Amos Ndemo

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Independent investigation into
the death of Mr Amos Ndemo,
a prisoner at HMP Norwich, on
10 December 2023
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
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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 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 Amos Ndemo was found hanged in his cell on 10 December 2023 at HMP Norwich. He
was 26 years old. I offer my condolences to Mr Ndemo’s family and friends.
Mr Ndemo’s behaviour for the first few months he was at Norwich was unusual,
challenging, and unpredictable, but this was managed effectively by staff. From
September, it appeared that Mr Ndemo was settling into the prison regime and said he
was looking forward to his upcoming release (although the date of this had not been
confirmed). There were no obvious triggers to Mr Ndemo taking his own life in December. I
am satisfied that staff could not have foreseen his actions.
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 August 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. Mr Amos Ndemo was a Kenyan national in the UK on a skilled workers visa,
employed as a nurse. On 16 May 2023, Mr Ndemo was arrested for harassment
offences and was taken into police custody. The next day, he appeared at court and
was remanded to HMP Norwich. It was his first time in prison. On his arrival, Mr
Ndemo told a nurse that he did not have any thoughts of suicide or self-harm, but
that he had a history of mental health issues. The nurse referred him to the mental
health team.
2. On 19 May, a mental health nurse assessed Mr Ndemo. The nurse noted that he
was anxious, agitated, confused, and that he had said “life was not worth living”.
The nurse started Prison Service suicide and self-harm prevention procedures,
known as ACCT. The next morning, Mr Ndemo said that he was missing his friends
and family in Kenya and felt like he had lost everything by coming to prison.
3. Mr Ndemo behaved in an unusual, inappropriate, and paranoid manner. Staff were
concerned about his mental health, and he was allocated a mental health co-
ordinator and referred to a psychiatrist. On 29 May, staff closed Mr Ndemo’s ACCT
as they no longer assessed him as a risk to himself.
4. In June, a psychiatrist assessed that Mr Ndemo was suffering from psychosis which
was likely to have been drug induced. Over the next few months, Mr Ndemo’s
behaviour became increasingly challenging. He continued to make inappropriate
sexual remarks towards female members of staff, assaulted a prisoner and a
member of staff, damaged prison property, flooded his cell and smeared faeces
around it. His behaviour was managed well by prison staff, and he was regularly
seen and reviewed by the mental health team.
5. Towards the end of September, Mr Ndemo’s behaviour started to settle. On 14
November, Mr Ndemo was convicted of stalking (several victims) and his case was
adjourned until 20 December for sentencing. Mr Ndemo told staff that he was
hoping to receive a short custodial sentence or be released.
6. On 21 November, Mr Ndemo spoke to his keyworker about his plans for the future.
Mr Ndemo said that he was settled on the wing and was enjoying working in the
production workshop. On 4 December, Mr Ndemo said that he would like to speak
to the mental health team about his anxiety, so the keyworker requested a GP
appointment on his behalf. The GP application was received and processed but did
not get to the Mental Health Team until 11 December
7. On 10 December at 11.30am, an officer discovered Mr Ndemo suspended from his
window by a ligature. The officer called a code blue (a medical emergency code
used when a prisoner is unconscious or having breathing difficulties) and control
room staff requested an ambulance immediately.
8. Seconds later, three prison officers responded to the code blue and entered Mr
Ndemo’s cell. They cut the ligature, lowered Mr Ndemo to the floor and started
chest compressions. Healthcare staff arrived and continued CPR. Mr Ndemo had
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signs of rigor mortis. At approximately 11.45am, paramedics arrived at Mr Ndemo’s
cell and, at 11.46am, the paramedics pronounced that Mr Ndemo had died.
Findings
9. On his arrival at Norwich, staff were concerned about Mr Ndemo’s mental
wellbeing. His behaviour was challenging and complex, but this was managed well
by prison staff and mental health professionals.
10. We found that Mr Ndemo gave no indication to staff that he was at risk of suicide in
the weeks leading up to his death and we are satisfied that they could not have
foreseen his actions.
11. The clinical reviewer found that the mental health care Mr Ndemo received at
Norwich was partially equivalent to that which he could have expected to receive in
the community.
