Andrew Winspear

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Andrew Winspear,
a prisoner at HMP Hull,
on 8 August 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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 Andrew Winspear was found hanging in his cell at HMP Hull on 8 August 2023. Staff
and paramedics tried to resuscitate him but were unsuccessful. Mr Winspear was 53 years
old. I offer my condolences to his family and friends. Mr Winspear was the fourth self-
inflicted death at Hull in three years.
Staff had started suicide and self-harm procedures (known as ACCT) for Mr Winspear on
the morning of 8 August, after he self-harmed by cutting. Later that day he received a
longer than expected prison sentence at a video link court hearing, but staff did not
reassess his risk.
We found similar failings in our investigation into a death at Hull in 2021 and were assured
that processes had since been reviewed and staff had been briefed on the correct
procedures to follow. It is disappointing therefore that the same issues have arisen again. I
have asked the Governor to carry out an audit to assure himself that staff are following the
correct procedures following video link appearances.
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 21 March 2023, Mr Andrew Winspear was remanded in prison, charged with
burglary, and sent to HMP Lincoln. It was not his first time in prison.
2. Mr Winspear had a long history of self-harm and was supported using suicide and
self-harm prevention procedures (known as ACCT) multiple times during previous
sentences.
3. From 15 to 16 May, staff supported Mr Winspear using ACCT procedures after he
self-harmed by cutting. Mr Winspear told staff that he was worried about his baby
son who had been taken into foster care as his ex-partner was also in prison. Mr
Winspear said he hoped to be released in a few months and then seek custody of
his son.
4. On 5 July, Mr Winspear was moved to HMP Hull.
5. On 27 July, Mr Winspear saw his son on an arranged visit. His son was then taken
to HMP New Hall’s Mother and Baby Unit to be with Mr Winspear’s ex-partner.
6. On 8 August, Mr Winspear was due to be sentenced at a video link hearing. He
refused to go, jumped from the first-floor landing onto the netting and then made
cuts to his arm. Staff started ACCT procedures. Mr Winspear said he had hoped to
go to court in person as he thought he could defend himself better and was more
likely to be released.
7. Later that morning, Mr Winspear did attend his video link court hearing and was
sentenced to 16 months. With time already served, it left him with three more
months in prison.
8. At around 5.18pm, two officers went to Mr Winspear’s cell and found him with a
ligature around his neck. One of the officers called a medical emergency code. The
other officer removed the ligature from Mr Winspear’s neck and started
cardiopulmonary resuscitation (CPR). Other prison staff arrived and continued CPR.
9. Ambulance paramedics arrived at 5.28pm and took over CPR. They were unable to
resuscitate Mr Winspear and at 5.56pm, they pronounced that he was dead.
Findings
10. Mr Winspear’s ACCT document did not accompany him when he attended his video
link court appearance as it should have done, so staff in Official Visits did not know
that Mr Winspear was on an open ACCT. The prison told us that managers had
spoken to the member of staff responsible who acknowledged that he had not
followed correct procedures.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
11. Staff in Official Visits were unaware that Mr Winspear’s status had changed (to a
sentenced prisoner) after his video link appearance. Under national policy, Mr
Winspear’s risk of suicide and self-harm should have been reassessed and he
should have been referred to healthcare staff. However, neither happened.
12. We found similar failings following a death at Hull in 2021. We were told then that a
review was undertaken in March 2022 and staff had been briefed on the correct
procedures to follow, including referring prisoners who have had a change in status
for a risk assessment in reception and to see a nurse. We have been told that staff
have again been briefed following the death of Mr Winspear but we have some
concerns about how well the new procedures have been embedded given that the
same issue has arisen again. We require assurance that staff are routinely following
the correct procedures following video link court appearances.
13. More generally, we are concerned that HMPPS’ policy relating to prisoner safety
should be amended to ensure that prisoners appearing in court by video link are
subject to the same processes to assess their risk as those appearing in court in
person. HMPPS has assured us that the new Prisoner Safety Framework, due to be
implemented in 2024, will reflect this.
