Alan Whelan

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Alan Whelan,
a prisoner at HMP Leeds,
on 30 December 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 Alan Whelan was found hanged in his cell at HMP Leeds on 25 December 2024. He
was 41 years old. I offer my condolences to Mr Whelan’s family and friends.
Mr Whelan was the fifteenth prisoner to take his own life at Leeds in three years.
Mr Whelan had a history of self-harm, anxiety and paranoia. He believed that he was
under threat from other prisoners due to a historical offence and gave this as his reason
for self-harming. My investigation found some issues in the management of suicide and
self-harm prevention procedures (known as ACCT), particularly on 25 December. The
prison also failed to thoroughly investigate Mr Whelan’s claim that he was under threat or
support him appropriately.
Due to the high number of self-inflicted deaths at the prison, Leeds continues to be
supported by the regional and national safety teams to improve the quality of ACCT
management and support for those who feel at risk from others. I have previously
commented that this is much needed, but clearly there are still some issues that need to
be addressed.
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 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 4 July 2024, Mr Alan Whelan was remanded to HMP Doncaster charged with
coercive behaviour. This was not his first time in prison. On 6 August 2024, Mr
Whelan transferred to Dovegate.
2. Mr Whelan had a history of substance misuse, anxiety and paranoia and was
prescribed medication for his conditions. He also had a history of self-harm and
during his time at Dovegate he was subject to suicide and self-harm monitoring
(known as ACCT).
3. Mr Whelan had regular contact with his family by telephone; in particular, he spoke
to his mother regularly and he viewed this as significant in reducing his risk.
4. On 3 September 2024, Mr Whelan transferred to HMP Leeds on an open ACCT.
5. On his arrival, reception staff reviewed the ACCT document and it remained open
until 8 October, when they considered his risk had reduced and he no longer
needed the additional support. Staff applied for vulnerable prisoner status on Mr
Whelan’s behalf because he felt under threat from other prisoners due to a
historical offence.
6. During December, Mr Whelan’s self-harm and suicidal behaviour increased. Staff
started ACCT monitoring after he made cuts to his head, set fire to his cell and was
twice found with a ligature around his neck. As a result of setting fire to his cell, Mr
Whelan was moved to the segregation unit for his own safety. Mr Whelan continued
to say that he self-harmed because he felt under threat. Staff considered his fears
and found no evidence to support his belief. Mr Whelan accepted that he could be
paranoid due to historical heavy cannabis use. No further action was taken in
relation to his fears.
7. On 25 December, an officer was running late conducting Mr Whelan’s ACCT check.
At 11.24pm, he went to Mr Whelan’s cell and found his observation panel covered
and he was unable to get a response. The officer asked the night manager to attend
the wing. When the night manager and three other members of staff entered Mr
Whelan’s cell, they found him suspended by a ligature around his neck. At
11.28pm, they radioed a medical emergency code, released Mr Whelan from the
ligature and started CPR. Nursing staff attended and continued to treat Mr Whelan
until paramedics arrived at 11.36pm.
8. The paramedics established a pulse, but Mr Whelan remained unconscious. At
12.27am, he was taken to hospital and placed on life support.
9. At 6.51am on 30 December, a hospital doctor confirmed that Mr Whelan had died.
Findings
10. Mr Whelan had several risk factors for suicide and self-harm. He had a history of
self-harm and suicidal behaviour, substance misuse, anxiety, and paranoia. He was
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
twice monitored under ACCT procedures including at the time he was found
hanging. The management of the first ACCT procedures provided good support to
Mr Whelan, but we identified some deficiencies in the decision making and
management of the second process.
11. Although staff found no evidence to support Mr Whelan’s claims that he was under
threat from other prisoners, we found that the prison did not investigate his
concerns adequately.
12. The officer who conducted the last ACCT check on 25 December was 13 minutes
late and failed to provide a justifiable reason for this delay. Two other officers who
were required to conduct ACCT checks that morning falsified the ACCT document.
