Ahmed Alshbli

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ahmed Alshbli,
a prisoner at HMP Durham,
on 10 November 2022
A report by the Prisons and Probation Ombudsman
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© Crown copyright, 2025
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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 HM 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 Ahmed Alshbli died in University Hospital North Durham on 10 November 2022, after
he was found hanging in his cell in HMP Durham on 2 November. He was 35 years old. I
offer my condolences to Mr Alshbli’s family and friends.
Mr Alshbli was found hanged on the day he was remanded to prison for the first time. He
had harmed himself at court and arrived with his risk of suicide and self-harm clearly
flagged.
Although he was subject to suicide and self-harm prevention procedures when he died,
there were missed opportunities to identify the level of his risk.
This investigation identified issues with the reception process at Durham, similar to our
findings in the investigation into the death of another prisoner at Durham who died three
days before Mr Alshbli. I am concerned that, on more than one occasion during Mr
Alshbli’s short time at Durham, there seemed to be confusion about who was responsible
for making key decisions.
Durham is receiving additional support from HMPPS headquarters as a result of the
number of self-inflicted deaths there in the last 12 months. The learning from this
investigation can usefully inform considerations about staff training and suicide and self-
harm risk management.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman September 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 2 November 2022, Mr Alshbli was remanded to Durham for a range of offences,
including harassment and assault of his partner. It was his first time in prison. Mr
Alshbli had banged his head against a wall and tied a jumper around his neck at
court. On the way to prison, Mr Alshbli wrapped his seatbelt around his neck. He
arrived with a suicide and self-harm warning form.
2. When Mr Alshbli arrived at Durham, he said he had not intended to harm himself in
court and was just trying to avoid being sent to prison. The prison officer Mr Alshbli
spoke to assessed that he did not need the support of suicide and self-harm
prevention procedures (known as ACCT) but asked the mental health team for their
view.
3. A nurse completed Mr Alshbli’s initial reception health screening. She was not
aware of the suicide and self-harm warning form he arrived with, and Mr Alshbli said
he had no history of self-harm or mental health issues but was tearful. The nurse
did not have any serious concerns and did not start ACCT procedures.
4. A mental health nurse assessed Mr Alshbli later that day. He said he felt hopeless
and suicidal, though he said he had no intention to act on those feelings. The
mental health nurse began ACCT procedures with checks at least once every 30
minutes.
5. Just after 8.00pm, an officer completed an ACCT check on Mr Alshbli. He had
obscured the view into his cell, was partially out of sight, and had tied something to
the underside of the upper bunk bed. The officer requested emergency assistance
and went into the cell. Mr Alshbli said that he had tied a loop in which to rest his
legs and had no intention of harming himself. The obstruction was removed, and Mr
Alshbli was told not to obscure the view and not to tie anything to the bed. His risk
was not reassessed, and observations were not increased.
6. At a further check just before 10.00pm, Mr Alshbli was found hanging. Staff went
into the cell and tried to resuscitate him. Ambulance paramedics were in the prison
attending to another emergency, and they took over. Mr Alshbli was transferred to
hospital, where he died on 10 November.
Findings
Assessment of risk
7. Mr Alshbli arrived at Durham with a suicide and self-harm warning form, clearly
setting out his self-harm attempts at court and on the way to prison. However, not
all of the prison and healthcare staff responsible for receiving Mr Alshbli into prison
had access to all of the relevant information about him. The supervising officer who
did have full access appeared not to fully understand his responsibilities in relation
to ACCT and considered it to be primarily a mental health process.
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Assessment Care in Custody and Teamwork (ACCT)
8. When it was suspected that Mr Alshbli had tied a ligature to his bed, no one
member of staff took responsibility for considering the incident in light of Mr Alshbli’s
known risk factors and earlier behaviour at court. The frequency of checks was not
reassessed, and no other measures were taken to manage the risks.
9. Staff checked Mr Alshbli at regular intervals, making it easy for Mr Alshbli to predict
when he would next be checked.
Mr Alshbli’s healthcare
10. The clinical reviewer concluded that the healthcare provided to Mr Alshbli in
Durham was equivalent to that which he could have expected in the community.
11. She considered that reception nurses should have access to available risk
information on prisoners to complete effective risk assessments.
12. The clinical reviewer makes several clinical recommendations to improve processes
around risk management that the Head of Healthcare should address.
Recommendations
• The Governor and Head of Healthcare should review reception procedures to
ensure that all staff supporting individuals and completing initial risk assessments
have access to relevant information, including digital PERs, SASH forms and prison
records.