Recommendations
• The Governor should undertake an audit to assure himself that staff are adhering to
the correct procedures following court appearances by video link and report the
results to the Ombudsman.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
14. HMPPS notified us of Mr Winspear’s death on 8 August 2023.
15. The investigator issued notices to staff and prisoners at HMP Hull informing them of
the investigation and asking anyone with relevant information to contact him. No
one responded.
16. The investigator visited Hull on 17 August. He obtained copies of relevant extracts
from Mr Winspear’s prison and medical records.
17. The investigator interviewed one member of prison staff at Hull on 17 August. He
interviewed two other members of prison staff over video call on 1 and 8 December.
18. NHS England commissioned an independent clinical reviewer to review Mr
Winspear’s clinical care at the prison. The clinical reviewer and investigator
conducted joint interviews with three members of healthcare staff on 6 October, and
on 4 and 7 December by video call.
19. We informed HM Coroner for Hull and East Riding 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 family liaison officer wrote to Mr Winspear’s brother to explain
the investigation and to ask if he had any matters he wanted us to consider. He did
not respond.
21. We shared our initial report with HMPPS. They found no factual inaccuracies.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Hull
22. HMP Hull is a local prison that holds up to 958 men in ten wings. Spectrum CiC
Healthcare took over delivery of primary healthcare services in August 2022, from
City Health Care Partnership. Mental health and substance misuse services are still
provided by City Health Care Partnership.
HM Inspectorate of Prisons
23. The last full inspection of Hull took place in July 2021. It found that standards and
outcomes had slipped after a succession of more positive inspections. Inspectors
noted that there had been eight self-inflicted deaths and two non-natural deaths
since the previous inspection in March 2018 and there was a lack of evidence that
PPO recommendations made following these deaths had led to sustained change,
particularly in relation to health care services. Inspectors reported that prisoners
they spoke to were positive about the care they had received while subject to ACCT
procedures. Working relationships between staff and prisoners remained positive.
24. Inspectors reported that health care services were weak well before the pandemic
and were failing in some critical areas. Mental health services were not properly
resourced. There were significant risks and unmet need which required immediate
attention.
25. HMIP carried out an independent review of progress in March 2022. Inspectors
found that there had been good or reasonable progress against eight of the
recommendations reviewed. The strategic oversight of PPO recommendations had
improved. Recommendations were now subject to monthly assurance checks, led
by a custodial manager, and were discussed at the monthly ‘safe and secure’
meeting. However, healthcare leaders did not attend these meetings, due to clinical
pressures, which meant that key recommendations for which health care managers
were responsible were not subject to multidisciplinary oversight with prison
colleagues. Inspectors found several examples of health recommendations which
had still not been implemented or reviewed. Despite assurances from City Health
Care Partnership that PPO recommendations were subject to corporate oversight,
inspectors were not confident that actions to drive up service improvement were
always implemented or embedded in practice.
Independent Monitoring Board
26. 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.
27. In its latest annual report for the year to 28 February 2023, the IMB reported that
positive prisoner and officer relationships were observed throughout the prison, with
officers demonstrating a detailed knowledge of prisoners in their care. They noted
that prisoner applications to the IMB on health matters had reduced when
compared to the previous reporting year and the Board had observed significant
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
operating changes and improvements from the new healthcare providers. However,
at the end of the reporting year, the provision of healthcare services was still in a
state of transition, with further improvements planned into the next year.
Previous deaths at HMP Hull
28. Mr Winspear was the 15th prisoner to die at Hull since August 2020. Of the previous
deaths,11 were from natural causes and three were self-inflicted.
29. Following a self-inflicted death in May 2021, we made a recommendation to Hull
that following a court appearance by video link, staff must record the outcome in the
prisoner’s prison record and should speak to the prisoner and consider whether the
risk to themselves has changed.
