a young man called David Greenhow, 23 years old, with learning difficulties, his hair matted with mucus he occupied the cell next to mine and I would often hear him screaming in the night.

That day he spent his hour of exercise standing against the wall of the cage rocking backwards and forwards – he was in E.Hall for repeatedly kicking his cell door in the main prison, he couldn’t explain why, and the Governor had responded by placing him in the E.Hall punishment block for what was euphemistically called the ‘Good Order and Discipline’ of the prison.

We never spoke that day, not once, I asked him how he was but he never responded, his ceaseless rocking backwards and forwards left me with the impression of a young man more in need of help than punishment, and I continued my circular walk lost in my own thoughts against the biting Dartmoor wind.

It was three hours later when I heard the first Officer shout, followed by the stampede of feet to the cell next door. Urgent voices rang out ‘Get the Minuteman’ – the resuscitation machine – but by the time that arrived 20 minutes later from the hospital at the other side of the prison, David Greenhow was beyond help.

His young life ended there, dangling from a ripped bed sheet that he had tied around the cell window bars. This young man, with his whole future stretching out before him, had chosen to take his own life rather than face the anguish of going through even one more day.

That evening the police arrived, they spoke only to prison officers and stayed long enough to rule out foul play. According to the later Inquest Report what were then called the ‘Board of Visitors’, but are today known as Independent Monitoring Boards (IMB) – the supposed ‘watchdogs’ of the public interest – never attended that night. The Chairman, according to the report, had been telephoned at home and advised of the death but seemingly saw no reason to drive the 20 miles from his home in Plymouth to the prison; the man was dead, so what?

Even a century ago, at least in Reading Gaol, the Chaplain called.

At 11pm as I looked through the drill hole in the centre of the spyhole fitted into my cell door I watched as David Greenhow’s lifeless body, wrapped in a green blanket and strapped to a wheelchair, was pushed along the landing outside my cell door to a waiting ambulance on what was to be his final journey in this world – a trip to the hospital mortuary.

David Greenhow was just one of many I have seen choose death over life to prison suicide over the years, it’s hard for those who have not experienced the devastation of despair that descends on a prison wing after someone has taken their own life to explain it, but there is a silence that wasn’t there before, some people talk in hushed whispers while others resort to morbid comedy to cope: “He was too young to be hanging around bars anyway.”

I’ve heard it all – but every death in custody is an event that I never forget and it is to this day what focusses my attention and drives me to confront the horrors of lives needlessly lost which are simply written off as par for the prison course by those who should know better.

Recently some on social media have criticised me for focussing on this, for not understanding, they assert, ‘the issues’; for seemingly misunderstanding the roles that certain officials have to play, and for critically pointing out that too many of today’s IMBs fail to mention in their annual reports how deaths in custody in the prisons that they monitor are treated as events unworthy of any real attention.

They’re wrong: I do understand, and too well as only someone who has been through it too many times can do.

The fact is that lessons that should be learnt from each death are not only routinely ignored, but the very fact that they are ignored is itself shamefully unworthy of any acknowledgement or note.

For every death in custody in England and Wales the Prisons and Probation Ombudsman (PPO) conducts an investigation, attempting to learn lessons to prevent the next death. They make a plethora of well-intended recommendations designed to prevent repetition, pointing out where things went wrong, how events may have turned out differently if the rules, regulations, practices, procedures, policies and previous identical recommendations made for the second, third and fourth time had been followed.

But they’re not followed; indeed they are almost routinely ignored, without consequence to those who ignore them, but not to those who later die needlessly when they may have been saved.

In IMB annual reports every year, and I read them all, so often the text relating to the number of deaths that have occurred in the prisons these IMBs ‘monitor’ are cut and pasted from one annual report to the next, with only the often increasing numbers changed from one year to the next.

Today, as I write this, 29th June 2019, the PPO published yet another death in custody report, this time into the death by hanging of 30 year old James Turnbull at HMP Durham. In that report the PPO again points out to HMP Durham the failures to implement the same recommendations in respect of Mr Turnbull’s death that the PPO had made previously to Durham Prison – and which like so many before it remain ignored and not implemented.