• The Governor and Head of Healthcare should ensure that staff responsible for
ACCT procedures comply with the following national policy requirements:
• assessing a prisoner’s risk based on their risk factors and not solely their
presentation;
• reassessing risk and observation levels after any indication of increased
risk.
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Durham informing
them of the investigation and asking anyone with relevant information to contact
him. There were no responses.
14. The investigator visited Durham and obtained copies of relevant extracts from Mr
Alshbli’s prison and medical records.
15. The investigator interviewed seven members of staff at Durham. He also
interviewed a member of staff on detached duty to another prison.
16. NHS England commissioned a clinical reviewer to review Mr Alshbli’s clinical care
at the prison. The investigator and clinical reviewer jointly interviewed healthcare
staff.
17. We informed HM Coroner for County Durham and Darlington of the investigation.
The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
18. The Ombudsman’s family liaison officer contacted a friend, whom Mr Alshbli had
noted as his next of kin, as well as Mr Alshbli’s brother, to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not have
any specific questions.
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Background Information
HMP Durham
19. HMP Durham is a local prison that receives men who are remanded or serving
sentences from courts in Tyneside, Durham and Cumbria. It has a maximum
capacity of 985 men. Spectrum Community Health provides primary healthcare
services. Tees, Esk and Wear Valleys Foundation NHS Trust provides mental
health services.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Durham was in November 2021. Inspectors
reported that serious staff shortages had affected all aspects of healthcare
provision. Inspectors also found that new prisoners often arrived late in the day and
a significant number did not receive an initial health screen before going to their
cells. The quality of care provided via ACCT procedures varied.
Independent Monitoring Board
21. 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 31 October 2022, the IMB
reported that Durham was generally a safe environment. There were concerns
about the lack of supervisors’ checks on ACCT documents.
Previous deaths at HMP Durham
22. Mr Alshbli was the eighth prisoner of HMP Durham to die since the beginning of
2021. One prisoner apparently took his own life three days before Mr Alshbli and we
have commented on the similarities in our learning in this report. The other deaths
were all due to natural causes. There have since been two further apparently self-
inflicted deaths.
23. Durham is currently receiving additional support from HMPPS headquarters due to
the number of self-inflicted deaths there in the last 12 months.
Assessment, Care in Custody and Teamwork (ACCT)
24. 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.
25. 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
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multi-disciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
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ACCT plan should not be closed until all the actions of the caremap have been
completed.
26. All decisions made as part of the ACCT process and any relevant observations
about the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction (PSI) 64/2011.
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Key Events
27. Mr Alshbli was a Syrian national who had been living in the UK since 2018. On 2
November 2022, he was remanded to HMP Durham charged with various offences
including harassment, assault and coercive behaviour in his relationship. This was
his first time in prison. Staff considered that Mr Alshbli spoke reasonable English,
and while he was not fluent, it did not inhibit communication.
28. At court, Mr Alshbli tied a jumper around his neck, punched walls and banged his
head against them. Custody officers put constant observation in place to prevent
him from harming himself. In the escort van, Mr Alshbli wrapped his seatbelt around
his neck. He arrived in Durham with a digital suicide and self-harm warning form
(SASH) detailing these events and highlighting the risks.
29. An officer took Mr Alshbli from the escort vehicle into reception, where he handed
over to colleagues who booked him in. Once Mr Alshbli had been booked in, the
officer provided Mr Alshbli with guidance on search procedures. Mr Alshbli said that
it was his first time in custody, and he had questions about how prison worked,
which the officer answered. The officer said that Mr Alshbli’s demeanour did not
cause him to have any concerns that he presented a risk to himself. He knew Mr
Alshbli had arrived with a SASH form, but as he was in a mobile role did not have
access to the digital form and therefore had not seen the details. He recorded that
Mr Alshbli was also advised of support available, including Listeners (prisoners
trained by the Samaritans to provide peer support), Samaritans and talking to staff.