30. Several PPO investigations in 2020, when the COVID-19 pandemic meant all court
appearances were remote, found that prisoners were not being risk assessed after
attending court by video link. We made a national recommendation to HMPPS to
review their guidance. In March 2021, the Director General wrote to all Governors
and Directors requiring them to review local processes to ensure that similar health
screening arrangements, and the same processes for assessing risk of suicide or
self-harm, were followed after video link appearances, as in reception following a
physical appearance in court.
31. Also in March 2021, HMPPS issued a safety briefing on assessing the risk of harm
in prisoners attending court by video link. In April 2021, they followed this up with
another safety bulletin containing early learning review analysis of several issues
including video court appearances. Both documents advised that it was vital that
staff engage with prisoners after a video court appearance, and that they assess
the prisoner’s risk on the basis of official information, as well as the individual’s
presentation. They also advised that a verbal handover of key information should be
given to wing staff and any new risk information should be recorded and shared on
the prisoner’s record (NOMIS) and the wing observation book. If necessary,
concerns should be escalated, including starting ACCT procedures where
appropriate.
32. We were told that in March 2022, the Head of Operations at Hull had completed a
review of the procedures that must be undertaken following a prisoner’s court
appearance by video link to ensure any change in risk is fully considered. All staff
involved in the process had been briefed by line managers regarding the updated
procedures to ensure they were aware that when there is a change in circumstance,
the prisoner should be taken to reception to undergo a Reception Risk Review.
Staff were also reminded that the Visits Log Book and the prisoner’s electronic
prison record should be updated with the details of the hearing and the outcome. In
addition, prisoners would be seen by the reception nurse to assess if the risk to
themselves had changed.
Assessment, Care in Custody and Teamwork
33. 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
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
34. On 21 March 2023, Mr Andrew Winspear was remanded in prison, charged with
burglary, and sent to HMP Lincoln. It was not his first time in prison.
35. Mr Winspear had a long history of self-harm (normally by cutting) and had been
managed using Prison Service suicide and self-harm procedures (known as ACCT)
multiple times during previous sentences. He also had a history of substance
misuse (including heroin) and depression.
36. Staff at Lincoln managed Mr Winspear using ACCT from 15 to 16 May, after he
made cuts to his arm. He told staff that he was worried about what would happen to
his five-month-old son, who had been taken into foster care as his ex-partner, his
son’s mother, was also in prison. Mr Winspear said his sentencing was in
September and he was hoping his charges would be reduced which would give him
a better chance of being released and getting custody of his son.
37. On 23 May, Mr Winspear told his key worker that all his burglary charges had been
dropped but he had one outstanding charge (of handling stolen goods, for which he
had been convicted on 18 May). He thought he would be released due to time
served on remand. Mr Winspear also said that he was offered the opportunity to be
released on bail but refused as he thought it was best to stay in prison to help him
with detoxification from alcohol and drugs.
HMP Hull
38. On 5 July, Mr Winspear was moved to HMP Hull.
39. A nurse conducted the reception screening. She noted Mr Winspear said he had no
thoughts of suicide or self-harm. She also noted that Mr Winspear had not harmed
himself in prison (which was incorrect as he had harmed himself as recently as 15
May).
40. The nurse noted that Mr Winspear said he had a problem with alcohol and drugs
within the last three months and that he had previously been diagnosed with
depression and was taking mirtazapine.
41. The nurse noted Mr Winspear was on methadone to treat his heroin addiction. Mr
Winspear was expected to be released that day to a rehabilitation facility, but
instead was remanded to Hull pending a court appearance on 17 July. A reduction
of methadone was started, as per the conditions of acceptance into rehabilitation.
42. On 6 July, Hull’s Mental Health Team (MHT) received a handover via email from
Lincoln’s MHT. The email said that Mr Winspear had been engaging in Eye
Movement Desensitization and Reprocessing (EMDR) and was due to be
discharged as he had completed the therapy. (EMDR is a comprehensive
psychotherapy that helps people process and recover from past experiences that
affect mental health and wellbeing.) A referral was created for the MHT at Hull.
43. Later that day, a nurse completed a MHT triage. He noted that there were no
current risks or behaviours suggesting Mr Winspear was a risk to himself. Mr
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Winspear was referred to ‘Rethink’ for a suitability assessment for ‘Step 2’ mental
health support.
44. All prisoners’ telephone calls, except those that are legally privileged, are recorded,
and prison staff listen to a random sample. On 20 July, Mr Winspear telephoned his
son’s social worker. Mr Winspear asked the social worker the outcome of an
assessment she was doing, but she said it was incomplete. Mr Winspear said he
was due to be sentenced on 21 July, and expected to be released as he had a
place booked in a rehabilitation facility near Glasgow. Mr Winspear sounded very
positive and said he would be in some sort of isolation for a couple of weeks and
then would be set up with his own flat.
45. On 20 July, an officer saw Mr Winspear for a key work session. She noted Mr
Winspear said his ex-partner had gained custody of their son, and his son was
going to stay with her at HMP New Hall’s Mother and Baby Unit. She noted Mr
Winspear was very happy about this and was continually smiling when he spoke
about his son.
46. The key worker said Mr Winspear told her that he had been working hard to get
himself back on track and clean (off drugs and alcohol). Mr Winspear said he had
completed several courses while in custody and EMDR therapy to deal with past
trauma. Mr Winspear said he had been sexually abused as a child while in the care
system and had used drugs to cope with the trauma. She noted that Mr Winspear
said he knew people in the care system should have protected him and he did not
ever want that to happen to his son.
47. The key worker had contacted Mr Winspear’s son’s social worker about organising
a visit, so Mr Winspear could see his son. She noted Mr Winspear was happy about
this and he hoped to be released soon but, if that did not happen, he wanted the
visit so he could see his son.
48. On 21 July, Mr Winspear called his son’s social worker, leaving a message on her
answer phone and asking if she could arrange for his son to visit him at Hull. This
was the last call Mr Winspear made from his prison phone account. (Mr Winspear
was not released on this date as he had anticipated.)
49. On 24 July, the key worker saw Mr Winspear for another key work session. She
noted that Mr Winspear talked a lot about his son. She said Mr Winspear’s son’s
social worker was trying hard to organise a visit for 27 July, so Mr Winspear could
see his son before he went to New Hall. She said Mr Winspear had asked for more
photographs of his son as he only had one and the social worker agreed to send
some new pictures. She noted that Mr Winspear was excited about this news.
50. On 26 July, a Senior Psychological Wellbeing Practitioner contacted Mr Winspear
on his in-cell telephone to assess whether Mr Winspear needed mental health
services. He noted that Mr Winspear declined talking therapies. He said Mr
Winspear told him that he had no thoughts of suicide or self-harm. He discharged
Mr Winspear from the MHT.
51. Later that day, the key worker saw Mr Winspear for a key work session. She told Mr
Winspear he would have the visit with his son the following day at 3.00pm. She
noted that Mr Winspear was “over the moon”.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
52. On 27 July, the key worker saw Mr Winspear during his visit with his son. She noted
that Mr Winspear’s son reacted to his voice which left Mr Winspear in tears. She
said that photographs were taken of Mr Winspear with his son, which would be
printed out and given to Mr Winspear.
Events of 8 August
53. On the morning of 8 August, Mr Winspear was due to attend a video link court
appearance for sentencing. An officer noted that, when told which way he would
walk to Official Visits (where video link court appearances take place at Hull) Mr
Winspear refused to go. As Mr Winspear would not follow staff’s directions, they
told him to go back to his cell.
54. At around 8.45am, Mr Winspear jumped onto the netting (which stops prisoners
from falling between floors on the wing) from the first-floor landing. He said he was
not getting off the netting because staff had stopped him going to court. Prison staff
convinced Mr Winspear to come off the netting and escorted him back to his cell.
55. At around 10.10am, staff found that Mr Winspear had made a cut to his left arm.
They called a code red medical emergency (used to indicate severe bleeding).
56. A nurse attended and dressed Mr Winspear’s wound. She told the investigator that
the cuts were not very deep. She said Mr Winspear told her that he was triggered to
self-harm because he was expecting to go to court in person, but this was changed
to video link. He felt that he could better defend himself in person, which he thought
would have made it more likely he be released.
57. A Supervising Officer (SO) on G Wing noted in his statement that Mr Winspear said
he self-harmed because he felt prison staff were stopping him from attending his
court appearance.
58. An officer started ACCT procedures for Mr Winspear and handed the ACCT
document to the SO.
59. At around 10.30am, the SO noted he received a telephone call requesting Mr
Winspear attend the video link court appearance. He noted that he completed the
ACCT Immediate Action Plan (IAP) verbally while he escorted Mr Winspear to
Official Visits. He then returned to G Wing to complete Mr Winspear’s ACCT
document. He noted that he had forgotten to inform the prison staff in Official Visits
that Mr Winspear was on an open ACCT, and because he wanted to complete his
section of the ACCT document, it did not accompany Mr Winspear to Official Visits
as it should have.
60. A Custodial Manager (CM) completed a ‘Lessons Learnt Review’ following Mr
Winspear’s death and spoke to several staff involved.
61. An officer told the CM that she personally set Mr Winspear up in video link booth 9.
He was on his own as there were not enough staff to sit in with him. The officer said
she told Mr Winspear that he needed to let an officer know the outcome of his court
hearing when it finished. She said she was then deployed to another area and did
not see Mr Winspear leave his hearing and was not aware that he had any
communication with other staff.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
62. A SO said that a prisoner from the segregation unit also had a video link court
appearance that morning and additional staff were required to supervise him. As a
result, no one was available to sit with Mr Winspear during his court appearance.
63. At his court appearance, for handling stolen goods, Mr Winspear received a
determinate sentence of 16 months. (Accounting for the time he had already
served, this meant Mr Winspear would not be released from prison for a further
three months.)
64. At around 12.00pm, Mr Winspear was taken back to G Wing. No prison staff in
Official Visits recalled interacting with Mr Winspear before he left.
65. The Head of Residence and Safety told the investigator he saw Mr Winspear
sometime between 4.30pm and 4.45pm. He said Mr Winspear told him he had just
been sentenced and asked what would happen to him next. He said he told Mr
Winspear about the normal procedure. He did not know that Mr Winspear’s risk to
himself had not been reassessed following the court appearance as it should have
been.
66. At around 4.55pm, an officer completed an ACCT check on Mr Winspear.
67. At around 5.18pm, two officers attended Mr Winspear’s cell to hand Mr Winspear
his adjudication paperwork for climbing on the netting earlier that day.
68. Officer A looked through the observation panel in Mr Winspear’s cell door and saw
that Mr Winspear had a ligature around his neck. Officer A turned to Officer B, who
was approaching, and said, “Code Blue” (a medical emergency code used when a
prisoner is unconscious or having breathing difficulties).
69. Officer B looked through the observation panel and saw Mr Winspear on the left
side of the cell sitting on the floor, with his back resting on furniture units and his
feet towards the bed. He said Mr Winspear had a ligature around his neck made
from a ripped green bedsheet, which was attached to a screw in the wall.
70. Officer B unlocked the cell door and entered, while Officer A radioed a Code Blue.
Staff in the control room immediately called for an ambulance.
71. Officer B activated his Body Worn Video Camera (BWVC). He used his anti-ligature
knife to cut the ligature from around Mr Winspear’s neck. He said Mr Winspear was
blue and purple in colour. After checking and finding no signs of breathing, he
started CPR.
72. More prison staff attended the cell and they took it in turns to carry out CPR.
73. A nurse attended the cell and set up an automated external defibrillator (AED). (An
AED is a medical device that can analyse the heart's rhythm and, if necessary,
deliver an electrical shock, or defibrillation, to help the heart re-establish an effective
rhythm.) Two other healthcare staff arrived. Another nurse noted that the AED
advised no shock, so staff continued CPR.
74. At around 5.28pm, an ambulance crew arrived at the cell and took over CPR. They
were shortly followed by a second ambulance crew. Paramedics were unable to
resuscitate Mr Winspear and at 5.56pm, pronounced that he was dead.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contact with Mr Winspear’s family
75. On 8 August, the prison appointed two family liaison officers (FLOs). At around
10.00pm, they attended Mr Winspear’s brother’s home and informed him of Mr
Winspear’s death.
76. The following day, the FLOs contacted New Hall and arranged for Mr Winspear’s
ex-partner to be informed of his death.
77. The FLOs stayed in touch with Mr Winspear’s brother over the following weeks,
offering support and advice.
78. The prison contributed to the costs of Mr Winspear’s funeral in line with national
policy.
Support for prisoners and staff
79. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to supplying staff and prisoners support following all deaths in
custody. Postvention procedures should be started 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 supply confidential peer-support) to identify prisoners most affected by the death.
80. Postvention is not fully embedded at Hull. The Samaritans are not able to fully
support Hull due to staffing levels. However, the Samaritans will be added to Hull’s
death in custody contingency plans early in 2024.
81. After Mr Winspear’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
82. The prison posted notices informing other prisoners of Mr Winspear’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 Winspear’s death.
Post-mortem report
83. The post-mortem report concluded that Mr Winspear died from hypoxic brain injury
(lack of oxygen to the brain) caused by hanging.
84. The toxicology report showed no illicit substances in Mr Winspear’s system at the
time of his death.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Management of Mr Winspear’s risk of suicide and self-harm
85. Prison Service Instruction (PSI) 64/2011, Managing prisoners at risk of harm to self,
to others and from others (Safer Custody), sets out the procedures (known as
ACCT) that staff should follow when they identify that a prisoner is at risk of suicide
and self-harm. It says that, once opened, the ACCT document must accompany the
prisoner to any activities outside of the wing/unit where they are located.
86. Staff at Hull started ACCT procedures for Mr Winspear on the morning of 8 August,
after he self-harmed by cutting. He had failed to attend his video link court
appearance earlier that morning. The noted reasons for his refusal to attend differ,
but he said he was expecting to go to court in person and thought that he could
better defend himself in person and have a better chance of being released.
87. Later that morning, Mr Winspear did attend his video link court appearance, which
took place in Official Visits. However, his ACCT document did not accompany him.
88. A SO took Mr Winspear to Official Visits but did not take Mr Winspear’s ACCT
document with him, nor tell staff in Official Visits that Mr Winspear was on an ACCT,
so they were unaware.
89. The Head of Safety told us that he and two other prison managers had spoken with
the SO. He said the SO was fully aware of the errors that he had made during the
ACCT process and understood what he should have done differently.
90. As the SO has acknowledged his mistakes, has received feedback from senior
managers and understands the correct procedure, we make no recommendation.
Change in status
91. Mr Winspear was sentenced to 16 months at his video link hearing. With time
already served, he had three months left to serve.
92. Prison Service Order (PSO) 3050, Continuity of healthcare for prisoners, says that
events such as attending court or sentencing at court, are factors that might have a
significant impact on the health of a prisoner. When prisoners pass through
reception on their return from court, prisons are required to have protocols in place
for risk assessing them to identify any potential suicide and self-harm issues. Prison
Service Instruction (PSI) 07/2015, Early days in custody, states that there must be
arrangements in place to assess prisoners whose status or demeanour may have
changed after a court appearance by video link.
93. As prisoners appearing by video link do not leave the prison, they are not always
subject to the standard screening procedures that they would receive when
returning to the prison and passing through reception.
94. Several PPO investigations in 2020, when the COVID-19 pandemic meant all court
appearances were remote, found that prisoners were not being risk assessed after
attending court by video link. We made a national recommendation to HMPPS to
review their guidance. In March 2021, the Director General wrote to all Governors
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
and Directors requiring them to review local processes to ensure that similar health
screening arrangements, and the same processes for assessing risk of suicide or
self-harm, were followed after video link appearances, as in reception following a
physical appearance in court.
95. Also in March 2021, HMPPS issued a safety briefing on assessing the risk of harm
in prisoners attending court by video link. In April 2021, they followed this up with
another safety bulletin containing early learning review analysis of several issues
including video court appearances. Both documents advised that it was vital that
staff engage with prisoners after a video court appearance, and that they assess
the prisoner’s risk on the basis of official information, as well as the individual’s
presentation. They also advised that a verbal handover of key information should be
given to wing staff and any new risk information should be recorded and shared on
the prisoner’s record (NOMIS) and the wing observation book. If necessary,
concerns should be escalated, including starting ACCT procedures where
appropriate.
96. Mr Winspear was in a video link booth on his own. The officer who took Mr
Winspear into the booth, told a prison manager that she asked Mr Winspear to let
staff know the outcome of his hearing. She was then deployed elsewhere and did
not see Mr Winspear leave the booth. No one checked on Mr Winspear following
his hearing, he did not tell staff what had happened in court and staff were unaware
of his change in status. No one assessed him for suicide and self-harm risk or
referred him to healthcare staff. This was even more important given that Mr
Winspear was being supported using ACCT. While we accept that staff in Official
Visits did not know about the ACCT, it should still be standard procedure to assess
prisoners who have had a change in their status following a video link hearing.
97. Following a death at Hull in May 2021, we made a similar finding that prisoners
were not being properly risk assessed after attending court by video link. We were
told that a review had been undertaken in March 2022 and that staff had been
briefed on the correct procedures to follow, including that prisoners whose
circumstances had changed should be taken to reception for a Reception Risk
Review and referral to a nurse, as well as having details of the outcome of their
hearing added to their electronic prison record. None of this happened in Mr
Winspear’s case.
98. The Head of Safety told us that after Mr Winspear’s death, all staff in reception and
in Official Visits had been briefed on the HMPPS safety briefing on ‘Assessing risk
of harm in prisoners attending court and other appointments by video link’. He said
that the safety briefing was displayed in Reception and Official Visits to remind staff
and that custodial managers had been told to add the safety briefing to their regular
meetings with staff.
99. We note that despite being assured that all staff had been reminded in March 2022
of the correct procedures following a court appearance by video link, staff failed to
follow the correct procedures for Mr Winspear in August 2023. We therefore
consider that some assurance is needed that the correct processes are fully
embedded at Hull and being followed routinely by staff. We recommend:
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Governor should undertake an audit to assure himself that staff are
adhering to the correct procedures following court appearances by video link
and report the results to the Ombudsman.
100. We discussed with senior HMPPS colleagues our continued concerns about how
the risk of suicide and self-harm in prisoners appearing in court by video link was
managed. They confirmed that the new Prison Safety Policy Framework, due to be
implemented in 2024, would highlight that the period following a video court
appearance is one of heightened risk and would restate the requirement for a fresh
assessment of risk. Prison Group Directors will be responsible for monitoring their
establishments’ compliance with the requirements.
101. A review of PSO3050 Continuity of Healthcare for Prisoners is also underway and
the revised policy will be clear that where there is a change of circumstances or
demeanour following a video court hearing there is a requirement for healthcare
staff to see the prisoner, in the same way as following an in-person court
appearance.
Clinical care
102. The clinical reviewer concluded that the care Mr Winspear received at Hull was in
the main of a good standard and was equivalent to that which he could have
expected to receive in the community. She made several recommendations, not
directly related to Mr Winspear’s death, which the Head of Healthcare will wish to
address.
Good practice
103. The key worker supported Mr Winspear with the difficulties he was experiencing,
which included the complex issues surrounding his son. She spent several weeks
liaising with Mr Winspear’s son’s social worker to help arrange a visit between Mr
Winspear and his son. It is due to her efforts that Mr Winspear and his son were
able to spend some time together before Mr Winspear died. She showed genuine
kindness and compassion and went above and beyond her normal professional
duties to support Mr Winspear. We consider that this is an example of best practice
and that she should be commended for the quality of her key work.
Inquest
104. The inquest, held from 7 to 13 May 2025, concluded that Mr Winspear died by
misadventure.
14 Prisons and Probation Ombudsman
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