The investigator referred the officers’ actions to the police, who advised us that they
would not be investigating the matter. The prison is conducting an internal
investigation into the officers’ actions.
13. The clinical reviewer concluded that the physical and mental health care Mr Whelan
received at Leeds was equivalent to what he could have expected to receive in the
community.
Recommendation
• The Governor should provide training and guidance for duty governors on
segregation Defensible Decision Logs and how and when these should be
completed.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
14. HMPPS notified us of Mr Whelan’s death on 30 December 2024.
15. The investigator issued notices to staff and prisoners at HMP Leeds informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
16. The investigator visited Leeds on 7 January 2025. He obtained copies of relevant
extracts from Mr Whelan’s prison and medical records, along with CCTV and Body
Worn Video Camera (BWVC) footage.
17. The investigator interviewed 11 members of staff at Leeds on 24 and 25 February
2025.
18. NHS England commissioned a clinical reviewer to review Mr Whelan’s clinical care
at the prison. The clinical reviewer attended all interviews with the investigator.
19. We informed HM Coroner for Wakefield of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
20. The Ombudsman’s office contacted Mr Whelan’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. The family did not
respond.
21. An inquest into Mr Whelan’s death was concluded on 16 March 2026. A narrative
verdict was given, which stated:
Alan Joseph Whelan was found ligatured in his cell on 25 December 2024 and
subsequently died on 30 December at Leeds General Infirmary. It is possible that
loss of work was a trigger to Alan’s mental state and thought process. Following
previous incidents, we feel that observations should have been made more
regularly, and any ACCT reviews should have considered previous incidents. It
cannot be established that Alan not being more frequently observed probably
contributed to his death, but it is possible that it did so.
Admissions by MoJ
The prison officer conducting ACCT observations on Alan on the night of 25
December did not comply with the requirement to conduct one check at irregular
intervals every 60 minutes. By the time he conducted the check which led to Alan’s
discovery, it had been 1 hour and 11 minutes since the last check. It cannot be
established that this finding probably contributed to the death but may have done
so.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Leeds
22. HMP Leeds is a local prison holding male prisoners who are on remand, convicted
or sentenced. The prison serves the courts of West Yorkshire. Practice Plus Group
provides healthcare services, including mental health and substance misuse
services.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Leeds was in June 2022, which was followed
up by a review of progress inspection in July 2023. Inspectors said that since their
last inspection in June 2022, seven prisoners had taken their own lives and Leeds
now had the second highest rate of self-inflicted deaths of any prison in England
and Wales. The inspectors highlighted Prison and Probation Ombudsman reports
and outlined repeated failings in identifying risks when prisoners arrived. They
found unemployment and the long periods spent locked in their cells during the
weekend were common factors in many of the previous deaths. Inspectors noted
that leaders seemed unable to focus on these key issues while they were managing
an unwieldy plan with more than 100 recommendations from the various recent
reviews, audits and investigations that had followed the incidents.
Independent Monitoring Board
24. 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 December 2023, the IMB
reported that it remained concerned about the number of deaths at Leeds.
Previous deaths at HMP Leeds
25. Mr Whelan was the 23rd prisoner to die at Leeds since January 2022. Of the
previous deaths, seven were from natural causes, 14 were self-inflicted and one
was drug related. Up to the end of June 2025, there have been two further self-
inflicted deaths at Leeds since Mr Whelan’s death.
26. As a result of the self-inflicted deaths at Leeds, Yorkshire Prisons Group Regional
Safety Team and the National Safety Team are supporting Leeds to improve the
quality of ACCT management and support for those who feel at risk from others.
27. In previous investigations, we have found that Leeds needed to improve their
assessment and management of prisoners at risk of suicide and self-harm.
