Aaron Taylor

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Aaron Taylor,
a prisoner at HMP Garth, on 28
August 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Aaron Taylor was found hanged in his cell on 28 August 2023 at HMP Garth. He was
32 years old. I offer my condolences to Mr Taylor’s family and friends.
Mr Taylor was recalled to prison seven months before he died. He struggled with being in
prison and the potential length of his sentence. He was supported by HMPPS suicide and
self-harm monitoring procedures on three occasions while at HMP Garth.
My investigation found there was a missed opportunity for further suicide and self-harm
monitoring following a self-harm incident three weeks prior to Mr Taylor’s death. However,
I am satisfied that there was no particular evidence to indicate that Mr Taylor’s risk of
suicide had dramatically increased in the days before his death.
This version of my report, published on my website, has been amended to remove the
name of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 3 January 2023, Mr Aaron Taylor was recalled to HMP Preston for breaching his
licence conditions relating to a 10-year sentence for wounding with intent. He had a
history of self-harm.
2. Prison staff managed Mr Taylor under Prison Service suicide and self-harm
monitoring procedures (known as ACCT) when he arrived at Preston after he told
them that he intended to self-harm and would kill himself given the chance.
3. On 7 February, Mr Taylor transferred to HMP Garth after reporting being sexually
assaulted by a prisoner at Preston. He lived on the prison’s Residential Support
Unit and was supported by ACCT procedures a further two times.
4. On 4 August, Mr Taylor self-harmed. Staff did not start ACCT procedures.
5. At around 7.20pm on 27 August, an officer saw Mr Taylor in his cell during the
evening routine check. The night officer did not do the morning routine check
between 5.00am and 6.00am.
6. At 8.07am on 28 August, an officer unlocking prisoners’ cells for work, opened Mr
Taylor’s observation panel and found it to be obstructed. The officer did not attempt
to gain a response from Mr Taylor and continued unlocking prisoners.
7. Another officer was one minute behind and was conducting routine welfare checks
on prisoners. When she saw that Mr Taylor’s observation panel was obstructed, she
entered his cell and saw that he had ligatured from the light fitting. The officer
immediately radioed a medical emergency code and untied the ligature. The first
two staff that arrived at the cell decided not to start cardiopulmonary resuscitation
(CPR) because it was clear that Mr Taylor had died. The third officer arrived and
started CPR. Healthcare staff arrived shortly after and agreed that CPR was not
appropriate. Ambulance staff arrived at 8.30am and confirmed that Mr Taylor had
died.
Findings
8. Mr Taylor had been subject to ACCT monitoring three times at Garth. Staff
managed the process well; multi-disciplinary reviews were held and actions to
address his immediate needs were completed.
9. Mr Taylor self-harmed three weeks before he died, but staff did not start ACCT
procedures. However, Mr Taylor did not present as in crisis in the days before his
death and we do not think there was sufficient evidence for staff to consider him a
high suicide risk.
10. The officer on night duty did not complete the morning routine check and falsified
records to say that he had.
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11. The officer who was unlocking prisoners for work the morning Mr Taylor died did not
take appropriate action when he found that Mr Taylor had covered his observation
panel, and he did not attempt to gain a response from him.
12. The clinical reviewer concluded that Mr Taylor’s clinical care was equivalent to what
he could have expected to receive in the community. She found his risk of self-harm
and suicide was high.
Recommendation
• The Head of Healthcare should ensure that all healthcare staff are aware of their
responsibilities regarding ACCT procedures, including communicating with wing
staff if there are concerns around suicide and self-harm.
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The Investigation Process
13. HMPPS notified us of Mr Taylor’s death on 28 August 2023.
14. The investigator issued notices to staff and prisoners at HMP Garth informing them
of the investigation and asking anyone with relevant information to contact her. Five
prisoners responded. Two prisoners asked to remain anonymous.
15. The investigator obtained copies of relevant extracts from Mr Taylor’s prison and
medical records and viewed CCTV and body worn video camera (BWVC) footage.
She also obtained the HMPPS Early Learning Review and HMPPS Investigation
Report.
16. NHS England commissioned a clinical reviewer to review Mr Taylor’s clinical care at
the prison.
17. The investigator interviewed three members of staff at Garth in February 2024. She
and the clinical reviewer jointly interviewed healthcare staff. The investigation was
transferred to another investigator.
18. We informed HM Coroner for Lancashire and Blackburn with Darwen of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
19. The Ombudsman’s office contacted to Mr Taylor’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Taylor’s family
did not have any questions but asked for a copy of this report.
20. Mr Taylor’s family received a copy of the initial report. The solicitor representing Mr
Taylor’s family did not provide a response.
21. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Garth
22. HMP Garth is a category B training prison and holds long-term and life-sentenced
prisoners. It is part of the Long-Term High Security Estate (LTHSE). Greater
Manchester Mental Health NHS Foundation Trust provides physical health, mental
health, social care and clinical substance misuse treatment 24-hours a day and
seven days a week. Delphi is subcontracted to provide psychosocial substance
misuse services. There are seven residential wings and a segregation unit next to
the prison’s healthcare department. Prisoners live in single cells.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Garth was in November 2022. The inspection
noted that the Residential Support Unit and Building Hope Unit provided
targeted support for vulnerable prisoners and those re-entering mainstream
conditions, respectively. The number of places on the Residential Support Unit had
increased since the previous inspection, so that more vulnerable prisoners could be
accommodated. These units provided calmer environments and offered valuable
input from psychology services to support prisoners. However, the daily regime and
the frequent planned or unplanned cancellations of unlocking prisoners’ cells limited
the potential to provide structured activities that would support progression. Self-
isolators were managed and supported well, and residential staff had more day-to-
day input into their care.
24. Inspectors reported self-harm had reduced since the last inspection in 2019. The
safer custody department had worked hard to deliver training to staff in the new
version of assessment, care in custody and teamwork (ACCT) case management
for prisoners at risk of suicide and self-harm, but in practice the quality of support
delivered was inconsistent. Assessments were usually good, but care plans, risks
and triggers were often incomplete, and some daily interactions and supervisor
checks were missing. Leaders were aware of this, and work was under way to
address the issues. Most prisoners who were or had been subject to ACCT
monitoring were positive about staff support.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 30 November 2022, the IMB
reported they did not identify any significant issues in relation to how well prisoners’
health and well-being needs were being met. The IMB noted that the number of
deaths at the prison had reduced compared to previous years. There was a death in
custody plan in place, against which, good progress was being made.
26. The safer custody department had delivered training to staff regarding the new
ACCT procedures. Many prisoners had complex issues and were subject to ACCT
procedures. Complex case meetings took place for prisoners who were identified as
having significant needs and vulnerabilities, with a view to either continuing or
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varying the ACCT process. Healthcare representatives and prison staff took part in
assessments and the support of prisoners subject to the ACCT process, which
clearly worked well. The IMB monitored this area and attended assessment
meetings by invitation.
Previous deaths at HMP Garth
27. Mr Taylor was the 15th prisoner to die at Garth since August 2020, and the third
self-inflicted death. By the end of April 2024, there had been two self-inflicted
deaths since Mr Taylor’s death.
Assessment, Care in Custody and Teamwork
28. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
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Key Events
29. On 11 December 2015, Mr Aaron Taylor was sentenced to 10 years in prison for
wounding with intent. On 5 November 2021, Mr Taylor was released from HMP
Preston. On 3 January 2023, he was recalled to HMP Preston for breaching his
licence conditions.
30. When he arrived at Preston, Mr Taylor said he had thoughts of suicide and would
kill himself given the chance. Staff started Prison Service suicide and self-harm
monitoring procedures (known as ACCT). Observations were set at four per hour
and three meaningful conversations throughout the day. Mr Taylor engaged well
with the ACCT reviews and staff provided ongoing support.
31. Between 6 and 8 January, staff put Mr Taylor under constant supervision due to his
lack of engagement with the ACCT process. Once he started to engage again, his
observations reduced to four per hour.
32. On 11 January, staff from the Offender Management Unit (OMU) told Mr Taylor he
was subject to a full recall, which meant he would have to serve another seven
years in prison. Mr Taylor struggled with this information and said that he ‘did not
have it in him’ and would not be around to serve the sentence. Staff continued to
observe Mr Taylor four times per hour and have three meaningful conversations
with him per day. Staff noted he engaged with the regime and interacted with his
peers.
33. On 3 February, Mr Taylor told staff that another prisoner had sexually assaulted
him. His clothing was taken as evidence, and he was taken to Royal Preston
hospital. Mr Taylor told staff he did not have any thoughts of self-harm or suicide. A
few days later, the police interviewed Mr Taylor and offered the opportunity to stay
at the Safe Centre at Royal Preston hospital, but he declined. (Mr Taylor refused to
name the perpetrator and so the police investigation did not proceed.)
HMP Garth
34. On 7 February, Mr Taylor transferred to HMP Garth.
35. The ACCT remained opened following Mr Taylor’s transfer from Preston. That day,
Healthcare staff completed his initial health screen and referred him to the mental
health team, drug and alcohol services and the GP. Mr Taylor had an extensive
history of impulsive reactions to situations and his needs were complex. He had a
history of self-harm by cutting himself, ligaturing and ingesting foreign objects. Mr
Taylor was allergic to wasp stings and was prescribed an epi-pen.
36. A mental health nurse completed a mental health assessment. The nurse noted
there were no current concerns or risks to Mr Taylor or others. There was no
evidence of current mental health issues, thoughts of self-harm or suicide. The
nurse noted Mr Taylor was on an ACCT and told him how to contact support
services.
37. On 8 February, Mr Taylor told staff that he had been assaulted in his cell. He would
not disclose who the perpetrator was, but said he believed the assault was because
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of the on-going investigation into the incident at Preston and that he had been
labelled a ‘grass’. Mr Taylor had abrasions to his head and torso and healthcare
staff assessed and treated him. Mr Taylor said he would not self-isolate, however
staff applied for him to move to the Residential Support Unit (for vulnerable
prisoners that need additional support with mental health, debt, personality
disorders or learning difficulties) so that his contact with the general prison
population was carefully managed.
38. On 9 February, Mr Taylor moved to the Residential Support Unit. Staff gave him
distraction packs and encouraged him to find employment on the wing, but he
declined. He generally kept to himself and said that he did not like to mix but would
come out of his cell for showers and to collect meals.
39. Mr Taylor had a generalised anxiety assessment, and the result indicated he had
moderate anxiety. As a result, a GP at the prison prescribed Citalopram 20mg (an
antidepressant) on 13 February. The GP referred Mr Taylor to Manchester
Survivors (which supports male victims of sexual assault) and to the psychology
team to address the incident at Preston.
40. On 21 February, Mr Taylor’s ACCT was closed because he became more settled.
41. Between March and May staff started ACCT monitoring twice because Mr Taylor
had self-harmed by making superficial cuts to his arms. Mr Taylor told staff his
‘head had gone’. On both occasions, Mr Taylor was well supported by staff. The
care plan (designed to identify the main areas of concern and the actions required
to reduce risk) included that he should maintain contact with external support, such
as his family and partner, keep his mind busy with distraction packs and apply for
work. Observations were appropriately staggered with the frequency amended to
reflect Mr Taylor’s mental state and care needs at the time. Mr Taylor kept in
regular contact with his mother, sister and partner, and staff helped to maintain this
contact on the occasions he ran out of phone credit. Mr Taylor’s ACCT was closed
on 2 May. During his post-closure review staff noted that he said he felt better as he
was engaging with his peers and the regime, and he had no thoughts of suicide or
self-harm.
42. Between May and July, Mr Taylor self-isolated twice because he felt under threat on
the wing and for being in debt (there is no further information in his prison file about
the nature of the debt). Staff offered regular support to him. His keyworker also saw
him regularly. On 7 June, Mr Taylor moved to another part of the Residential
Support Unit, which he said he was happy with.
43. On 4 August, Mr Taylor dismantled his epi-pen, filled the chamber with faeces and
injected it into his left forearm. Mr Taylor asked an officer to take him to see
healthcare staff. Mr Taylor had a lump on his hand but did not tell the officer what
the lump was, or that he had injected himself with faeces.
44. The officer took Mr Taylor to the medications hatch to see a nurse. Mr Taylor did
not verbally tell her what had happened but passed her a note. The nurse said Mr
Taylor’s arm looked swollen and he explained what he had done with the epi-pen.
Because she was occupied dispensing medications, she told him to leave it with
her, and the officer took Mr Taylor back to his cell. Once the nurse had finished, she
went to the healthcare unit and informed a prison GP, who gave Mr Taylor an
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emergency appointment. The nurse said when she saw Mr Taylor in the healthcare
unit and spoke to him about his intent, he did not really engage, would not maintain
eye contact and was looking down. She did not start ACCT monitoring. She told the
investigator that she assumed the officer had done so. (The officer did not know
what Mr Taylor had done at that time). The incident was not documented in Mr
Taylor’s electronic prison record, or the wing observation book.
45. The prison GP discussed Mr Taylor with an on-call microbiologist. He then
examined Mr Taylor and prescribed antibiotics and pain relief. Mr Taylor said that
he was not suicidal and was more concerned about his physical health.
46. On 5 August, a task was sent to the mental health team to review Mr Taylor. The
task was marked as ‘completed,’ but there is no entry in his medical record to
suggest that the mental health team saw him.
47. On 11 August, healthcare staff noted that Mr Taylor’s wound was smelly and black
in the centre, and he subsequently attended Royal Preston hospital for surgical
intervention. He returned to Garth the following day.
48. On 23 August, staff recorded that Mr Taylor was settled on the Residential Support
Unit and engaged well with staff and his peers. Mr Taylor said he wanted
employment in the workshop and was advised to contact the activities department
to discuss this.
49. Mr Taylor made a few phone calls between 23 and 25 August. The investigator
listened to recordings of the calls and noted nothing of concern. Mr Taylor did not
make any phone calls in the 48 hours preceding his death. He did not receive any
visits at Garth.
Events of 27 and 28 August
50. On 27 August, the Residential Support Unit was on a ‘split regime’ due to low
staffing levels (for safety reasons, only a certain number of prisoners are allowed
time out of their cell in the morning and then the remainder have time out of their
cell in the afternoon). Mr Taylor had time out of his cell in the morning, but after
lunch at around midday, he was locked in his cell for the remainder of the day.
51. CCTV shows that at approximately 7.20pm, Officer A completed the evening routine
check and said Mr Taylor was lying on his bed. He did not document the routine
check in the wing observation book. This was the last time Mr Taylor was seen
alive.
52. As Mr Taylor was not on an open ACCT, staff were only required to check him
during the routine check at around 5.00am or if he pressed his cell bell. Mr Taylor
did not press his cell bell on the evening of 27 August or the morning on 28 August.
53. Officer A was responsible for completing the routine checks and observing
prisoners on ACCT monitoring procedures at regular intervals during the night. He
recorded that he had completed routine check between 5.00am and 6.00am and
observed two prisoners on ACCT through the night. CCTV shows that he did not
complete these checks. Following a prison internal investigation, he was dismissed
from the Prison Service. We wrote to him, but he did not respond, so we have not
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been able to interview him as part of this investigation. We informed the police of
the falsified checks.
54. At approximately 8.07am on 28 August, Officer B unlocked prisoners for work, while
Officer C conducted the welfare checks and was one minute behind Officer B.
55. Mr Taylor did not need to be unlocked for work as he was not employed. Officer B
said that he accidentally opened Mr Taylor’s observation panel. He saw that Mr
Taylor’s observation panel was blocked with tissue paper. He told the investigator
that he did not think anything of it as prisoners on the Residential Support Unit often
blocked their observation panels (under national policy, prisoners are not allowed to
block their observation panels). He continued to unlock prisoners for work.
56. Officer C arrived at Mr Taylor’s cell around a minute after Officer B. She saw that
his observation panel was blocked and opened his cell door to do a welfare check.
She saw that Mr Taylor had ligatured from the light fitting using bedsheets, and
immediately radioed a code blue (indicating a prisoner is unconscious or is having
breathing difficulties). Control room staff called an ambulance immediately. Officer
B returned to the cell.
57. Officer C used her anti-ligature knife to try to cut the ligature. It was too tight, so she
untied the knot. Mr Taylor had clear signs of rigor mortis, so both officers decided
not to start cardiopulmonary resuscitation (CPR). Another officer arrived and did not
feel comfortable not to conduct CPR and started compressions until healthcare staff
arrived. When healthcare staff arrived, they advised the officer to stop CPR
because there were clear signs that Mr Taylor had died.
58. At 8.30am, paramedics arrived and confirmed that Mr Taylor had died.
Information received after Mr Taylor’s death
59. Mr Taylor left three notes in his cell. The first note was addressed to staff asking
them to telephone his mother and partner. Mr Taylor apologised to staff for having
to find him and thanked them for their support. The second note was to his mother
and the third to his partner. Mr Taylor indicated in the notes that it was his intention
to die.
60. Mr Taylor had hidden a piece of wood in his cell. The wood had holes through it at
either end, and he had tied what looked like shoelaces through it. He had then put
his bedsheet through and fashioned a ligature. He had glued the wood to the ceiling
of his cell and the light fixture.
61. A Custodial Manager (CM) said that fabric checks are done daily by staff just before
the routine check. (Fabric checks are carried out to ensure a cell’s physical
condition is up to standard.) The last fabric check was completed just before
7.20pm on 27 August. Staff do not search the cell for illicit items during these
checks. It is not unusual for prisoners to have wood glue as they can buy it from the
canteen to use during purposeful activity such as model making. As the
accommodation fabric checks are not an in-depth search of the cell, it appears Mr
Taylor had hidden the wood and staff did not see it. We note that staff were not
conducting an in-depth search of the cell and so it is reasonable that they would not
have found the piece of wood Mr Taylor had hidden.
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Contact with Mr Taylor’s family
62. The prison appointed a family liaison officer (FLO) and an officer as assistant family
liaison officer. On 28 August, they both visited Mr Taylor’s mother to inform her of
her son’s death, offered their condolences and explained the next steps that would
follow.
63. The prison contributed towards Mr Taylor’s funeral costs in line with national policy.
Support for prisoners and staff
64. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
65. The Early Learning Review identified that Garth did not initiate Postvention
procedures and parts of the contingency plan were not completed. There was a
delay in the Samaritans entering the prison to offer support to staff and prisoners
following Mr Taylor’s death.
66. A prison manager debriefed the staff involved in the emergency response to ensure
they had the opportunity to discuss any issues arising, and to offer support. The
staff care team also offered support.
67. The prison posted notices informing other prisoners of Mr Taylor’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Taylor’s death.
Post-mortem report
68. The post-mortem report gave Mr Taylor’s cause of death as hanging. The
toxicology report did not detect any illicit substances in Mr Taylor’s blood or urine.
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Findings
Assessment of Mr Taylor’s risk of suicide and self-harm
69. Mr Taylor had been at Garth for almost seven months when he died. He was a
vulnerable prisoner but had external support from his family and partner. He felt
angry for being recalled to prison after 14 months in the community and he was
worried about the length of time he would have to serve in prison before he was
eligible for release.
70. Prison Service Instruction (PSI) 64/2011 on safer custody, requires all staff who have
contact with prisoners to be aware of the triggers and risk factors that might increase
the risk of suicide and self-harm, and take appropriate action. Mr Taylor had several
of these risks including being a recalled prisoner, relationship instability, previous self-
harm, impulsiveness, and feelings of hopelessness.
71. Mr Taylor was supported by ACCT procedures when he arrived at Preston, after he
told staff he would attempt suicide in prison if he got the chance. At Preston, Mr Taylor
alleged he had been sexually assaulted; however, he would not engage with police
and so the investigation did not proceed.
72. Mr Taylor remained on ACCT procedures when he transferred to Garth. Shortly
after arriving, he was physically assaulted by other prisoners and was moved to the
Residential Support Unit for vulnerable prisoners. He was supported by ACCT
procedures on two further occasions at Garth. We found that on both occasions, Mr
Taylor was well supported by staff. Actions to address Mr Taylor’s immediate needs
were added to a care plan and actioned, and notes of conversations were detailed.
Observations were appropriately staggered with the frequency amended to reflect
Mr Taylor’s mental state and care needs at the time. Mr Taylor’s last ACCT was
closed on 2 May.
73. Mr Taylor self-harmed on 4 August when he injected himself with faeces. Due to a
lack of communication between prison and healthcare staff, no one started ACCT
procedures. An officer did not know that Mr Taylor had self-harmed. A nurse said
that she knew that Mr Taylor had self-harmed but had assumed prison staff had
initiated the ACCT process. She said that on reflection, she should have followed
this up and checked if an ACCT had been opened. We consider an ACCT should
have been opened and staff missed an opportunity to offer Mr Taylor more targeted
support. We recommend:
The Head of Healthcare should ensure that all healthcare staff are aware of
their responsibilities regarding ACCT procedures, including communicating
with wing staff if there are concerns around suicide and self-harm.
74. However, we consider that there was no particular reason for staff to be concerned
about Mr Taylor in the days before his death, or to consider his risk of suicide to be
raised.
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Blocked observation panels
75. An HMPPS Safety Briefing on Observation Panels, issued in February 2018, says
that local safety measures should explain what staff should do if the occupant of a
cell cannot be seen due to the panel being covered or blocked. It goes on to say that
when staff discover that a panel has been blocked, and the prisoner does not comply
with instructions to remove the blockage, they must take immediate action to remove
the obstruction and check on the prisoner’s welfare.
76. The Governor at Garth issued an Order to staff in February 2022 about best
practice when staff find observation panels are blocked. The Order reiterates the
guidance set out in national policy. It says that if staff find observation panels
obstructed, they must make an attempt at dialogue with the prisoner and try and
see through the sides or top of the door if possible. Repeated obstruction of the
observation panel should be managed through the Incentives and/or the
adjudication policy and document it on NOMIS. If the prisoner does not respond to
requests to remove the obstruction, staff must radio for assistance to enter the cell,
or if they feel there is a risk to life, to make a dynamic risk assessment whether to
enter the cell alone. Staff must not leave the cell door unless it is to raise the alarm.
77. A CM said prisoners at Garth do block their observation panels, for a variety of
reasons. He said that, for the most part, staff stayed at the door until they got a
response and that it was not the norm for staff to carry on their duties after finding a
blocked observation panel.
78. Officer B said he was not surprised to find Mr Taylor’s observation panel blocked as
prisoners often did it on the Residential Support Unit and so it did not immediately
cause concern for him. He said he was aware of the Governor’s Order, but as he
was unlocking prisoners for work and knew Officer C was behind him, he carried on
without ensuring Mr Taylor’s welfare. Officer B said that, on reflection, he would
now react immediately, regardless of what task he was undertaking. The prison
conducted an internal disciplinary investigation into Officer B’s actions and
concluded he should receive advice and guidance. We do not make any further
recommendations about this.
Routine checks
79. Routine checks are primarily a visual security check to count prisoners to ensure
that they are present in their cells, but they are also an opportunity for any concerns
about a prisoner’s safety to be identified and managed. HMPPS’ National Security
Framework expects welfare checks to take place at routine checks including that
staff are able to see the prisoner’s face and confirm that they are alive and well.
There are four routine checks per day to ensure the number of prisoners in the
prison is correct. Two of these checks are done by the night staff between 7.00 -
8.00pm and 5.00 - 6.00am.
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80. An officer conducted a routine check at 7.20pm on 27 August 2023, and noted Mr
Taylor lying on his bed. It is a requirement for the routine check to be noted in the
wing daily diary, but he did not do this. Mr Taylor did not need additional monitoring
or welfare checks through the night and did not press his cell bell, so his next
routine check would have been at between 5.00 - 6.00am. CCTV shows that the
officer did not complete the morning check and falsified the records to say that he
had done so. He was subsequently dismissed from the Prison Service.
Clinical care
Mental and physical healthcare
81. The clinical reviewer concluded that Mr Taylor’s clinical care at Garth was, in the
main, of a reasonable standard and equivalent to what he could have expected to
receive in the community. She found that due to Mr Taylor’s extensive history of
very impulsive reactions to certain situations, his needs were complex. This,
combined with his history of self-harm, impulsive behaviour and previous custodial
sentences, meant his risk of serious self-harm and suicide was high.
82. On 5 August, a task was sent to the mental health team to review Mr Taylor. The
task was marked as completed, but there is no evidence in his medical record to
suggest the mental health team saw him.
83. The clinical reviewer made recommendations about post hospital care and record
keeping, which we do not repeat in this report, but which the Head of Healthcare will
wish to address.
Good practice
84. Mr Taylor’s location on the Residential Support Unit was appropriate and met his
complex needs. He was a vulnerable prisoner, who needed additional support with
his mental health needs and periods of self-isolation. He was noted to be a quiet
prisoner who generally kept to himself. There are detailed entries in Mr Taylor’s
prison case notes which show he was well supported by staff during his time on the
Residential Support Unit.
85. At the inquest, which took place between 20 and 29 October 2025, the Coroner
concluded that Mr Taylor died by suicide.
Prisons and Probation Ombudsman 13
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