30. A supervising officer (SO) interviewed Mr Alshbli to complete an initial risk
assessment. He referenced Mr Alshbli’s SASH and PER forms. Mr Alshbli told the
SO that the events in court and in the escort vehicle were misunderstood and he
had been wearing his jumper around his neck. The other actions had been to try to
prevent staff from taking him to prison, but he regretted them. Mr Alshbli said that
his alleged offence was committed against his ex-partner, and he was angry at her
and pleased that they were now separated. The SO asked if he had any thoughts of
harming himself, and Mr Alshbli said he did not. He mentioned protective factors
including his friends and his business, which he planned to return to. Mr Alshbli said
he had been nervous in the police station and in court but felt more comfortable in
prison now that he had spoken to staff. The SO explained the support that was
available, and Mr Alshbli said that he understood and knew how to ask if he needed
help. The SO recorded that Mr Alshbli explained the issues raised in the SASH form
and gave him no cause for concern during the interview. However, the SO asked a
mental health nurse to assess Mr Alshbli. (The SO did not turn up for his scheduled
interview, was then on long term sick leave and has now left the Prison Service. He
was not interviewed as part of the investigation.)
31. Mr Alshbli saw general nurse for a reception health screening. He said he had no
mental health issues or recent history of harming himself and had no plans to do so.
The nurse noted that the SO had referred Mr Alshbli to the mental health team to
assess whether he needed any support. Mr Alshbli said that he was angry at his
situation, saying that he felt hopeless. The nurse noted that he talked of protective
factors including his family and his children, but that his mood was low and that he
was tearful. She did not see the digital PER and was not aware that there was a
SASH form for Mr Alshbli. She said that she did not have any concerns that he
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might harm himself. The investigator was told that not all healthcare staff had
access to prisoners’ digital information because they did not have Nomis (the prison
record system) accounts.
32. Staff took Mr Alshbli to the First Night Centre. An officer gave Mr Alshbli his
induction interview, explaining the support that was available. He noted on Mr
Alshbli’s electronic record that he signed all the necessary paperwork and was in a
good mood with no thoughts of self-harm and no issues to raise.
33. Later in the day, a nurse from the mental health team met with Mr Alshbli. The
nurse also did not have access to any of Mr Alshbli’s records, including his PER
and SASH forms. He engaged well but was in a low mood and tearful. He said that
he had no mental health issues but felt suicidal. Mr Alshbli told the nurse he had no
plans to harm himself. Mr Alshbli spoke of his son as a protective factor but said
that he felt like he had lost everything: his family, his house, his car, his job. The
nurse judged that Mr Alshbli needed further support and opened ACCT procedures
with checks at least once every 30 minutes. She explained the support that was
available, and that someone from the mental health team would see Mr Alshbli the
following day.
34. A custodial manager (CM) was the wing manager on the First Night Centre. The
nurse told him that she had opened ACCT procedures for Mr Alshbli. She explained
her concerns and recorded them on the ACCT document. The CM said there were
several issues on the wing that evening and he did not see Mr Alshbli in person. He
completed the immediate action plan.
35. Mr Alshbli was taken to his allocated shared cell, but the occupant objected to
sharing so Mr Alshbli was taken to a double cell as a single occupant.
36. At 8.01pm, an officer completed an ACCT check on Mr Alshbli. He looked through
the observation panel and saw Mr Alshbli was sitting on the bottom bunk. He had
put a bed sheet up at the end of his bed, attached to the frame of the top bunk. This
obscured the view into the bottom bunk where he was sitting. He had tied his socks
together to form a long strand and tied the end to the underside of the top bunk,
forming a loop. He briefly saw Mr Alshbli’s face but when he called to him, Mr
Alshbli leaned back behind the sheet. He saw the tied socks go taut and felt
concerned that Mr Alshbli might have the other end tied to his neck. He radioed a
code blue emergency (meaning a prisoner is unconscious or having trouble
breathing and seeking assistance). As his colleague arrived, he unlocked and
entered the cell. Mr Alshbli had reclined on the bottom bunk and put his foot through
the loop, suspending his leg in the air.
37. The officer told Mr Alshbli why he was concerned and had entered the cell. He said
Mr Alshbli must be visible at all times. Mr Alshbli said that he had put his ankles into
the loop to stretch his legs, something he did frequently at home. He found it funny
that anyone would think he had tied something around his neck and said that it was
not the case. The officers removed the screen Mr Alshbli had tied to the bed and
told him that he should not tie anything to the bedframe. A CM went to the cell when
he heard the emergency call. When he arrived, he could see Mr Alshbli sitting
talking to the officers, so returned to his duties.
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38. A nurse also responded to the emergency call. As she approached Mr Alshbli’s cell,
prison officers told her that it was a false alarm. She decided to see Mr Alshbli
anyway and went into the cell. Mr Alshbli told her that he had tied the loop so he
could put his feet up and relax. She said that he was in a jovial mood and told her
that he was not attempting to harm himself and that he had not put anything around
his neck. She noted the torn bed sheet (which an officer confirmed that the officers
removed from the cell) and asked the prison officers if Mr Alshbli was under ACCT
management. They told her that he was. Staff left the cell. They did not make any
changes to the frequency of checks or take any other action.