Previous clinical reviews have also found that improvement was needed to mental
health referral, assessment and treatment. The same issues were found in this
investigation.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Assessment, Care in Custody and Teamwork (ACCT)
28. Assessment, Care in Custody and Teamwork (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.
29. 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 identifying support actions is put in place. The ACCT plan
should not be closed until all the support actions on the caremap have been
completed.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
30. On 4 July 2024, Mr Alan Whelan was remanded to HMP Doncaster charged with
coercive behaviour. This was not his first time in prison as in December 2023, he
had been released from HMP Leeds. He transferred to HMP Dovegate on 6 August
2024.
31. Mr Whelan had a history of self-harm. Staff started suicide and self-harm monitoring
(known as ACCT) at Doncaster and Dovegate after Mr Whelan self-harmed by
cutting. He said that he felt under threat due to a previous offence and that other
prisoners had called him names.
32. On 3 September, Mr Whelan transferred to HMP Leeds on an open ACCT to
facilitate his court appearance.
33. On his arrival at Leeds, Mr Whelan went through the reception procedures. He had
a shower, a meal, and tried to call his mother but there was no answer. Mr Whelan
told staff that he was happy to be back at Leeds. The digital person escort record
(DPER – an electronic document that travels with a prisoner and records key
information about them) highlighted Mr Whelan’s risk factors, which included
previous self-harm, mental health issues, depression, anxiety and attention deficit
hyperactivity disorder (ADHD). Mr Whelan told staff that he wanted to apply for
vulnerable prisoner (VP) status because he was concerned he might be under
threat. Due to limited spaces on the VP wing, Mr Whelan was located on D wing
(induction wing).
34. Staff held an ad-hoc ACCT review. Mr Whelan said that his anxiety had reduced
now he was back at Leeds. He said that he had not seen his family for around nine
weeks, although he had spoken to them on the telephone. Staff agreed that ACCT
welfare checks would remain at two an hour until a full ACCT review could take
place.
35. On 4 September, Supervising Officer (SO) A chaired an ACCT review. Mr Whelan
and Nurse A from the mental health team attended. SO A recorded that Mr Whelan
engaged well and answered all questions openly. Mr Whelan said that he believed
he had been transferred to Leeds to facilitate a pre-trial hearing. He said he had
applied for VP status due to an offence he had committed when he was 17 years
old. He said that he was worried about being located on D wing. SO A reassured
him and explained that he would be located on D wing until space became available
on E wing, the VP overflow wing, due to the main VP wing (F wing) being full.
36. Mr Whelan said that he experienced paranoia which he blamed on 20 years of
cannabis use and that he intended to engage with the substance misuse team. Mr
Whelan said he was prescribed propranolol for anxiety and had previously been
prescribed sertraline (an antidepressant), but this had been stopped at Dovegate as
it was felt it was making his paranoia worse. Mr Whelan said that although he felt
anxious waiting for a decision on his VP status, he felt better now that he was at
Leeds. The review concluded that the ACCT would remain open with staff required
to check him once an hour and a further review would take place on 12 September.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
37. On 12 September, SO A chaired the ACCT review. Mr Whelan engaged well, and it
was recorded that his application for VP status had been accepted and he would be
moved to the overflow on E wing when space became available. Mr Whelan said
that he had been in contact with his mother, who he said was a source of support.
Mr Whelan said that he had a court appearance the following day but that he had
no concerns around this. SO A recorded that because Mr Whelan was still located
on D wing and the court appearance was taking place the following day, the ACCT
would remain open with staff required to check him six times throughout the night
and record their interactions with him during the day. A further review was
scheduled for 20 September.
38. On 20 September, SO B chaired the ACCT review in SO A’s absence. A member of
the mental health team attended. Since the last review, Mr Whelan had moved to E
wing. He said that he had not liked being on D wing and claimed that while on the
wing, prisoners shouted abuse at him, but he did not specify what this had been.
There were no entries in the ongoing ACCT record to support these claims. Mr
Whelan spoke about his positive relationship with his mother and brother, that he
wanted a fresh start and wanted to avoid returning to excessive alcohol and
cannabis use on his release. He said that while on D wing, he had made cuts to his
leg due to feeling stressed and described his current mood as low but said he had
no thoughts or plans of suicide or self-harm. Staff agreed that ACCT checks would
be increased to hourly, with a review scheduled for 1 October.