Mr James Turnbull was found hanged in his cell on 23 December 2017 at HMP Durham. He was 30 years old. Mr Turnbull experienced a severe decline in his mental health in the weeks before he died. His transfer to a psychiatric hospital had been approved and he was awaiting a bed space when he died. The investigation found there was a delay in arranging a psychiatric assessment for Mr Turnbull. If he had been assessed more promptly, it is possible he may have been transferred to hospital earlier where he could have received appropriate treatment. 

Staff managed Mr Turnbull under suicide and self-harm prevention procedures (known as ACCT) when his mental health declined. Initially, they did this well. However, I am concerned that staff wrongly assessed his level of risk and stopped ACCT procedures prematurely. They restarted ACCT procedures on 20 December, after Mr Turnbull told them he had been thinking of ways to hang himself, but worryingly, stopped them just over 24 hours later. I am concerned that despite Mr Turnbull’s continued paranoid behaviour, his pending transfer to psychiatric hospital and a recent stated intention to take his life, he was not being monitored under ACCT procedures when he died. Previous investigations at Durham have identified similar deficiencies in assessing prisoners’ risk and managing ACCT procedures. The Prison Group Director needs to satisfy himself that staff at Durham are properly applying ACCT procedures to protect prisoners at risk of suicide and self-harm. 

Why were the recommendations by the PPO of failures in the past to carry out the mandatory suicide and self-harm procedures correctly at Durham not implemented – and why were these later criticisms even required at all?

Durham is a prison with a shocking record of suicides – precisely perhaps because the lessons and PPO recommendations are neither learned nor implemented. But the failure to implement death in custody recommendations is not something the IMB at Durham found worthy of any note at all – indeed they imply that all is well when it clearly isn’t.

In the latest HMP Durham IMB annual report, covering the period November 2017 (a month before Mr Turnbull died) to October 2018 and published in March 2019, this is what they say:

“Over the last year deaths in custody have increased from 7 (2017) to 11 (2018). Out of the 11 deaths this year, no Coroner’s report is available. The Board have been informed promptly of these deaths and where possible have observed the initial actions and subsequent investigation. All Prison and Probation Ombudsman (PPO) reports have been monitored by the Board and discussed with the Governor. The prison action plans have been monitored accordingly. “

Not a single word about the death of Mr Turnbull, indeed none of the 11 prisoners who died at Durham during this year warrant any specific mention at all. There is nothing, not a word, about the criticism of the PPO and the prison’s failure to implement previous recommendations – and the fact is they must have known when writing their annual report because every prison and its IMB are given the contents of PPO Reports within weeks of a death, and often well over a year before the report itself is made public.

Instead the Durham prison IMB just make the risible claim that PPO reports have been monitored; what on earth does that even mean?

This isn’t just happening at Durham, this is a nationwide problem where IMBs fearful of rocking the Ministry of Justice’s ‘boat’ prefer silence to sanction, concealing from the public whose loved ones have died in their jail, how their deaths might have been prevented if the prisons they monitor had implemented recommendations made previously and ignored.

This problem was made more obvious recently when Anne Owers, the Chair of the National IMB Management Board, issued her first National IMB Annual Report on 5th June 2019. Because this report is merely a rehashing of the flawed IMB annual reports from Boards around the country, this too made no mention at all of any failures, by any prison, to implement PPO recommendations on deaths in custody.

Indeed when you read this report, which others who ought to know better have commended, you will find that the word ‘death’ or ‘deaths’ in this 56 page report appears just once, as a passing reference only, on page 11.

This lamentable fact was forcibly brought home in the Ministerial Response to the National IMB Annual Report when the Prisons Minister, Robert Buckland QC, responded formally to the Report on 28th June 2019 – in which he failed to mention even once, the subject of deaths in custody.

It is not just IMBs and Ministers who are to blame for this, the independent Prisons and Probation Ombudsman are themselves complicit in this concealment – and it starts right on Day One.

The PPO is advised immediately there is a death in custody. But they make no announcement about it, they conceal what deaths they are currently investigating and they have absolutely no mechanism in place for monitoring the implementation of their recommendations at all – which is why prisons ignore them with impunity and without consequence.

That concealment is supported by both HM Prison and Probation Service and the Ministry of Justice, neither of whom make public when someone has died in their care; they leave that to journalists to discover when news ‘leaks’ out days or weeks later – if at all.

The PPO is the first to trumpet its alleged independence, it makes much of it in every report they publish, but the fact is that this is little more than a mirage.