39. At approximately 9.00pm, an officer carried out an ACCT check on Mr Alshbli. In
interview she said that Mr Alshbli was asleep. At approximately 9.30pm, she
returned for a further check and spoke briefly to Mr Alshbli, who told her he could
not get back to sleep. She had no concerns about him.
40. The officer returned for a further check at 9.58pm and saw Mr Alshbli hanging by a
jumper attached to his shower rail. She called a code blue emergency and she and
a fellow officer went into the cell. The emergency call prompted the control room to
call an ambulance. She said that she had difficulty cutting the ligature because it
was thick, but once she had managed to break it officers brought Mr Alshbli out of
the cell onto the landing to provide space for cardiopulmonary resuscitation (CPR).
CCTV footage showed that this was at 9.59pm. Other staff had responded to the
emergency call, including a nurse, and together they began to perform CPR.
Ambulance paramedics were already on the wing, having responded to another call
from the prison, and within a minute they joined the staff in attempting to resuscitate
Mr Alshbli. Further paramedics arrived and transferred Mr Alshbli to hospital.
Contact with Mr Alshbli’s family
41. The prison appointed a family liaison officer soon after Mr Alshbli’s transfer to
hospital. Mr Alshbli had noted a friend as his next of kin, so the following morning
prison staff contacted her. They also identified his brother and made contact to
share the news. Mr Alshbli’s family visited him in hospital.
42. Mr Alshbli remained on life support until 10 November. After discussion with his
family, doctors withdrew Mr Alshbli’s life support. Mr Alshbli died at 3.37pm that
day.
43. Prison staff were at the hospital when Mr Alshbli died. They engaged with his family
at the time and following his death. In line with Prison Service guidance, Durham
offered a contribution to the cost of the funeral.
Support for prisoners and staff
44. When Mr Alshbli went to hospital, a senior member of staff debriefed 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.
45. When Mr Alshbli died, prison managers spoke to staff who were at the hospital with
him. They offered support, but the staff declined a formal debrief.
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46. The prison posted notices informing other prisoners of Mr Alshbli’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 Alshbli’s death.
Post-mortem report
47. Post-mortem reports showed that Mr Alshbli died as a result of brain injury caused
by lack of oxygen due to hanging. Because he had been in hospital for some days
before he died, toxicology tests were not undertaken.
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Findings
Assessment of suicide and self-harm risk
48. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm, including violent offences against a
family member, first reception into custody and previous suicide attempts and self-
harm. It says all staff should be alert to the increased risk posed by prisoners with
these risk factors and should act appropriately to address any concerns. Any
prisoner identified as at risk of suicide and self-harm must be managed under
Assessment, Care in Custody and Teamwork (ACCT) procedures, for which there
are mandatory requirements.
49. Person Escort Records (PERs) are electronic or hard copy documents used to
share risk information when individuals move between police, court and prison
custody. PERs are a key source of information for new receptions and should
inform initial risk assessments completed by prison and healthcare staff. Suicide
and self-harm (SASH) warning forms highlight the particular risks for individuals
moving between police and prison custody.
50. Mr Alshbli presented several risk factors listed in PSI 64/2011. He arrived at
Durham with a PER and SASH warning form completed by the police, court and
escort staff, which noted head banging, wall punching and attempts to ligature at
court and in the escort vehicle. Mr Alshbli had been charged with offences against
his former partner, some of which were violent. He was a new arrival, and it was his
first time in prison.
51. It is clear that Durham has put efforts into ensuring reception processes are
comprehensive. Prisoners have a health check and are interviewed by at least one
senior prison officer and two nurses. They are assessed by a mental health nurse if
required. Mr Alshbli moved through each stage of the process. However, there were
issues with some staff accessing his information and some poor decision making,
particularly by the SO in reception.
52. Records suggest that the SO, the supervising officer responsible for interviewing
new arrivals that day, had access to all of the relevant information about Mr Alshbli.