39. SO A, chaired the ACCT review on 1 October, and a member of the mental health
team attended. Mr Whelan said that he had been ‘up and down’, but he had not
self-harmed since the previous review. He was collecting his medication and all his
meals but said he was not leaving his cell much because he could hear people
talking about him. Mr Whelan accepted that he was experiencing paranoia. He said
that he had been speaking with his family daily and was hopeful that they would
book a visit. He spoke positively about completing the induction and said that he
was keen to work and keep busy. SO A told him that she would chase a work
placement with the activities team, but due to the large VP population, places were
limited. It was decided that the ACCT would remain open and ACCT checks would
remain at hourly, with a further review on 8 October.
40. On 8 October, Mr Whelan said he had been allocated a job in the workshops. He
spoke positively about the future and his family and denied any thoughts of suicide
or self-harm. Staff agreed that the ACCT could be closed. He also moved to the
main VP unit on F wing.
41. On 2 December, Mr Whelan was de-selected from his position in the textiles
workshop because he no longer met the criteria. Staff noted that following a review
of work placements, a decision was taken that only prisoners who were risk
assessed as low or medium could be allocated to the workshop. Mr Whelan had
been assessed as high risk prior to his arrival at Leeds and therefore no longer met
the criteria. Mr A, workshop instructor, noted that Mr Whelan had worked well
without any disruption for several weeks and when he was informed that he would
no longer be able to work there, he was compliant and showed a positive attitude.
42. At 8.40am on 19 December, Officer A, who knew Mr Whelan well, answered his cell
bell. On looking through the observation panel in the cell door, Officer A saw Mr
Whelan with blood dripping from his head. Officer A entered the cell and Mr Whelan
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
told him that he had self-harmed because he ‘had had enough of everything’.
Officer A alerted a nurse who was on the wing and shouted to his colleagues for
assistance. Mr Whelan said that he had used a razor to cut his head. The wound
was cleaned but did not require stitches. Anything sharp was removed from his cell.
Mr Whelan said that he had not been taking his anxiety medication. Officer A
opened an ACCT and checks were set at hourly, pending an assessment and initial
ACCT review. Mr Whelan was allocated a Listener (A prisoner who has volunteered
to be trained by the Samaritans to offer confidential support to prisoners in crisis).
43. At 11.00am on 20 December, SO A chaired the ACCT review along with Nurse B
from the mental health team. Mr Whelan said that he had self-harmed because he
was stressed about losing his job and had only been given a vague reason for it.
SO A sent an email to the activities team to explore why he had been removed.
They responded and explained the change in position. SO A noted that Mr
Whelan’s removal from employment had been a trigger for his recent self-harm.
While acknowledging his recent self-harm, Mr Whelan said that he was glad that he
was not dead. He said that he had chosen not to engage much with the wing
regime and preferred to spend time in his cell. He said that he was eating, drinking
and taking care of his personal hygiene. Mr Whelan also said that he felt people
were talking about him but acknowledged that he may be experiencing paranoia.
Staff agreed that observations would be reduced to one check every two hours and
the next ACCT review would be held on 2 January 2025.
44. Following the ACCT review, Nurse B recorded in Mr Whelan’s medical record that
that Mr Whelan had not shown any symptoms of an acute psychotic illness and
there was no indication of a mental health crisis at that time.
45. At 5.27am on 21 December, Operational Support Grade (OSG) A completed a
routine check on Mr Whelan and discovered that he had tied a ligature to the upper
part of his bed frame and around his neck and was lying on his back on his bed.
OSG A radioed a code blue (indicating a prisoner is unconscious or having difficulty
breathing) and immediately entered the cell. Officer B was the first to respond. The
ligature was not tied in such a way that it was putting pressure on Mr Whelan’s
neck, but he was clearly shaken. Nurse C attended and quickly established that an
ambulance was not required and Mr Whelan did not need medical intervention. Mr
Whelan told staff that two prisoners had recently moved onto the wing and they ‘had
it in for him’.