When a person dies in the custody of the State the PPO should announce they are investigating, there should be an online list of current investigations, it can be anonymised, there are sensitivities of next of kin to be considered and the judicial process of an Inquest to consider too, I understand all that. But the very fact they are investigating a death in custody, where it happened, when it happened, male or female and the age of the deceased should be made public – this is the United Kingdom, not North Korea.

This concealment has to stop.

I recently conducted a search of our Fatal Incident database, it contains all the PPO Fatal Incident Reports and I conducted a search of how many reports the PPO had issued on deaths in custody where the PPO had been forced to repeat recommendations that had been made previously but ignored – recommendations that had to be made again when further death in similar circumstances had occurred; the almost 100 cases runs to some six pages.

Unless we learn the lessons of why so many die in custody, unless we are open and transparent about deaths, acknowledging immediately when they occur, unless the PPO can put in place a robust mechanism for monitoring the implementation of their recommendations – and IMBs can be honest about when that implementation just isn’t happening – then people will continue to die, perhaps needlessly, in our prisons.

And, just like 35 years ago when 23-year-old David Greenhow was being driven out of the gates of Dartmoor Prison for the final time, the facts is that prison officials will continue to stamp the front of far too many prisoners’ records with the brutal self-explanatory text: “Discharged: Dead”.

Mark Leech FRSA, is the Editor of The Prisons Handbook for England and Wales.

PPO Confirms Concerns Raised By Inspection of HMP Nottingham

The Prisons and Probation Ombudsman, who investigates deaths and complaints in prisons, echoed the findings of the Chief Inspector of Prisons’ report of an inspection at HMP Nottingham.

The Acting PPO, Elizabeth Moody, said: “It is highly troubling that HMP Nottingham has a history of failing to implement recommendations from our investigations into deaths at the prison”.

The PPO makes recommendations following investigations into deaths in prisons so that the prison service can learn from mistakes and prevent them being made in the future.  Final PPO reports on deaths investigations are not published until the end of inquests but important findings and recommendations that could lead to greater safety in a prison are shared with the prison and HM Prison and Probation Service (HMPPS) as they emerge.

Elizabeth Moody added: “It is a matter of great concern that we found some similarities, not only between the deaths of the five prisoners who took their own lives last autumn, but also with deaths which happened earlier in the year and before.  The Chief Inspector is right to highlight the apparent inability of the prison to learn lessons and I agree that until it can demonstrate progress in this critical area the risk of future deaths will remain high.”

She also said: “Complaints from prisoners frequently indicate poor custodial care.  I am troubled that my office upheld proportionately more complaints from prisoners at HMP Nottingham, than in other similar prisons.  This is consistent with the findings of the Chief Inspector and should be a source of concern to the management of HMPPS.”

The Chief Inspector, Peter Clarke, wrote publicly to David Gauke on 18 January, invoking a new procedure to demand urgent action on HMP Nottingham from the Justice Secretary. He raised concerns over eight apparent self-inflicted deaths at HMP Nottingham in the two years up to January 2018, as well as high levels of self-harm.

At the same time, Elizabeth Moody raised key concerns with the Ministry of Justice which had been identified in her investigations into recent deaths at the prison:

  • The importance of initial identification in prisoners of risk of suicide or self-harm.
  • Assessment and management of those individuals, particularly applying multi-disciplinary assessment rather than relying on the way the prisoner presents and talks on arrival in the jail.
  • Referring mental health concerns and issues to healthcare or other experts.
  • The importance of staff responding, in line with HMIP expectations, when prisoners press their cell call bells and of staff entering cells promptly when prisoners are found unresponsive.
  • Keeping proper medical records.
  • Effective emergency response.

Elizabeth Moody said: “HMPPS is preparing an Action Plan to address the urgent concerns raised by the Chief Inspector, particularly in relation to suicide and self-harm at HMP Nottingham. It is vital that, this time, HMPSS fully incorporates PPO recommendations into the Action Plan. That will help HMP Nottingham create a new culture of safety and protection for vulnerable prisoners. Put simply, it will help save lives and prevent a repetition of the tragedies we saw in 2017.”

Transgender Prisoners Often Vulnerable and Need to be Better Managed Says Ombudsman

transgender_logoPrisons need to be more flexible and proactive in managing transgender prisoners, based on their individual needs and circumstances, so that they can live safely, said Prisons and Probation Ombudsman (PPO) Nigel Newcomen. Today he published a bulletin on lessons that can be learned from his investigations.