12. We make no recommendations.
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The Investigation Process
13. HMPPS notified us of Mr Ndemo’s death on 11 December 2023.
14. The investigator issued notices to staff and prisoners at HMP Norwich informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Ndemo’s prison and
medical records.
16. The investigator interviewed nine members of staff at HMP Norwich and six
members of staff via Microsoft Teams in January and February 2024. In April 2024,
the investigation was reallocated to another investigator.
17. NHS England commissioned a clinical reviewer to review Mr Ndemo’s clinical care
at the prison. The clinical reviewer jointly interviewed staff with the investigator.
18. We informed HM Coroner for Norfolk of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
19. The Ombudsman’s office contacted Mr Ndemo’s next of kin, a friend, to explain the
investigation and to ask if he had any matters he wanted us to consider. He
contacted Mr Ndemo’s father in Kenya, who asked:
• How was it possible for Mr Ndemo to take his own life in prison?
• How did Mr Ndemo die?
• Was it possible that he was killed by somebody else in prison?
• Was there any CCTV footage of the events surrounding his death?
• Why was there a delay in the family being notified of his death?
20. We have answered these questions within this report.
21. Mr Ndemo’s next of kin received a copy of the initial report. He did not make any
comments.
22. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one inaccuracy within one of the transcripts, and this report has
been amended accordingly.
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Background Information
HMP Norwich
23. HMP Norwich is a multifunctional local prison and young offender institution (YOI)
which holds remand and sentenced category B, C and D men. The physical health
care provider is Health Care Resourcing Group Limited. Mental health services are
provided by Norfolk and Suffolk NHS Foundation Trust.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Norwich was in August and September 2022.
Inspectors reported that the recorded number of self-harm incidents was higher
than in similar prisons and increasing, although repeat self-harmers accounted for
around 68% of incidents. Monthly safety meetings analysed a wide range of data,
but actions to address and understand the causes of self-harm were too limited.
The number of prisoners receiving support through suicide and self-harm
prevention procedures (ACCT) for was high, especially on A wing. Most staff
inspectors spoke to were knowledgeable about the needs of those on ACCTs in
their care, but staff on A wing were overstretched. Good quality assurance
processes and consistent case management had improved the quality of ACCTs
overall, but ongoing records of meaningful conversations were lacking.
25. Inspectors reported that mental health services were provided by a skilled,
experienced, and multidisciplinary team, who were well led. Any immediate mental
health needs were identified during the initial reception screening and appropriate
information was shared to ensure continuity of care. A duty worker was allocated
daily within the team to respond to urgent applications, triage new referrals and
attend ACCT case management reviews. Patients with urgent referrals were seen
promptly, but there were 47 patients on the waiting list for a routine appointment,
with a waiting time of up to four weeks. Managers had put in place an appropriate
strategy to reduce the waiting list and patients were being offered assessment
appointments.
26. In July 2023, inspectors completed a review of the progress made since the last
inspection. In their review, inspectors reported that fewer incidents of self-harm had
been recorded since the last inspection. The number of prisoners receiving ACCT
support had reduced, and prisoners they spoke to were more positive about the
support they received.
Independent Monitoring Board
27. 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 2022 to 2023, the IMB reported that
healthcare was broadly equivalent to that available in the community. They noted
that the safety team continued to work hard to support men with mental health
needs, however that caseloads for the mental health team were very high. Although
self-harm had increased, staff acted professionally and with care towards prisoners
who self-harmed and managed them through the ACCT process as necessary.
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Previous deaths at HMP Norwich
28. Mr Ndemo was the fifteenth prisoner to die at Norwich since 1 December 2020.
Eleven of the previous deaths were from natural causes and the other three were
self-inflicted. None of these investigations raised issues relevant to the death of Mr
Ndemo. Up to May 2024, there had been one further death due to natural causes
since that of Mr Ndemo.
Assessment, Care in Custody and Teamwork
29. 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.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011. 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.
30. As part of the process, a care plan (plan of care, support and intervention) is put in
place. The ACCT should not be closed until all the actions on the care plan 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.
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Key Events
31. Mr Amos Ndemo was a Kenyan national who was in the UK on a skilled worker
visa. Mr Ndemo was a nurse who worked for Norfolk and Suffolk NHS Foundation
Trust.
32. On 16 May 2023, Mr Ndemo was arrested for harassment offences and was taken
into police custody.