46. Custodial Manager (CM) A spoke with Mr Whelan. Mr Whelan said that he was
being bullied by a prisoner and gave a name. CM A asked an officer to check for
the named prisoner on E or F wing. There were two prisoners of that name at Leeds
but they were housed on different wings and staff were confident that Mr Whelan
would not have come into contact with them. There were no prisoners matching the
name on E and F wing.
47. When asked about his current thoughts of further self-harm, Mr Whelan said that he
was a ‘6 out of 10’ but he could keep himself safe. CM A noted from the previous
ACCT reviews that Mr Whelan experienced paranoia. Mr Whelan had mentioned
that he preferred to stay in his cell. CM A arranged for Mr Whelan to be referred for
a Challenge, Support and Intervention Plan (CSIP, a tool designed to manage
prisoners who are violent but, in some prisons, used to manage potential victims of
violence too) and the Safety Intervention Meeting (SIM, where complex or at risk
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
prisoners are discussed). Nurse C also noted on his medical records that Mr
Whelan had said that he was unsure whether he would self-harm again. Checks
were raised to twice an hour and the next ACCT review remained scheduled for 2
January.
48. On 23 December, SO C completed a CSIP investigation. He recorded that Mr
Whelan had been interviewed, but we were not provided with any evidence that he
was spoken to as part of the investigation process. SO C noted that he had spoken
to SO A, who was Mr Whelan’s appointed ACCT case manager, and had been told
that Mr Whelan was very paranoid and felt that staying in his cell was safer. SO C
concluded that no further action was necessary.
49. At 2.50pm on 24 December, Mr Whelan deliberately set a fire in his cell. Staff used
a fire hose to tackle the fire before they removed Mr Whelan from the cell. He was
initially unresponsive and staff called the emergency services. Once he had
recovered, Mr Whelan was assessed to have no injuries from the fire. He was
escorted without force to the segregation unit.
50. Mental Health Nurse D assessed Mr Whelan for the purposes of completing the
segregation safety algorithm (which assesses whether a prisoner can safely be
segregated). Nurse D noted that Mr Whelan said that he was being bullied on the
wing, had been raising this for a few days with no benefit, was struggling and said
that he wanted to die. Nurse D noted that Mr Whelan was on an open ACCT and
was now subject to five observations an hour in line with the segregation policy (set
out in Prison Service Order (PSO) 1700), but she did not deem him fit for a
prolonged stay in the segregation unit due to the increased risk to himself.
51. Mr B, the duty governor, attended the segregation unit, completed a defensible
decision log (which sets out the rationale for segregating someone on an open
ACCT) and recorded that Mr Whelan could not be located anywhere else in the
prison and that the segregation unit was the safest location to manage his risk at
that time. He recorded that he had considered alternative locations including other
wings and the healthcare unit, but due to Mr Whelan’s current risk level, they were
not appropriate, and that the decision for Mr Whelan to remain in the segregation
unit was considered by ‘all parties’ to be the safest (although Mr B did not detail
who the other parties were).
Events of 25 December
52. The following account has been taken from documentary evidence provided by
Leeds, CCTV and Body Worn Video Camera (BWVC) footage, medical records and
transcripts of interviews with staff.
53. At 10.30am on 25 December, SO C chaired an ACCT review. Mr C, the duty
governor, and mental health nurse Nurse A attended. The reasons for Mr Whelan
being located in segregation were recorded, and Mr Whelan said that he was happy
to engage with the review. Neither Mr C nor SO C had had any previous interaction
with Mr Whelan. SO C told the investigator that SO A (with whom he worked in the
safety team and who was on duty that morning) had told him about Mr Whelan’s
issues.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
54. Mr Whelan spoke about his family and said that he hoped that he would be able to
telephone his mother that afternoon. He said that recently, his sleep had been
broken and spoke about his paranoia and anxiety. Mr Whelan said that he had felt
that people were after him because they believed him to be racist. He had asked
staff to move him back to the VP overflow wing to avoid conflict. Mr Whelan said
that he was happy to remain in the segregation unit until a transfer to another prison
could be arranged. SO C said that this was not an option and that Mr Whelan would
need to return to the residential wing before a transfer could be arranged.