However, he considered that ACCT monitoring was not necessary, largely it seems
on the grounds that Mr Alshbli said he had not really intended to harm himself –
despite the objective evidence saying something quite different. The SO asked the
mental health nurse to review Mr Alshbli, but it is not clear why. One interpretation
is that the SO considered ACCT to be a mental health process, which the guidance
makes clear it is not. Overall, we consider that the SO’s decision making was, at
best, poor and, at worst, fell far below the standard expected of a supervising
officer. Had the SO not already left the Prison Service, we might well have been
recommending that the Governor consider a disciplinary investigation into his
actions.
53. When the nurses in reception completed Mr Alshbli’s initial healthcare interview
they did not have access to his digital PER or SASH form, which they told us was
not unusual. They were therefore unaware of events in police custody, court and
during Mr Alshbli’s escort to prison. They could see that he had been referred to the
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mental health team by prison officers because this was recorded on the healthcare
system but did not explore the reasons for this. Healthcare noted Mr Alshbli’s low
mood and hopelessness but assessed that he did not present an increased risk of
harm to himself and did not require ACCT monitoring. Fortunately, despite also not
having access to the digital PER or SASH form, the mental health nurse promptly
began ACCT monitoring when Mr Alshbli mentioned low mood and thoughts of
suicide.
54. Durham is currently receiving additional support from HMPPS headquarters
because of the number of self-inflicted deaths there in the last 12 months. Risk
identification in reception has been identified as a key issue and additional training
has been provided to staff on risks, triggers and protective factors, with further
training to follow. The prison’s senior leadership team has implemented processes
to improve first night interviews and initial health screens and to ensure that every
prisoner is able to make a telephone call on their first night. These are welcome
initiatives, but the issue of appropriate access to vital digital information remains a
concern. We make the following recommendation:
The Governor and Head of Healthcare should review reception procedures to
ensure that all staff supporting individuals and completing initial risk
assessments have access to relevant information, including digital PERs,
SASH forms and prison records.
Increase in risk
55. PSI 64/2011 requires an urgent ACCT case review if an event or disclosure
suggests risk is likely to have increased.
56. An officer called a code blue emergency when he thought Mr Alshbli might have
ligatured in his cell. Mr Alshbli persuaded staff that he had not tied a ligature but
had been fashioning a support for his legs. He was right to be concerned about Mr
Alshbli’s behaviour, and his account of it should have continued to ring alarm bells
for the staff and led to a review of Mr Alshbli’s level of risk.
57. Following the incident, no one member of staff took responsibility for considering
the implications. The CM did not discuss the event with the officer (who said he did
not know about Mr Alshbli’s earlier behaviour in court). A nurse told us that once
she knew Mr Alshbli was already on an ACCT, she assumed prison staff would
review the frequency of observations. In the event, no one increased the frequency
of observations, which remained at once every thirty minutes.
58. We make the following recommendation:
The Governor and Head of Healthcare should ensure that staff responsible for
ACCT procedures comply with the following national policy requirements:
• assessing a prisoner’s risk based on their risk factors and not solely their
presentation;
• reassessing risk and observation levels after any indication of increased
risk.
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Mr Alshbli’s healthcare
59. The clinical reviewer concluded that the healthcare provided to Mr Alshbli in
Durham was equivalent to that which he could have expected in the community.
However, the clinical reviewer makes several recommendations to improve
processes around risk management that the Head of Healthcare should address.
Governor to note
60. PSI 64/2011 requires specific actions to be completed by a wing manager once an
ACCT has been opened. ACCT User Guidance advises staff to meet with the
prisoner and complete the Immediate Action Plan (IAP) within an hour. ACCT
managers must also open an alert on the prisoner’s electronic record that ACCT
procedures have begun. Prisoners should be provided with information on the
ACCT process and how it works, to ensure they understand the process and can
contribute to their risk management effectively.
61. Mr Alshbli’s ACCT manager completed the IAP within guideline timescales.
However, he did not seek any engagement with or input from Mr Alshbli. He was
also unable to confirm that Mr Alshbli had been given written material explaining the
ACCT process. We do not know how well Mr Alshbli understood the process, which
was new to him and would have benefited from his input.
62. ACCT guidance says that observations should be made at irregular intervals so that
they cannot be predicted by prisoners at risk of self-harm or suicide. The
observations completed for Mr Alshbli were all made around the hour and half-hour.
63. PSI 58/2010 says that the PPO should have unfettered access to Prison Service
data and information for the purposes of their investigations. Durham was unable to
provide us with copies of the digital PER and SASH forms.
64. The Governor will wish to consider and address these issues.
Inquest
65. The inquest, held from 14 to 18 October 2024, concluded that Mr Alshbli died by
suicide.
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