33. On 17 May, Mr Ndemo was taken to court. While at court, escort officers completed
a suicide and self-harm (SASH) warning form as Mr Ndemo had self-harmed by
scratching and biting his arm. It was noted that the SASH form was added to the
digital Person Escort Record (PER – a document for capturing and ensuring the
transfer of information that can assist in the management of risk). After his court
hearing, Mr Ndemo was remanded into custody and taken to HMP Norwich. It was
his first time in prison.
34. Medical records show that Mr Ndemo was under the community mental health team
(CMHT) secondary service at the time of his imprisonment. The CMHT secondary
service supports adults with a severe mental illness or who have significant mental
health concerns. Mr Ndemo was referred to the service after the community crisis
team believed he was experiencing psychosis (a mental illness where a person
loses contact with reality and feels, hears or sees things that are not there).
HMP Norwich
35. When Mr Ndemo arrived at HMP Norwich on 17 May, a nurse completed his
reception health screen. Mr Ndemo said he had no thoughts of suicide or self-harm.
He said he had no ongoing health concerns and although he was evasive in the
details he provided, he said that he had a mental health history. He said that he had
stayed in a psychiatric hospital in Kenya in 2020 and had received treatment from a
psychiatrist in the community. The nurse noted that Mr Ndemo had presented with
problematic behaviour while being held for court which had included exposing
himself and masturbating in front of staff. The self-harm warning from the PER was
noted, and she referred him to the mental health team.
36. The next morning, healthcare staff completed Mr Ndemo’s secondary health screen
and he raised no issues.
37. Later that day, a Phoenix Futures recovery worker (the prison’s substance misuse
service) attempted to see Mr Ndemo as part of his induction. When she arrived on
the wing, prison staff were speaking to Mr Ndemo at his cell door. An officer told the
recovery worker that it was not appropriate to speak to Mr Ndemo at that time and
his appointment should be rebooked. A few hours later, a member of the chaplaincy
team saw Mr Ndemo as part of his induction. They noted that Mr Ndemo appeared
a little distressed but said he had no thoughts of harming himself. They relayed this
to wing staff.
38. The next morning, night duty staff reported that overnight, Mr Ndemo had
consistently misused his cell bell for mundane requests, ignored instructions,
disturbed the wing by banging the cell window bars and smashed his television.
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Wing staff relayed their concerns about Mr Ndemo’s mental health to the mental
health team who agreed to see him later that day.
39. At 10.40am, a Phoenix Futures recovery worker saw Mr Ndemo to complete his
induction. Mr Ndemo did not answer any of her questions relating to substance
misuse and refused to sign the associated paperwork. The recovery worker noted
that Mr Ndemo was very emotional and appeared to be confused and was asking to
see the mental health team. She rescheduled another induction session and noted
that he was due to see the mental health team later that morning.
40. At approximately 11.00am, a mental health nurse saw Mr Ndemo to complete an
assessment. She noted that Mr Ndemo had a history of drug induced psychosis and
said that he had taken psychoactive substances (PS) overnight. She also noted that
he was anxious, agitated, confused, and that he had said “life was not worth living”.
She started Prison Service suicide and self-harm monitoring and support
procedures, known as ACCT. Staff set his ACCT observations at one every hour.
41. The next morning, ACCT case co-ordinator and a Supervising Officer (SO) chaired
an ACCT review with a mental health nurse and Mr Ndemo. Mr Ndemo said that he
was missing his friends and family in Kenya and felt like he had lost everything by
coming to prison. They discussed his previous PS use and the nurse reminded Mr
Ndemo that PS would have a negative impact on his mental health. The SO
explained the support available to him at Norwich including the wellbeing
representative, Listeners (prisoners trained by the Samaritans to provide
confidential peer-support), staff and Samaritans and they discussed ways he could
distract himself when feeling low. Mr Ndemo said that although he felt a bit better
that day, he still had thoughts of harming himself. His ACCT remained open with
observations set at one per hour.
42. Approximately one hour later, two prisoners assaulted Mr Ndemo after he entered
another prisoner’s cell and began masturbating. Due to his recent behaviour, Mr
Ndemo was downgraded from the standard to the basic prison regime (where a
prisoner loses access to certain privileges). A plan was created to help him improve
his behaviour.
43. On 22 May, a recovery worker from Phoenix Features attempted to complete Mr
Ndemo’s substance misuse induction for the third time. As Mr Ndemo was behaving
inappropriately and groping his crotch, the recovery worker ended the session and
relayed this to the mental health team.
44. Later that day, a nurse was allocated as Mr Ndemo’s mental health co-ordinator
under the secondary mental health care team. Primary care is usually managed by
the prison GP and patients are seen by primary mental health staff as required.
Secondary care is usually managed by a mental health specialist and is for those
with severe and enduring mental health problems.
45. On 23 May, staff discussed Mr Ndemo at the mental health multi-disciplinary
meeting. They agreed that he needed to be assessed by a psychiatrist. Over the
next few days, Mr Ndemo continued to act inappropriately towards female staff and
misuse his cell bell. Prison management agreed that he should not be seen by lone
working females.
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46. On 29 May, a SO chaired an ACCT review with Mr Ndemo and a mental health
nurse. Mr Ndemo said that he was feeling more settled and that being in prison was
giving him a chance to ‘collect his thoughts’. He said that he was constantly hungry
and that he was not collecting his food. The SO arranged for an officer to assist him
in collecting his food from the servery. They discussed Mr Ndemo’s hobbies and
spoke about education courses he could complete while in prison. Mr Ndemo said
he did not have any thoughts of suicide or self-harm and that he would be very
content if he had access to more food. The SO reminded him about the servery and
canteen processes, and he said he understood. Staff decided to close Mr Ndemo’s
ACCT (subject to seven days post-closure monitoring) and reminded Mr Ndemo of
the support networks available to him.
47. On 1 June, a nurse met Mr Ndemo for a mental health review. She noted that he
said he had taken PS two days previously, and he said that this was why he had
acted inappropriately towards female members of staff. She said that Mr Ndemo
was coherent and appropriate throughout their conversation and his presentation
did not raise any cause for concern.
48. The next week, a consultant forensic psychiatrist assessed Mr Ndemo. He
concluded that Mr Ndemo’s behaviours were consistent with an episode of
psychosis, and it was likely that this psychosis was drug induced. He assessed that
Mr Ndemo did not need any psychiatric treatment. He noted that Mr Ndemo could
be managed under the primary mental health team and recommended that Mr
Ndemo engage with Phoenix Futures for substance misuse support. As per the
advice of the psychiatrist, on 20 June, Mr Ndemo was transferred from the care of
the secondary mental health team to the primary mental health team. It was agreed
that he would be seen on a fortnightly basis. However, he was not referred to
Phoenix Futures.
49. Over the next few months, Mr Ndemo’s behaviour became increasingly challenging.
He continued to make inappropriate sexual remarks towards female members of
staff, assaulted a prisoner and a member of staff, damaged prison property, flooded
his cell and smeared faeces around it. His challenging behaviour meant he was
moved to the Care and Separation Unit (CSU) on numerous occasions. A
Challenge, Support and Intervention Plan (CSIP) was also opened. (CSIP is a
process used to support and manage prisoners who are considered to pose a risk
to or be a victim from other prisoners.) Throughout this time, Mr Ndemo was
regularly seen and reviewed by the mental health team. Keywork sessions were
also facilitated when appropriate.
50. On 14 August, a nurse attended Mr Ndemo’s segregation review. As Mr Ndemo
was sexually inappropriate towards her, it was agreed that a Healthcare Assistant
(HCA) should see Mr Ndemo for all mental health appointments going forward.
51. On 26 September, Mr Ndemo stopped smearing faeces around his cell, had a
shower and came out of his cell for association.
52. On 29 September, an HCA saw Mr Ndemo for a mental health review. Mr Ndemo
was calm and polite throughout the session and said that he felt his mental health
was improving. He told the HCA that he was looking forward to his sentencing date
(which was in November) and would feel more settled when he knew his release
date. When asked, Mr Ndemo said that he did not have any thoughts of suicide or
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self-harm, and that he had no issues to raise with mental health at that time. The
HCA reminded Mr Ndemo how to contact the mental health team, should this
change.
53. A few hours later, as a result of him showing consistently positive behaviour for the
previous seven days, Mr Ndemo was moved from the basic to the standard prison
regime. In the regime review, it was noted that Mr Ndemo’s behaviour and attitude
had improved significantly, and that he was on a waiting list to work in the
production workshop.
54. On 26 October, a Custodial Manager (CM) saw Mr Ndemo for a CSIP review. Mr
Ndemo said that he was enjoying working in the production workshop and that he
was getting on well with staff. The CM noted that he had shown no negative
behaviour for the previous four weeks, was engaging well with staff, and had
received positive feedback from the workshop instructors. Due to this, he decided to
close the CSIP. He reminded Mr Ndemo to contact him if he needed any further
support.
55. On 14 November, Mr Ndemo attended Norwich Crown Court and was convicted of
stalking (several victims). His sentencing date was adjourned pending a pre-
sentence report from the Probation Service. He returned to Norwich later that day.
Mental health staff tried to see Mr Ndemo that day, however he did not return from
court in time, so they rebooked his appointment.
56. On 16 November, Mr Ndemo told a HCA that he would be returning to court for
sentencing on 20 December. He said that he was hoping to receive a short
custodial sentence or be released the same day due to the time he had already
served. They spoke about his release plans and Mr Ndemo said that he had
accommodation to return to, was registered with a GP, and had support from
friends in the community. Mr Ndemo said he felt stable and when asked, said there
was nothing he needed from the mental health team at that time.
57. On 21 November, an officer introduced himself to Mr Ndemo as his new keyworker.
The officer noted that Mr Ndemo was receptive, engaging and pleasant throughout
his keywork session. They spoke about Mr Ndemo’s life before prison and his plans
for the future, which included returning to Kenya, getting back in contact with his
family, and continuing his job as a nurse. Mr Ndemo said that he was now very
settled on the wing, was enjoying working in the production workshop, and had
friends who visited him. He said that he occasionally felt anxious due to it being his
first time in prison, and that he sometimes found it difficult to sleep due to the noise
on the wing. Mr Ndemo also asked about his immigration status, and the officer
assured him that this would be confirmed once he was sentenced. The officer
scheduled Mr Ndemo’s next keywork session for 4 December but told Mr Ndemo to
get in contact should he need anything before then.
58. On 4 December, the keyworker met Mr Ndemo for a keywork session. Mr Ndemo
said that he continued to enjoy his job in the production workshop and was looking
forward to his upcoming release. He said that he was concerned that he had not
been assigned a prison offender manager yet. The keyworker confirmed this was
because he was still unsentenced. Mr Ndemo said that he would like to speak to the
mental health team about his anxiety, so the keyworker filled in an application
requesting a GP appointment on his behalf. The application was received and
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processed but did not reach the Mental Health Team until 11 December. At
interview, the keyworker explained that Mr Ndemo said he wanted to go back on
medication for his anxiety, and the process for that was to request to see a GP who
could then discuss treatment options with him. He told us that he was concerned
that Mr Ndemo was staying in his cell during association time. He said that he had
advised Mr Ndemo to try to spend time out of his cell, get some fresh air and chat to
his peers, as this would help to lift his mood. This was the last recorded entry on the
prison system before Mr Ndemo’s death.
Events of 10 December
59. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to prison radio transmissions from 10 December. She also obtained
information from the East of England Ambulance Service. The following account
has been taken from all sources.
60. At approximately 5.40am, an officer completed a routine check on B-wing. At
interview, he said that Mr Ndemo was asleep in his bed and that he saw nothing
that caused him to be concerned. Mr Ndemo was locked in a single cell and no
other prisoners had access to his cell that morning. He was not required to be
checked again until 11:30am.
61. At 11.30am, officers on B-wing began unlocking the cells for lunch. An officer
looked through Mr Ndemo’s observation panel into his cell. She thought that he was
stood still, looking out of his window, so she unlocked his door. She then realised
that he was suspended from his window by a ligature made from a torn bedsheet.
She radioed a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties) at 11.31am. Control room staff
requested an ambulance immediately.
62. Seconds later, three officers responded to the code blue and entered Mr Ndemo’s
cell. As she was in distress, an officer escorted her out the cell. Another officer saw
that Mr Ndemo was unconscious and was not breathing, so he relayed this to the
control room.
63. An officer held Mr Ndemo whilst a colleague cut through the ligature. They then
lowered Mr Ndemo onto the floor and lay him on his back. At interview, both officers
said that they believed Mr Ndemo was already deceased and they thought he had
signs of rigor mortis (he was rigid and cold to the touch). One officer said that he did
not start resuscitation as it would not have been the right or respectful thing to do.
Both officers stayed in the cell and waited for healthcare to arrive.
64. Despite believing that Mr Ndemo was deceased, at 11.34am, an officer started
chest compressions. Approximately 10 seconds later, healthcare staff arrived, and a
nurse continued giving CPR. They then moved Mr Ndemo onto the wing landing
where they applied a defibrillator (a device that gives shocks to the heart to restore
a normal heartbeat) and continued resuscitation attempts.
65. At approximately 11.45am, paramedics arrived at Mr Ndemo’s cell. Their notes
confirm that there were signs of rigor mortis present, with Mr Ndemo’s fists
clenched in a fixed position. At 11.46am, the paramedics pronounced that Mr
Ndemo had died.
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Contact with Mr Ndemo’s family
66. At 11.50am, the prison appointed a family liaison officer (FLO). The FLO and a
member of the chaplaincy team visited Mr Ndemo’s listed next of kin, his friend, at
his home address. The friend’s wife answered the door and said that he was at
work. She gave the FLO his mobile telephone number and several attempts were
made to contact him. At 3.25pm, the FLO managed to locate Mr Ndemo’s friend
and they agreed to meet at his workplace.
67. At 4.05pm, the FLO and a senior prison manager met Mr Ndemo’s friend and
notified him of Mr Ndemo’s death. The friend explained that Mr Ndemo’s parents
lived in Kenya and that he would contact them to inform them of the death of their
son.
68. On 12 December, the FLO made multiple attempts to contact Mr Ndemo’s parents
via telephone, but the prison phone system would not allow him to telephone an
international number. He contacted the Head of Security for advice. He tried
multiple times to telephone Mr Ndemo’s friend in England to inform him of this, but
he did not answer. A few days later, Mr Ndemo’s friend contacted the FLO and
advised him not to attempt to contact Mr Ndemo’s parents any longer, as they
would find another person contacting them too painful.
69. The prison contributed to the cost of Mr Ndemo’s funeral in line with national
guidance.
Support for prisoners and staff
70. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners to identify prisoners most affected by
the death.
71. After Mr Ndemo’s death, staff held a debrief and those involved in the emergency
response were given the opportunity to discuss any issues arising. They were also
offered support by the staff care team and signposted to support services available
to them. Arrangements were made for the staff who were directly involved in the
incident to be taken home and their line managers contacted them the following day
to check on their welfare and offer additional support.
72. The prison posted notices informing other prisoners of Mr Ndemo’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 his death.
Post-mortem report
73. The post-mortem concluded that Mr Ndemo died from suspension by ligature
(hanging). There were no significant toxicological findings to report.
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74. At an inquest held on 25 February 2025, the coroner concluded that Mr Ndemo died
by suicide.
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Findings
Management of Mr Ndemo’s risk of suicide and self-harm
75. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of suicide or self-harm 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. PSI 64/2011 also states that any information that
becomes available which may affect a prisoner’s risk of harm to self must be
recorded and shared, to inform proper decision making. Mr Ndemo had several risk
factors including that it was his first time in prison, he had experienced serious
mental health issues, he misused drugs which impacted on his mental health, and
he missed his family who lived overseas.
76. On 19 May, Mr Ndemo attended a healthcare appointment and staff correctly
identified that he was at risk of suicide and self-harm. They started ACCT
procedures, which continued until 29 May. We found these were procedures were
managed correctly and closed appropriately.
77. Over the next few months, Mr Ndemo displayed inappropriate sexual behaviours
towards female members of staff, smeared faeces around his cell, damaged prison
property, flooded his cell and assaulted both a prisoner and a member of staff. His
behaviours were described by staff as unusual, erratic and bizarre. Both prison and
healthcare staff attempted to explore his behaviour with him, but he gave conflicting
and obscure answers. It is still unknown whether Mr Ndemo’s behaviour was drug
induced or whether he was showing symptoms of an emerging acute mental illness.