55. Mr Whelan talked about working and how he had enjoyed this until a change in the
risk assessment meant he could no longer be employed. It was recorded that Mr
Whelan was ‘future focused’ although the review did not record any conversations
around Mr Whelan’s current thoughts of further self-harm or further actions about
his mental health concerns. Staff decided Mr Whelan would be checked once an
hour. The next review date was left as 2 January. No updates were made to the
defensible decision log. When interviewed, all those present at the ACCT review
told the investigator that they were not aware that prior to Mr Whelan’s move to the
segregation unit, he had been subject to two ACCT checks per hour.
56. During the afternoon, Mr Whelan telephoned his mother from the unit phone
(segregation cells do not have in cell telephones). He told her that he loved her and
wished her a Merry Christmas. Mr Whelan’s mother told us that there was nothing
unusual in Mr Whelan’s tone or manner during the call. CCTV showed Mr Whelan
returning to his cell at around 2.20pm. This was the last time Mr Whelan was
captured on CCTV.
57. Segregation unit staff checked Mr Whelan every hour during the afternoon and
evening as part of the ACCT checks. Officer C, the night officer on the segregation
unit, checked Mr Whelan at 10.11pm and recorded no concerns.
58. At approximately 11.24pm, Officer C went to check on Mr Whelan and found his
observation panel to be covered. He called out to Mr Whelan but he did not
respond. Officer C radioed Custodial Manager (CM) B to attend. While waiting for
him to arrive, Officer C continued to check on other prisoners.
59. At 11.27pm, CM B arrived in the segregation unit along with Officer D, Officer E and
Officer F. CM B immediately entered Mr Whelan’s cell and found him hanging at the
back of the cell with a ligature around his neck made from bedding. At 11.28pm,
staff radioed a code blue and control room staff called an ambulance. CM B and the
officers supported Mr Whelan, removed the ligature, placed him on the floor and
started CPR.
60. At 11.28pm, Nurse E responded to the code blue. Nurse E noted that Mr Whelan’s
face was blue and he was cold to the touch. A defibrillator was applied which
advised there was no shockable rhythm.
61. At 11.36pm, paramedics arrived and took over treatment. They managed to regain
a pulse, but Mr Whelan remained unconscious. At 12.27am, Mr Whelan was taken
to hospital by emergency ambulance.
62. In hospital, Mr Whelan was placed on life support until a decision was taken to
remove treatment on 29 December.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
63. At 6.51am on 30 December, Mr Whelan died.
Contact with Mr Whelan’s family
64. Following Mr Whelan’s admission to hospital, the prison appointed Ms A as family
liaison officer. Ms A along with Officer G visited Mr Whelan’s mother’s address and
informed her that her son was in a serious condition in hospital. They drove her to
the hospital and arrived at around 11.00am. They remained with the family at the
hospital but later left so the family could be with Mr Whelan. Ms A remained in
contact with the family and after Mr Whelan’s death, arranged for the family to visit
the prison and collect his belongings.
65. The prison contributed towards funeral expenses in line with national policy.
Support for prisoners and staff
66. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner 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.
67. After Mr Whelan was taken to hospital on 26 December, Mr C 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 were also available to
offer support.
68. Staff reviewed all prisoners assessed as being at risk of suicide or self-harm. The
Samaritans were notified on 26 December that Mr Whelan had attempted to take
his own life and visited Leeds to offer support. Further support was provided on 30
December. There is evidence that Leeds followed postvention procedures.
