Alex Verdu Munoz

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Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Alex Verdu Munoz,
a prisoner at HMP Manchester,
on 15 May 2022
A report by the Prisons and Probation Ombudsman
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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 Alex Verdu Munoz was found hanged in his cell at HMP Manchester, on 15 May 2022.
He was 26 years old. I offer my condolences to Mr Munoz’s family and friends. Mr Munoz
was the third prisoner to take his own life at Manchester in three years.
Prison staff monitored Mr Munoz under suicide and self-harm prevention procedures
(known as ACCT) for much of his time in prison. He told staff that he had received
numerous threats from other prisoners, and he isolated himself as a result. The ACCT
procedures were generally supportive, and prison staff arranged a move to the healthcare
inpatient unit. Mr Munoz received particularly good support from a chaplain at Manchester.
While staff acknowledged Mr Munoz’s fear for his safety, and created an isolation plan to
support him, there is no evidence that they investigated the threats against him or sought
to identify and address the perpetrators. There was also a missed opportunity to provide
additional support through the key worker scheme.
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 April 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On 11 March 2022, Mr Alex Verdu Munoz (an Argentinian national) was charged
with murder and remanded to HMP Dovegate. He sustained serious leg injuries in a
car accident while being chased by police. Due to his offence, staff monitored him
under suicide and self-harm prevention procedures (ACCT) while in prison.
2. On 17 March, Mr Munoz was transferred to HMP Manchester. Staff at Manchester
kept the ACCT in place as a supportive measure. On 23 March, Mr Munoz reported
that he had been threatened by prisoners on the wing due to his offence. In
response, staff arranged a separate, isolated, regime for Mr Munoz and, on 14
April, transferred him to the healthcare inpatient unit when a space became
available.
3. On 13 May, Mr Munoz attended court as part of the ongoing legal proceedings
relating to his murder charge. The next day, a nurse completed a welfare
assessment as a precautionary measure following his court appearance. She raised
no concerns.
4. At around 9.15am on 15 May, a prisoner who was delivering canteen sheets saw
Mr Munoz hanging and shouted for an officer to attend his cell. The officer entered
the cell and cut the ligature. He told us that Mr Munoz showed no signs of life.
5. Three members of healthcare staff attended the cell and agreed that it was too late
to start cardiopulmonary resuscitation (CPR).
6. At around 9.30am, paramedics arrived and confirmed that Mr Munoz had died.
Findings
7. Some positive action was taken to support Mr Munoz through his time in prison.
The ACCT procedures were generally well managed, and staff identified quickly
that he was under threat from other prisoners. A prison chaplain provided
particularly commendable support.
8. However, there were some missed opportunities to provide additional support to Mr
Munoz. His isolation and management under ACCT procedures meant he should
have been recognised as a priority prisoner for key work, but he was not allocated a
key worker in line with expectations. While staff recognised that he was under
threat, there is little evidence that any action was taken to identify the perpetrators.
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The Investigation Process
9. We were notified of Mr Munoz’s death on 16 May 2022.
10. The investigator issued notices to staff and prisoners at HMP Manchester informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Munoz’s prison and
medical records.
12. The investigator interviewed 11 members of staff at HMP Manchester in December
2022 and January 2023.
13. NHS England commissioned a clinical reviewer to review Mr Munoz’s clinical care
at the prison. The majority of interviews were conducted jointly by the investigator
and clinical reviewer.
14. We informed HM Coroner for Manchester City of the investigation. We suspended
our investigation between 16 June and 29 November 2022 while awaiting the post-
mortem and toxicology reports for Mr Munoz. We have sent the Coroner a copy of
this report.
15. The Ombudsman’s family liaison officer contacted Mr Munoz’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. They
requested a copy of our report but did not have any specific questions.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy, and this report has been amended
accordingly.
17. Mr Munoz’s family received a copy of the initial report. They raised a number of
issues that do not impact on the factual accuracy of this report and have been
addressed through separate correspondence.
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Background Information
HMP Manchester
18. HMP Manchester is a high security prison which accepts category A and B
prisoners. The prison holds up to 744 men in nine residential units, a segregation
unit, specialist intervention unit and a healthcare unit. Greater Manchester Mental
Health NHS Foundation Trust provides 24-hour nursing care.
HM Inspectorate of Prisons
19. The most recent full inspection of HMP Manchester was in September 2021.
Inspectors reported that 25% of prisoners said they felt unsafe at the time of the
inspection and results for those with mental health problems or other disabilities
were significantly more negative than other prisoners.
20. Inspectors reported that the mental health team was responsive to demand,
promptly assessing patients and prioritising support. They noted that a dual
diagnosis pathway for patients with both mental health and substance misuse
needs was being used effectively.
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 28 February 2022, the IMB
reported that the prison had a steady decrease of self-harm in the early part of
2021, which mirrored trends shown across the prison estate throughout the COVID-
19 pandemic.
22. Self-harm rose sharply in September 2021, when COVID-19 restrictions were lifted
and has remained higher since then. This rise coincided with prisoners being
allowed to return to mixing in larger groups, visits recommencing and increased
Covid-related staff shortages. Initial analysis indicated that the stability of having
regular staff working with the prisoners and a predictable regime provided the
continuous support needed by prisoners who were struggling. To reduce this risk of
self-harm, the Head of Residence aimed to ensure that all prisoners being
monitored under suicide and self-harm prevention measures (ACCT) were allocated
a key worker to provide them with that stability of support on top of the usual ACCT
processes.
Previous deaths at HMP Manchester
23. Mr Munoz was the 20th prisoner to die at Manchester since May 2019. Eleven of
the previous deaths were from natural causes, three were drug-related, three were
self-inflicted and two were unascertained. Since Mr Munoz’s death, three more
prisoners have taken their own lives at Manchester.
24. Our report into the self-inflicted death of a prisoner in February 2022 identified that
he was the victim of an assault that was not properly investigated.
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Assessment, Care in Custody and Teamwork
25. 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
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
26. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the support actions have been completed. 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.
Key worker scheme
27. The key worker scheme aims to improve safer custody by engaging with prisoners,
building better relationships between staff and prisoners and helping prisoners
settle into life in prison. It provides that all adult male prisoners will be allocated a
key worker who will spend an average of 45 minutes a week on key worker
activities, including having meaningful conversations which each of their allocated
prisoners.
28. The key worker scheme was suspended across the estate on 24 March 2020 due to
the COVID-19 pandemic. To ensure that meaningful interaction continued for
priority prisoners, the Prison Service used an Exceptional Delivery Model until May
2022. This involved weekly conversations with prisoners identified as vulnerable
due to their risks or circumstances.
29. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan, which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
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Key Events
30. On 11 March 2022, Mr Alex Verdu Munoz was charged with murder and remanded
to HMP Dovegate (a Category B prison). According to his records, Mr Munoz had
been in the United Kingdom for around six weeks prior to committing his offence.
He reported having no criminal record in his home country of Argentina. A prison
chaplain who knew Mr Munoz well told us that he spoke good English and was able
to hold reflective, theological conversations in English.
31. After committing the alleged offence, Mr Munoz sustained serious leg injuries in a
car accident while being chased by police. He was prescribed codeine for pain relief
but, following a risk assessment, was not allowed to keep his medication in
possession in prison. He attended regular GP and nurse appointments while in
prison, to assess and treat his injuries.
32. At Mr Munoz’s initial healthcare screening, the nurse submitted an automatic
referral to the mental health team. Prison staff began monitoring him under suicide
and self-harm prevention procedures (ACCT) due to the nature of alleged offence.
Observations were set at a minimum of three per hour, with three quality
conversations per day.
33. On 14 March, staff transferred Mr Munoz from the induction unit to the segregation
unit pending a transfer to a Category A (high security) prison. Due to being in
segregation, staff increased Mr Munoz’s observations to a minimum of five per
hour.
34. The next day, Mr Munoz attended an initial ACCT assessment and said that he had
never spoken to a mental health professional or counsellor before. He reported
having no emotions and said he could not laugh or cry properly. He said that the
COVID-19 lockdown had exacerbated his feelings of hopelessness. Mr Munoz
refused to answer questions about any previous trauma he may have experienced
and said he had no thoughts of suicide or self-harm.
HMP Manchester
35. On 17 March, Mr Munoz was transferred to HMP Manchester while still under
ACCT monitoring. The reception nurse completed an initial health screening. She
recorded that Mr Munoz engaged well. She raised no immediate mental health
concerns. She added that Mr Munoz should be allocated a “low level” cell because
he was using crutches and had restricted mobility.
36. A mental health nurse completed Mr Munoz’s mental health triage assessment. Mr
Munoz told her that he had no thoughts of suicide and self-harm and was coping
well with being in prison. She referred him to the mental health team for a full
assessment due to the nature of his offence.
37. On 18 March, a mental health nurse completed Mr Munoz’s full mental health
assessment. She recorded that she had no concerns about Mr Munoz’s mental
health and noted that his ACCT remained in place as a supportive measure. An
ACCT review took place later that day, which reduced Mr Munoz’s observations to
five nightly observations and four quality conversations per day.
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38. Mr Munoz was recovering from an open fracture to his shin bone and had
contracted methicillin-resistant staphylococcus aureus (MRSA - a type of bacteria
that is resistant to several widely used antibiotics) while in hospital. Therefore, staff
decided that Mr Munoz was not fit for work or cell sharing. They allocated him a cell
on E Wing (a standard residential unit).
39. On 21 March, an officer recorded that Mr Munoz was “quite clearly a target and
under threat” on E Wing due to his offence, which had received national media
coverage. The officer noted that a move to the prison healthcare centre was
necessary to ensure Mr Munoz was supported while recovering from his injuries.
The move was not possible at the time due to lack of space. He noted that officers
were trying to facilitate a separate regime for Mr Munoz in the meantime, to
separate him from other prisoners. There was no evidence of any further action to
identify who Mr Munoz might be at risk from, or to address any negative behaviour
directed at him.
40. On 23 March, at an ACCT case review, Mr Munoz reported that he felt “fine” and
said he had started reading the Bible. However, he said he had been threatened by
prisoners on the wing due to his offence. Staff had now arranged a separate regime
for Mr Munoz and assured him that he would be moved to the healthcare centre as
soon as a space became available. Staff decided to keep the ACCT open with the
same level of observations.
41. Staff opened a self-isolation plan to record Mr Munoz’s daily regime. The next
ACCT review meeting took place on 30 March. Mr Munoz said that he was
concerned he may become addicted to his codeine medication. In response, staff
agreed to put measures in place to support him with advice and support when this
medication was eventually reduced. Mr Munoz reported that his mental health was
“fine”, and he had no intention of harming himself. Staff decided to keep the ACCT
open with the same level of observations.
42. On 13 April, prison staff held Mr Munoz’s next ACCT case review. They recorded
that Mr Munoz was making progress but that the ACCT should be kept open due to
his upcoming trial and lack of family support in the UK. Observations were reduced
to three quality conversations per day and four observations at night.
Move to Inpatients’ unit
43. On 14 April, Mr Munoz was transferred to the healthcare inpatient unit when a
space became available. Staff closed Mr Munoz’s self-isolation plan, however they
continued to monitor him under ACCT procedures.
44. On 27 April, Mr Munoz’s first ACCT review on the healthcare unit took place,
attended by a Supervising Officer (SO) (the ACCT case coordinator), a nurse, a
prison chaplain and Mr Munoz. Mr Munoz told the group that he had been
threatened by prisoners on the healthcare unit due to his offence. With Mr Munoz’s
consent, the SO agreed to facilitate a separate regime where Mr Munoz would be
kept apart from other prisoners. He warned Mr Munoz that this could restrict his
time out of his cell, but Mr Munoz said he was okay with this. He recorded in the
ACCT document that staff would observe prisoners closely to see if they could find
out who was making threats towards Mr Munoz. Mr Munoz told the group that he
had no thoughts of suicide and self-harm and would speak to staff if this changed.
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45. The chaplain confirmed that Mr Munoz was working with chaplaincy and completing
an education course, which he was positive about. Mr Munoz told the group that he
was writing a novel, watching television, and exercising in his cell to distract himself.
She said she would continue to support Mr Munoz through regular contact. The
group agreed that Mr Munoz’s ACCT should remain open with the observations set
at three daily observations and conversations and four observations during the
night.
46. On 5 May, Mr Munoz’s next ACCT review meeting took place. The review was
attended by the new ACCT case coordinator, the chaplain and Mr Munoz. Mr
Munoz told the group that prisoners were shouting names during the night, but he
did not know if they were talking about him. He said he was content in his own
company. Mr Munoz said he was due to see his solicitor the next day to find out
more about his upcoming court appearances. He said he had not been in contact
with his family in Argentina, but that his solicitor kept him updated about them. He
said he saw the chaplain regularly, was writing a lot and taking the necessary steps
to get involved in education classes. With a court appearance looming and no
family contact, the group agreed to keep the ACCT open with the same level of
observations. They set the next case review for 19 May.
47. On 13 May, Mr Munoz attended court as part of the ongoing legal proceedings
relating to his murder charge.
48. On 14 May, a nurse completed a welfare assessment on Mr Munoz as a
precautionary measure following his court appearance. Mr Munoz said that he was
fine. She did not raise any concerns about Mr Munoz and found him to be pleasant
and polite during the conversation. Mr Munoz said that he did not have any
thoughts of suicide or self-harm and she noted that no other concerns had been
raised by officers on his landing. Mr Munoz was due to attend court on 16 May, and
there was a documented plan for a mental health nurse to complete a welfare check
on his return. For the rest of the day, officers continued their ACCT checks on Mr
Munoz as normal and raised no concerns.
49. At around 9.30pm, an officer completed the first of four overnight ACCT checks for
Mr Munoz. In interview, he told us that Mr Munoz was sitting up watching television.
He had a brief conversation with Mr Munoz and raised no concerns.
50. At around 11.30pm, the officer completed the second ACCT check on Mr Munoz
and recorded that he was asleep in bed, noting signs of movement. He raised no
concerns.
51. The officer completed two further ACCT checks at around 3.00am and 5.00am. On
both occasions he saw that Mr Munoz was asleep and noted signs of movement.
He raised no concerns.
Emergency response
52. CCTV shows that, at 7.10am on 15 May, an officer completed the first of the daily
ACCT observations on Mr Munoz. He told us that Mr Munoz was lying in bed with
the television on. He said that Mr Munoz did not acknowledge him, however, he
noted that his chest was moving up and down. He raised no concerns and
continued with his ACCT checks.
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53. At around 8.30am, an officer started collecting outstanding canteen sheets from
prisoners on the healthcare unit, assisted by a prisoner. At around 9.15am, the
prisoner reached Mr Munoz’s cell and shouted for the officer to join him. The officer
ran to the cell and looked through the observation panel in Mr Munoz’s cell door. He
was lying on the cell floor with a ligature around his neck, attached to the bedframe.
The officer immediately radioed a medical emergency code blue, which triggered
the control room to telephone an ambulance. He entered the cell and cut the
ligature. He told us that Mr Munoz showed no signs of life.
54. Another prisoner on the healthcare unit quickly approached a healthcare assistant,
a nurse, the Deputy Inpatient Manager and a social care worker, who were nearby
at the treatment room. Within seconds, the three members of healthcare staff
attended the cell and were told by the officer that it was too late to start
cardiopulmonary resuscitation (CPR), which the other staff agreed with. The nurse
checked for a pulse but could not find one. She confirmed that there was clear
evidence of rigor mortis in Mr Munoz’s body.
55. At around 9.30am, paramedics arrived and quickly confirmed that Mr Munoz had
died.
56. Police attending Mr Munoz’s cell found a note written in Spanish. The note was
addressed to Mr Munoz’s family and indicated that his intention was to take his life.
Contact with Mr Munoz’s family
57. Manchester nominated a prison family liaison officer (FLO). After initially struggling
to find up-to-date contact details for Mr Munoz’s family in Argentina (he had not
telephoned his family from prison), she identified their telephone number. She broke
the news of Mr Munoz’s death to his sister at around 9.00am on 16 May 2022.
58. Manchester contributed to the cost of Mr Munoz’s funeral in line with national
HMPPS policy.
Support for prisoners and staff
59. After Mr Munoz’s death, the an operational 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.
60. The prison posted notices informing other prisoners of Mr Munoz’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 Munoz’s death. Staff
spoke to the prisoner who found Mr Munoz hanging in his cell and offered him
support, which he declined. However, the prisoner asked for an inter-prison
telephone call with a family member which staff facilitated for him.
Post-mortem report
61. The post-mortem report concluded that the cause of Mr Munoz’s death was
hanging. The toxicology examination found nothing significant in Mr Munoz’s
system.
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Findings
Management of risk of suicide and self-harm
62. Prison service Instruction (PSI) 64/2011 ‘Managing Prisoner Safety in Custody’
requires that staff who have contact with prisoners are aware of the risk factors and
triggers that might increase suicide and self-harm, so that they can take relevant
action. Risk factors include violent offences and first entry into prison. The PSI
requires staff to start ACCT procedures where they identify an increased risk of
harm.
63. Staff appropriately began ACCT procedures when Mr Munoz first arrived in prison
charged with murder and continued monitoring him under ACCT procedures when
he arrived at Manchester. He was an Argentinian national who had spent only a
matter of weeks in the United Kingdom before his remand, so there was no
documented health history available, and Mr Munoz did not disclose any history of
or thoughts of suicide or self-harm. Case reviews were multidisciplinary and
involved a range of staff who knew Mr Munoz and could make good quality
contributions.
64. At his final ACCT case review on 5 May 2022, Mr Munoz appeared well, was
making future plans and was positive about his regular contact with the prison
chaplain.
65. The chaplain told us that she suspected Mr Munoz may have felt isolated due to
being on a separate regime. Striking a balance between Mr Munoz’s safety (due to
the alleged threats he was receiving) and managing the impact of isolation on his
wellbeing was difficult. Prison staff made consistent efforts to respond to Mr
Munoz’s specific needs in challenging circumstances by moving him to the
healthcare inpatient unit and implementing a separate regime while monitoring his
wellbeing through the ACCT process. After his initial concerns about threats from
other prisoners, Mr Munoz appeared to settle on the healthcare unit. He told staff
that he was content in his own company and did not exhibit any obvious signs that
he was in crisis.
66. Prison staff rightly completed welfare checks following Mr Munoz’s court
appearances, which might have increased his risk of harm to himself. A nurse had
no concerns about his wellbeing and told us that he appeared “quite unremarkable”.
67. We do not consider that prison or healthcare staff missed any opportunities to
identify an imminent risk of harm.
Good practice
68. Despite Mr Munoz repeatedly and consistently denying that he had any thoughts of
self-harm, prison staff took account of wider known risk factors and kept the ACCT
procedures open. This is a good example of staff recognising that what a prisoner
says is not a reliable indicator of their likelihood of self-harm.
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Clinical care
69. The clinical reviewer concluded that the clinical care provided to Mr Munoz at
Manchester was equivalent to that which he could have expected to receive in the
community. She makes recommendations on issues that did not impact on Mr
Munoz’s death, for the Head of Healthcare to address.
Good practice
70. We were impressed by the dedication shown by the prison chaplain. She provided
excellent support to Mr Munoz throughout his time at Manchester and displayed
genuine concern for his safety and wellbeing. She took time to build a meaningful
relationship with Mr Munoz through frequent contact. We commend her for her
efforts.
Governor to note
Key work
68. One of the main aims of the Key Worker Scheme is to improve prisoner safety
through meaningful contact with a consistent member of staff. The scheme usually
requires 45 minutes of key work per prisoner per week, delivered by a named
officer. Despite being a prisoner remanded for murder under ACCT monitoring, Mr
Munoz was not allocated a key worker at Manchester.
69. The Exceptional Delivery Model in place for key work during the Covid-19 pandemic
was stood down in March 2022 and key work was expected to be rolled out again in
full from April 2022. The IMB Annual Report for the year to February 2022 notes
that the Head of Residence at Manchester was aiming to ensure that all prisoners
being monitored under ACCT procedures were allocated a key worker to provide
them with further stability on top of the usual ACCT processes.
70. Mr Munoz spent two months at Manchester, during which time he did not receive
any key work. In interview, an operational manager at Manchester told us that Mr
Munoz should have been allocated a key worker when he came on to the
healthcare inpatient unit. He said that failure to do this had been an oversight.
71. Another operational manager told us that key worker delivery has fluctuated since
the pandemic but has never been above 30 per cent. She identified various reasons
for this, including staff sickness, priority escorts for Category A prisoners and
provision of staff on detached duty. She identified that Manchester has reviewed
prisoner groups who are priorities for key work and that this now includes those who
are isolating (which would have included Mr Munoz). She told us that Manchester
now allocates staff on restricted duties (such as those with health conditions that
might prevent them from completing some wider duties) to key work to achieve
better completion.
72. Key work might have provided Mr Munoz with an opportunity to develop a
meaningful relationship with another named member of staff and to share his
concerns. We note the chaplain was able to develop a relationship with Mr Munoz,
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which he reflected on positively. However, it is important that Manchester is
supported to roll out key work in full, in line with national HMPPS policy.
Threats to Mr Munoz
73. Mr Munoz isolated himself from other prisoners as a result of threats he said he had
received. Staff recognised that he was under threat, with one officer recording that
Mr Munoz was “quite clearly a target”.
74. Manchester has a local violence reduction policy which states that they will identify
and support those who are victims of violence. This should include those under
threat of violence. The policy states that all incidents should be reported correctly,
with investigations and actions undertaken.
75. Prison staff recognised that Mr Munoz needed additional support when he was
under threat and some positive action was taken. While Mr Munoz did not name
any of the apparent perpetrators of threats against him, there is little evidence that
any investigation was undertaken to identify them or to take action to address the
issue. Given that it was clear to staff that his fears, particularly when he lived on E
Wing, had some substance, this was a significant omission.
Inquest
76. The inquest into Mr Munoz’s death finished on 13 May 2026 and concluded that he
died as a result of suicide.
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