We recognise that managing Mr Ndemo’s complex and difficult behaviour presented
staff at Norwich with challenges, but that staff coped well. We are satisfied that
there was no evidence to suggest that Mr Ndemo was at risk of suicide or self-harm
during this period.
78. From 29 September, Mr Ndemo’s behaviour improved significantly. He appeared
more settled, was located back on a standard wing, and had no regime restrictions.
Mr Ndemo attended work and engaged well with his peers, the mental health team,
and his keyworker. We did not find any explanation for the sudden improvement in
his behaviour.
79. On 4 December, Mr Ndemo told his keyworker that he would like to speak to the
mental health team about anxiety medication. The keyworker filled in an application
requesting to see a GP on his behalf, and this was submitted to healthcare the
following day. The application was received and processed but did not get to the
Mental Health Team until 11 December, the day after Mr Ndemo died. The
investigator spoke to the Deputy Service Manager for the Mental Health and
Wellbeing Team. She explained that as the application was directed towards the
GP, it did not reach the mental health team until 11 December. She said that as
there was no urgency within the healthcare application and given the long waiting
lists and GP clinic availability, it was unlikely that Mr Ndemo would have been seen
prior to 13 December. It is noted however that as Mr Ndemo was open to the
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primary mental health team and he was being seen on a fortnightly basis, a review
may have occurred in the intervening period.
80. Although records indicate that Mr Ndemo had a vulnerable mental state, we are
satisfied that prior to his death he gave no indication to staff that he was at risk of
suicide and that they could not have foreseen his actions.
Emergency response
81. We found that when staff found Mr Ndemo unresponsive, they attempted CPR
despite noticing clear signs of death. A nurse, who was the first member of
healthcare staff on scene, continued CPR because she thought that she had to
continue, based on policy. The European Resuscitation Guidelines 2015 state that
resuscitation is inappropriate when there is clear evidence that it will be futile.
82. The European Resuscitation national guidance is available to assist staff in this
area, but staff were not aware. Healthcare staff have confirmed they are now aware
of this guidance and for this reason, we make no recommendation.
83. We consider that an officer provided clear and unambiguous information about Mr
Ndemo’s condition to colleagues in the control room, which allowed for the local
Ambulance Service to dispatch an ambulance with sufficient priority. This is an
example of good practice.
Clinical care
84. The clinical reviewer concluded that Mr Ndemo’s physical and substance misuse
healthcare was of a reasonable standard and equivalent to that he would have
received in the community.
85. The clinical reviewer found that the mental health care Mr Ndemo received at
Norwich was only partially equivalent to that which he would have received in the
wider community. She noted that this was due to missed opportunities for the
mental health team to refer Mr Ndemo to substance misuse services and issues
with record keeping and care planning. The clinical reviewer made several
recommendations around these issues as well as other issues unrelated to Mr
Ndemo’s death, which the Head of Healthcare will wish to address.
Head of Healthcare to Note
Substance misuse support
86. Mr Ndemo reported using psychoactive substances (PS) prior to coming to custody.
The prison’s substance misuse service, Phoenix Futures, made significant efforts to
engage Mr Ndemo on his arrival at Norwich, however he said that he did not want
help from their service. No further referrals to Phoenix Futures were made for
substance misuse support to be considered.
87. On 1 June, a nurse noted that Mr Ndemo said that he had taken PS recently. She
determined in her clinical notes that this was likely to be the reason for his
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challenging and inappropriate behaviour. At interview, she said that she did not
consider a referral to Phoenix Futures at this time.
88. Two weeks later, the consultant psychiatrist assessed Mr Ndemo and
recommended that he would benefit from substance misuse support from Phoenix
Futures. We found that this recommendation was not actioned. The Deputy Service
Manager said that she would have expected this recommendation to have been
followed up by Mr Ndemo’s mental health care co-ordinator. At interview, the nurse
said that she was unaware of this recommendation.
89. It would have been good practice for the nurse to refer Mr Ndemo to Phoenix
Futures. We recognise, however, that a referral was unlikely to have changed the
outcome for Mr Ndemo, given that there was no evidence to suggest that Mr
Ndemo was using PS after the dates mentioned above, and he did not test positive
for PS post-mortem. Additionally, we acknowledge that his engagement would have
been voluntary. For this reason, we make no recommendation, but we bring this to
the attention of the Head of Healthcare
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