Post-mortem report
69. The Coroner gave Mr Whelan’s cause of death as hypoxic ischaemic
encephalopathy caused by hanging.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of risk
70. At the time of Mr Whelan’s death, Prison Service Order (PSI) 64/2011 set out the
procedures (known as ACCT) that should be followed when a prisoner is identified
as being at risk of suicide and self-harm and listed risk factors and potential triggers
for suicide and self-harm. (In January 2025, the PSI was replaced by the Prison
Safety Policy Framework in which the assessment of risk and management of
ACCT procedures remain largely the same). The PSI said that all staff should be
alert to the increased risk of self-harm or suicide 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 ACCT
procedures.
ACCT management
71. When Mr Whelan arrived at Leeds, he had a number of significant risk factors for
suicide and self-harm including previous self-harm, mental health issues (paranoia
and anxiety) and a history of substance misuse. He transferred to Leeds on an
open ACCT.
72. Mr Whelan continued to be supported through ACCT monitoring until 8 October
and it provided effective support for him and Mr Whelan remained stable and ACCT
support was ended.
73. On 19 December, staff began ACCT procedures again after Mr Whelan self-
harmed. We identified some concerns about the decision making and management
of ACCT processes during the period that followed.
74. The case manager at the review on 20 December set the next review date for 2
January. We consider that this was too long a gap between reviews. The following
day, Mr Whelan was found to have tied a ligature around his neck. Night staff held
an ad-hoc case review and increased the frequency of welfare checks to two an
hour. They did not bring forward the date of the next scheduled review. Given that
there was a change in the method and potential lethality of Mr Whelan’s self-harm,
we consider that the amount of time between reviews was too long and the
frequency of checks was too low. We also consider that the actions recorded on the
care plan did not always sufficiently reflect discussions in the ACCT reviews.
75. On 24 December, Mr Whelan set fire to his cell and was moved to the segregation
unit and placed on five observations an hour, pending an ACCT review. The
following day, SO C chaired an ACCT review. SO C had not met Mr Whelan before
but said he was briefed by SO A. When staff present at the ACCT review were
interviewed, they said that they were not aware that prior to his move to the
segregation unit, Mr Whelan had been subject to two checks an hour. The record of
the ACCT review did not detail the reasons for Mr Whelan’s recent behaviour and
the assessment of his risk appeared to be largely based on his presentation at the
time. The review reduced the frequency of checks to one an hour, despite Mr
Whelan stating that he had set fire to his cell with the intent of taking his own life.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
76. We do not consider that SO C and the staff at the ACCT review on 25 December
adequately considered Mr Whelan’s increased risk or provided meaningful support.
While we consider that the frequency of checks was too low given Mr Whelan’s
recent behaviour, we do not think that there was sufficient evidence to suggest that
he should have been subject to constant supervision.
ACCT observations
77. Officer C was responsible for checking Mr Whelan on the night of 25 December. He
completed a check at 10.11pm but did not check Mr Whelan again until 11.24pm
(an hour and 13 minutes later). We cannot say for certain whether earlier
intervention would have made a difference in this case, but given paramedics were
able to regain a pulse and transfer Mr Whelan to hospital, it may have done. Officer
C’s actions on 25 December are subject to an ongoing internal investigation.
78. Following a recent PPO investigation, Leeds introduced an audit process to check
the accuracy of recorded ACCT checks against CCTV to ensure that there was not
a systemic issue with false entries or missing checks. Following Mr Whelan’s death,
CCTV from the segregation unit was viewed and identified that ACCT observations
recorded for Mr Whelan on the morning of 25 December had been falsified. The
investigator raised the issue of falsified ACCT checks with the police, who said that
they would not be investigating the matter. However, the actions of those staff
involved are the subject of an ongoing internal investigation.
79. Leeds have introduced various measures to improve the quality of ACCT
management since 2024. These include increased risks and triggers training and
additional suicide and self-harm training for prison staff. A new ACCT quality
assurance process was developed in May 2024 to better identify and manage
individuals' risks and identify staff who need support. The regional and national
safety teams have also provided more extensive guidance and resources to support
the prison, and this is ongoing.