The bulletin draws on recommendations from investigations into deaths in custody, as well as complaint investigations. It identifies six lessons from past cases that aim to protect transgender prisoners better from bullying and harassment and to support transgender prisoners better to live in their gender identity while in prison. It is difficult to estimate precisely how many serving prisoners are transgender, but while the number is growing, it is still relatively small – approximately 80. Nearly all of the complaints received, and deaths investigated (five between 2008 and August 2016) were related to transgender female prisoners, nearly all of whom were housed in the male estate.
Prisons house male and female prisoners separately, and will usually distinguish gender based on that which is recognised by law. According to the Gender Recognition Act 2004, proof of gender is determined either by the person’s birth certificate, or a gender recognition certificate (GRC). The process for obtaining a GRC is complex. Because of the process and the cost involved, because of the symbolism, or because it can have implications for existing marriages, many transgender people choose not to obtain a certificate. Most transgender prisoners are, at least upon first arrival in prison, housed according to the gender they were assigned at birth.

The regulations that guide the care and management of transgender prisoners in England and Wales are found in a Prison Service Instruction (PSI), issued in November 2016. Many of the lessons outlined, and many of the recommendations previously made by the PPO, are reflected in the new PSI.

Previous research has shown there is a greater prevalence of mental health concerns and risk of suicide in the transgender population. When a person enters prison, they leave behind what support they had in the community. The prison environment can be particularly difficult for transgender prisoners, exacerbating existing vulnerabilities.

The bulletin highlights the need for:

  • evaluating the location of a transgender prisoner based on an individual assessment of their needs and considering the possibility of them residing in the estate of their acquired gender;
  • all relevant people involved in a transgender prisoner’s care attending ACCT case reviews (for those deemed at risk of suicide or self-harm);
  • meaningfully investigating all allegations of transphobic bullying and harassment and taking steps taken to challenge and prevent it;
  • personal officers having regular, meaningful contact with transgender prisoners, staff being aware of their vulnerabilities and challenging inappropriate behaviour;
  • local policies to be in line with national guidance and not imposing unfair additional restrictions; and
  • reasonable adjustments being made for transgender prisoners to help them to live in their gender role.

Nigel Newcomen said:

“My office has historically received few complaints from prisoners identifying themselves as transgender, and, fortunately, has investigated relatively few deaths of transgender individuals in custody. However, more recently, these numbers have been climbing. Last year, in quick succession, two transgender women tragically took their own lives while in custody. A third transgender woman is thought to have taken her own life in November 2016, and a fourth in December 2016.

“Prisons are always difficult environments, never more so than in recent months, but they have a fundamental responsibility to keep prisoners safe and to protect and support those with particular vulnerabilities. Transgender prisoners are among the most vulnerable, with evident risks of suicide and self harm, as well as facing bullying and harassment.

“This bulletin also coincides with a long-awaited review of the Prison Service Instruction (PSI) that governs the care and management of transgender prisoners. This PSI reflects the appropriately heightened awareness of transgender issues in prison – and in society as a whole.”

A copy of the report can be found on our website from 10 January 2017. Visit www.ppo.gov.uk.

More deaths in prison from natural causes and still too many suicides says Prisons Ombudsman

Nigel Newcomen
Nigel Newcomen

A rapidly ageing prison population was largely behind the 15% increase in deaths of prisoners from natural causes in 2014-15. This has meant that prisons designed for fit young men must increasingly adjust to the roles of care home and even hospice, said Prisons and Probation Ombudsman Nigel Newcomen, as he published his annual report. He added that, while suicides reduced by 16%, the number remained unacceptably high.

The Prisons and Probation Ombudsman (PPO) independently investigates the circumstances of each death in custody and identifies lessons that need to be learned to improve safety. In 2014-15:

there were 250 deaths in 2014-15, 11 (5%) more than the year before;
the PPO began 15% more investigations into deaths from natural causes (155 deaths), largely as a consequence of rising numbers of older prisoners;
the average age of those who died of natural causes was 58 compared to 37 for all other deaths;
there were 76 self-inflicted deaths, a welcome 16% decrease from the previous year, but high relative to recent years;
there were four apparent homicides, the same number as the previous year; and
a further seven deaths were classified as ‘other non-natural’ and eight await classification.

Nigel Newcomen said:

“It is remarkable that the fastest growing segment of the prison population is prisoners over 60 and the second fastest is prisoners over 50. Longer sentences and more late in life prosecutions for historic sex offences mean that this ageing prisoner profile – and rising numbers of associated natural cause deaths – will become an ever more typical feature of our prison system.”

“My investigations into deaths from natural causes have identified some lessons which have not previously been of such widespread importance. For example, the need for improved health and social care for infirm prisoners; the obligation to adjust accommodation and regimes to the requirements of the retired and immobile; the demand for more dedicated palliative care suites for those reaching the end of their lives; and the call for better training and support for staff who must now routinely manage death itself.”

On suicides, he said:

“The number of self-inflicted deaths in custody remains unacceptably high and, in 2014-15, there were still 38% more than in 2012-13. I am, therefore, pleased that the review of the Prison Service’s suicide and self-harm prevention (ACCT) procedures, which I called for in last year’s annual report, has begun. I am also pleased that Lord Harris’s important review of self-inflicted deaths among 18 to 24-year-olds in prison has been published. Together, these reviews should put suicide prevention in prisons centre stage and ensure that ACCT procedures – now over a decade old – are fit for purpose in a prison system with many more prisoners and fewer staff.”

The other principal part of the PPO’s remit is the independent investigation of complaints. In 2014-15, a substantial backlog of complaints was eradicated, and:

the total number of complaints received increased slightly to 4,964, a 2% increase on the previous year;
however, the number of cases accepted for investigation rose by 13%;
2,380 investigations were started, compared to 2,111 the year before;
overall, 2,159 investigations were completed, an 11% improvement compared to 2013-14;
39% of complaints were upheld, compared to 34% the previous year; and
the largest category of complaints was about lost, damaged and confiscated property, making up 28% of investigations.

Nigel Newcomen said:

“The types of complaint I am called upon to investigate vary year to year, although property complaints consistently predominate. Last year, there were more complaints about regime issues and transfers, which was predictable at a time of cutbacks and crowding. Perhaps of greatest concern was the 23% increase in complaints about staff behaviour, including allegations of assault and bullying.

“My staff have responded well to the increasing demands. Not only were almost all draft fatal incident reports on time (97%), we also eradicated a substantial historic backlog of complaints which has enabled a gradual improvement in complaint timeliness. These improvements have been achieved by changing the way we work, for example by being more proportionate and declining to investigate more minor complaints so we can focus on more serious cases and – of course – by the sheer hard work of my staff.

“There is much more to do, but we are well placed to deliver on our vision of supporting improvement in safety and fairness in prisons, immigration detention and probation, even at this particularly challenging time.”

The recommendations made as a result of PPO investigations are key to making improvements in safety and fairness in custody. The past year also saw the publication of a range of learning lessons publications which build on the analysis and recommendations in individual investigations to look thematically and more broadly at areas for improvement. Five of this year’s seven publications focused on self-inflicted deaths. Other publications explored learning from complaints about prisoners’ difficulties in maintaining family ties and why some groups of prisoners, such as women and children, rarely make complaints at all.

A copy of the report can be found on the PPO website. Visit www.ppo.gov.uk.

Jail suicides up by 64%

The number of suicides in jails in England and Wales increased by a “troubling” 64% last year, the prisons complaints watchdog has said.
As he published his annual report, Prisons and Probation Ombudsman Nigel Newcomen said the increase reflected the level of mental-ill health in prisons and “a rising toll of despair” among some prisoners.
Mr Newcomen said it suggested the need for the Prison Service to review its suicide and self-harm procedures.
Some 90 inmates took their own lives in the year 2013/14, up from 55 the previous year.
Commenting on suicides, Mr Newcomen said: “It has been suggested that prison staff are now so stretched, and the degree of need among some prisoners so high, that they may no longer be able to provide adequate care and support for some vulnerable prisoners.
“The evidence for this remains anecdotal and every day prison staff do save many prisoners from themselves – an achievement which goes largely unreported and without which the tragic number of suicides would be even higher.
“Nevertheless, the prison system is undeniably facing enormous challenges.
“It is nearly a decade since the Prison Service introduced its current suicide and self-harm procedures and, given the examples of poor implementation described in this annual report and the worrying increase in suicides, I believe it is time to review and refresh these arrangements.”
Mr Newcomen started 239 investigations into deaths in prison,immigration detention and probation service approved premises, 25% more than the previous year.
Of these, 130 deaths were from natural causes, up 7%, nine were classified as ‘other non-natural’ and a small number – six – await a cause of death.
And there were four homicides, twice as many as the year before.
In July, figures released by the Ministry of Justice painted a bleak picture of English and Welsh prisons with high levels of deaths in custody and a rise in the number of jails considered to be ”of concern”.
Juliet Lyon, director of the Prison Reform Trust, said: “If the tragic and rapid rise in the number of self-inflicted deaths in custody does not wake ministers up to the damage drastic cuts and rushed policy decisions are doing to the prison service and the people in its care, it is hard to know what will.
“It’s time to reserve prison for the most serious and violent offenders and to ensure that, wherever possible, people who are mentally ill are diverted into the care and treatment they so urgently need.”
Prisons minister Andrew Selous said: “Reducing the number of self-inflicted deaths in custody is a key priority and we are working hard to understand the reasons for the recent rise – but there is no simple explanation.
“We have a high proportion of people with mental health issues in the prison population and, as the case in society, the reasons behind any suicide are complex and individual.
“Young adults are a particularly challenging and vulnerable group, and that is why we have commissioned an independent review into the deaths of 18-24 year-olds in prison custody. “Every death is also investigated by the police and the Prisons and Probation Ombudsman and a Coroner’s inquest, with strenuous efforts made to learn lessons.”



Prisons must improve how they risk assess, monitor and care for prisoners to help prevent suicides, said Nigel Newcomen, the Prisons and Probation Ombudsman (PPO). Today he published two reports on the lessons that can be learned from PPO investigations into self-inflicted deaths in custody.

There has been a sharp and troubling increase in self-inflicted deaths in custody in recent months. In 2013-14 there were 89 self-inflicted deaths in prison, an increase of 37 (71%) on 2012-13 when there were 52. The PPO independently investigates the circumstances of all deaths that occur in prisons in England and Wales and identifies lessons that need to be learned to improve safety. The PPO also investigates complaints from those held in prison.

The first report, Learning from PPO investigations: risk factors in self-inflicted deaths in prisons, uses information from investigations into 361 such deaths investigated between 2007 and 2013. It examines the characteristics of those who died, the events in the 72 hours leading to their deaths, and the prisons’ approaches to assessing and managing risk. Although various different groups of prisoners were looked at, the findings about the assessment and management of their risk were broadly similar. Too often prison staff placed too much weight on judging how the prisoner seemed, or ‘presented’ rather than on indications of known risk, even when there had been recent acts of self-harm.

Other findings include:

  • risk changes over time and in response to context and events;
  • contact with health services was common in the final 72 hours and represents a key opportunity for suicide prevention;
  • prisoners often withhold their distress from staff and other prisoners, and processes must be in place to respond effectively when family or friends raise concerns;
  • reception screening needs to take fully into account concerns raised by police, escort services or the courts; and
  • Prison Service Instructions should list being held on remand as a risk factor and the risk factors for suicide and self-harm should be presented clearly and concisely.

The second report, Learning from PPO investigations: Self-inflicted deaths of prisoners on ACCT looks at 60 investigations where the prisoner was being monitored under the Prison Service suicide and self-harm prevention procedures, the Assessment, Care in Custody and Teamwork Plan (ACCT), at the time of their death. At any one time around 2% of the prison population are on ACCT monitoring. When implemented properly, ACCT provides a comprehensive, multi-disciplinary framework to address the underlying cause of a prisoners’ distress. To be effective, ACCT requires a concerted, joined-up and holistic approach. The report finds that the ACCT process was not correctly implemented or monitored in half the cases in the PPO sample.

Other findings include:

  • the goals in ACCT plans should be realistic, achievable and relevant;
  • the trigger and warning signs section should be completed on all ACCT plans and reviewed and updated as and when necessary;
  • staff from across the prison and agencies working within it should be encouraged to attend ACCT reviews and offer input into an individual’s care;
  • all staff who come into contact with an individual should be responsible for updating the ACCT plan if they feel that their risk of self-harm or suicide is heightened; and
  • all staff should be up to date on their ACCT training.

Nigel Newcomen said:

“While I recognise the challenges facing busy prison staff and that my investigations have the benefit of hindsight, too often we find that assessments of risk of self-harm place insufficient weight on known risk factors and too much on staff perceptions of the prisoner’s behaviour and demeanour. While the professional judgment of staff is an essential ingredient in ensuring safety in custody, better staff awareness, consideration and training about risk factors could improve safety in custody.

“Nearly a decade after the introduction of ACCT (and a range of other safer custody measures) which saw self-inflicted deaths in custody fall, such deaths have risen sharply in recent months. It is too early to be sure why this rise is occurring, but the personal crisis and utter despair of those involved is readily apparent, as is the state’s evident inability to deliver its duty of care to some of the most vulnerable in custody.

“Learning the lessons from these two reports ought to help the Prison Service improve the implementation of ACCT and ensure greater safety in custody. However, given the repeated weaknesses in practice we identify and the rising toll of self-inflicted deaths, I believe it is also now necessary for the Prison Service to review and refresh its safer custody strategy in general and ACCT in particular.”


  1. A copy of the reports can be found on the PPO website. Visit www.ppo.gov.uk.
  2. The PPO investigates deaths that occur in prison, secure training centres, immigration detention or among the residents of probation approved premises. The

PPO also investigates complaints from prisoners, young people in secure training

centres, those on probation and those held in immigration removal centres.

  1. Prison Service Instructions provide a detailed guide to suicide and self-harm prevention through assessment, monitoring, staff and peer support. First night and induction procedures are intended to provide extra support for prisoners who are newly arrived in custody. The instructions also specify a non-exhaustive list of factors and triggers that indicate prisoners are at heightened risk. This includes having a history of self-harm, mental health issues, substance misuse problems, certain offence types, receiving a life sentence and being in the early days of custody.
  2. Assessment, Care in Custody and Teamwork plan (ACCT) was introduced in 2005-06 and built on a previous monitoring system known as F2052SH, introduced a decade earlier.
  3. Contact us: Please contact Jane Parsons, PPO Press Office, on 020 3681 2775 or 07880 787452 if you would like more information, or email mail@ppo.gsi.gov.uk

Poor Management of Prisoners’ Property is Wasting Public Money Says Ombudsman

prison int gate

Prisons need to manage prisoners’ property better to avoid claims for compensation and the cost of investigating complaints, said Nigel Newcomen, the Prisons and Probation Ombudsman (PPO). He added that if prisons paid greater attention to their responsibility for prisoners’ property, this would avoid frustration for prisoners and the wasting of staff time on investigating complaints and arguing about compensation. Today he published a report on the lessons that can be learned about complaints received from prisoners about property

While the PPO investigates some very serious complaints, including assaults and racism – as well as all deaths in custody – the most common subject of complaint is lost or damaged property. These complaints also have the highest uphold rates where the PPO finds in favour of the prisoner. Over the past ten years, property complaints made up between 14% and 18% of all eligible complaints received. This proportion increased to 21% in 2012-13. The report, Learning from PPO Investigations: Property complaints, reviews property complaints received by the PPO in the first six months of 2012-13. 

The report highlights steps that prisons can take to improve:

  • ensure paperwork is completed correctly to record prisoners’ property so it can be reviewed if disputes arise;
  • recognise that possessions even if low value can have great importance to prisoners and should be managed according to Prison Service instructions;
  • follow Prison Service instructions about which religious items prisoners are allowed in their cells;
  • be proportionate when destroying items;
  • use photography more widely to better record which items prisoners hold and to reduce compensation claims.
  • respond effectively to prisoners’ complaints about lost or damaged property; and
  • accept responsibility when processes have not been followed, and when a prisoner is transferred, the sending prison should ensure that property arrives intact and undamaged at the receiving prison.

Nigel Newcomen said:

“Most property complaints concern small value items, but these can still mean a lot to prisoners with little. Unfortunately, too many of the issues involved could and should have been dealt with more quickly and efficiently by the prisons concerned. Instead, despite perfectly sound national policies and instructions, prisons too often refuse to accept their responsibilities when property has been lost or damaged. This leaves prisoners in limbo, creates unnecessary frustration and tension and leads to complaints, too many of which require independent adjudication. Using up scarce staff resources in this way, both in prison and then in my office, is not a good use of public money.”

A copy of the report can be found on the PPO website. Visit www.ppo.gov.uk.