80. Leeds has also introduced a detailed project plan which highlights all
recommendations from early learning reports, PPO reports and actions identified
internally by the prison as risks. These are used to record progress against actions
and evidence quality checks of all safety related processes. While we make no
recommendation to reflect the ongoing work at Leeds, we are concerned that Leeds
received additional support after a high number of deaths in 2023, continue to
receive support and have put in place more robust quality assurance processes yet
many of the same issues have been identified again in this investigation.
Segregation
81. Prison Service Order (PSO) 1700 Segregation states that a safety algorithm must
be completed in all cases where a prisoner is located in segregation within two
hours of the move. When a healthcare professional considers there are healthcare
reasons to advise against segregation and the duty governor considers that
segregation is appropriate for operational reasons, they must immediately chair a
case review to determine the prisoner’s location. The nurse who assessed Mr
Whelan did not consider him suitable for prolonged segregation.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
82. On 24 December, Mr B completed the decision log as required however, we found
he did not sufficiently explain his decision and what the exceptional circumstances
were for segregating Mr Whelan, against the nurse’s advice. The document
requires managers to outline what other locations were considered and why they
were deemed not suitable. Mr B detailed those areas he had considered but the
reasons for them being unsuitable were vague and unspecific (‘his current risk level’
and ‘the risk he posed to others’) without further exploration. The decision to
segregate Mr Whelan was not subject to a case review as it should have been. The
defensible decision log should have also been updated and signed daily by the duty
governor, but Mr C did not update or sign the log on 25 December. We make the
following recommendation:
The Governor should provide training and guidance for duty governors on
segregation Defensible Decision Logs and how and when these should be
completed.
Challenge, Support and Intervention Plans (CSIP)
83. At Leeds, individuals at risk of violence can be supported through a CSIP. When Mr
Whelan arrived at Leeds, he told staff that he felt under threat and continued to do
so during ACCT reviews and in general conversation. He was isolating or not
engaging in the daily regime, but a CSIP referral was not made until 21 December.
SO C recorded that he had completed the CSIP investigation to decide next steps,
but there is no evidence that he sought any further information, spoke to wing staff
or Mr Whelan. He concluded Mr Whelan’s concerns were the result of paranoia and
indicated there was no need for further action.
84. The Head of Safety and the regional safety team identified the quality of CSIP
investigations as an issue in a previous investigation and as a result, the prison
introduced a more robust quality assurance process and educated staff about the
need for thorough CSIP investigations and plans. Staff had received training on
CSIP prior to Mr Whelan’s death. Clearly there are still issues in this area that the
Governor will want to address to ensure that those systems are working as
intended.
Clinical care
85. The clinical reviewer concluded that the physical and mental health care Mr Whelan
received at Leeds was equivalent to what he could have expected to receive in the
community. She noted that Mr Whelan was a complex individual with a long-
standing history of impulsive and self-harming behaviour. The healthcare staff tried
to support Mr Whelan as best as they could, based on his presentation at that time.
86. The clinical reviewer has made no recommendations relating directly to Mr
Whelan’s care or linked to his death but has made recommendations to the Head of
Healthcare specifically about mental health assessments during ACCT reviews,
contemporaneous record keeping and multi-disciplinary communication between
the mental health and primary care teams. Some of the recommendations are
repeated, having been made in a previous review. We bring this to the Head of
Healthcare’s attention.
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Governor to note
87. Mr Whelan was removed from the textile workshop on 2 December, following an
internal risk review for workshops at Leeds. Mr Whelan clearly enjoyed his job and
received positive feedback about it. About two weeks after being removed he began
to self-harm, which he had not done since starting work. During ACCT reviews,
work was said to have been a supportive factor for him. Mr Whelan appeared
confused about why he had been removed and had not been found alternative
employment before his death. We consider that the handling of this issue was sub-
optimal. The Governor will wish to consider the learning.
Prisons and Probation Ombudsman 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE