Angela Montgomery

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Independent investigation into
the death of Ms Angela
Montgomery,
at HMP Low Newton, on 25
February 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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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.
Ms Angela Montgomery died on 25 February 2024 at HMP Low Newton. She died from
drowning in a prison bath after taking a large number of antidepressant tablets. She was
51 years old. I offer my condolences to Ms Montgomery’s family and friends.
Ms Montgomery was subject to suicide and self-harm monitoring (known as ACCT) for
some of the time she was in prison, although she generally assured staff that she did
not want to die. Ms Montgomery’s final ACCT had been closed for almost a month by
the time of her death.
Aspects of the ACCT process were managed poorly. Ms Montgomery had made a
comment to a nurse that she would drown herself if she had the chance, but the
comment was not reported to ACCT case managers. There was also little input from
healthcare staff to ACCT reviews even though Ms Montgomery was receiving support
from a psychology support worker. It also seems likely that Ms Montgomery was able to
stockpile a large amount of medication that she had been receiving daily under
supervision.
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 October 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. On 30 December 2023, Ms Angela Montgomery was recalled to custody at HMP
Low Newton for breaching licence conditions by harassing neighbours. She had
been released on licence a week earlier having served a 12-week sentence for
harassment, contrary to a restraining order.
2. A reception officer started prison suicide and self-harm procedures (known as
ACCT) when Ms Montgomery said that she had thoughts of suicide.
3. On 31 December, Ms Montgomery told a nurse that she would drown herself if she
had the chance. The nurse did not note this comment in Ms Montgomery’s ACCT or
tell her ACCT case manager. Staff closed the ACCT on 11 January 2024.
4. Ms Montgomery was briefly supported through ACCT on two further occasions in
January.
5. At 10.07am on the morning of Sunday 25 February, Ms Montgomery went into the
landing bathroom to have a bath (the bathroom had three shower cubicles and a
bath which was behind a privacy screen).
6. At just before midday, officers began locking prisoners in their cells ahead of the
lunchtime patrol period. Officers could not find Ms Montgomery but when they went
into the bathroom, they saw her completely submerged in the bath. They lifted her
from the bath and started cardiopulmonary resuscitation (CPR). Nurses arrived one
minute later and gave oxygen.
7. Paramedics arrived at 12.11pm and took charge of Ms Montgomery’s care. At
around 12.38pm the paramedics ceased efforts to try to resuscitate Ms Montgomery
and pronounced that she had died.
8. The post-mortem examination found that Ms Montgomery had 24 prescribed
venlafaxine (an antidepressant) tablets in her stomach.
Findings
9. Ms Montgomery’s comment about drowning herself was not reported to staff
responsible for managing her ACCT.
10. Healthcare staff input into Ms Montgomery’s ACCT reviews was inadequate.
11. Ms Montgomery was able to accumulate a large number of venlafaxine tablets that
she was receiving under supervision.
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Recommendations
• The Governor and Head of Healthcare should ensure that:
• ACCT reviews are multidisciplinary,
• healthcare staff adequately consult clinical records before contributing to an
ACCT review and record their contribution afterwards, and
• ACCT case managers accurately record the name of healthcare staff from
whom they gain input before an ACCT review.
• The Head of Healthcare and the Governor should ensure that staff adhere closely
to protocols to limit prisoners’ ability to conceal and divert supervised medication.
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The Investigation Process
12. HMPPS notified us of Ms Montgomery’s death on 27 February 2024.
13. The investigator issued notices to staff and prisoners at HMP Low Newton informing
them of the investigation and asking anyone with relevant information to contact
him. One prisoner responded who he interviewed by telephone.
14. The investigator visited Low Newton on 6 March. He obtained copies of relevant
extracts from Ms Montgomery’s prison and medical records. He also interviewed
two prisoners.
15. The investigator interviewed seven members of staff at Low Newton on 6 and 7
May 2024.
16. NHS England commissioned an independent clinical reviewer to review Ms
Montgomery’s clinical care at the prison. The investigator and the clinical reviewer
conducted joint interviews with healthcare staff.
17. We informed HM Coroner for County Durham and Darlington of the investigation.
The Coroner gave us the results of the post-mortem examination. We have sent
him a copy of this report.
18. We contacted Ms Montgomery’s brother to explain the investigation and to ask if he
had any matters he wanted us to consider. He asked:
• What were the circumstances surrounding his sister’s death and did another
prisoner speak to her when she was using the bath?
• What care was she receiving for her mental health problems and was this care
appropriate?
• Why was she in possession of a large number of antidepressant tablets?
• Why was she allowed to bathe unsupervised?
19. We have answered these questions in the report.
20. We shared our initial report with HM Prison and Probation Service (HMPPS) and
with Ms Montgomery’s brother.
21. HMPPS did not find any factual inaccuracies and they provided an action plan in
response to our recommendations.
22. Ms Montgomery’s brother did not inform us of any factual inaccuracies.
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Background Information
HMP Low Newton
23. HMP Low Newton is located near Durham and holds women on remand and those
serving both short and long sentences including some high security prisoners.
Physical healthcare services are provided by Spectrum Community Healthcare CIC
and mental health provision is provided by Tees, Esk & Wear Valleys NHS
Foundation Trust.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Low Newton was in June 2021. Inspectors
found that relationships between staff and prisoners were excellent with 85% of
women saying that staff treated them with respect and 88% saying they could turn
to a member of staff if they had a problem. Inspectors noted that recorded self-harm
was lower than at most similar women’s prisons. Inspectors found that while the
day-to-day care provided to women in crisis was good, there were some key
weaknesses in ACCT case management. They noted that ACCTs did not always
consider the full range of risk factors and care plans were not always proactive and
well used.
25. Inspectors noted that staffing vacancies had presented challenges to the healthcare
team, although inspectors found that patients with long-term conditions were
managed well with appropriate care plans.
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. In its latest annual report, for the year to February 2023, the IMB wrote
that it believed Low Newton to be a reasonably safe prison for prisoners and staff
and that staff were vigilant, but not oppressive. The IMB noted a decrease in the
number of self-harm incidents compared to the previous year. although more
ACCTs had been opened compared to the previous year. The IMB concluded that
this reflected a greater willingness among staff to use ACCT procedures in
supporting prisoners.
Previous deaths at HMP Low Newton
27. Ms Montgomery was the second prisoner to die at Low Newton since February
2021. The previous death was a death from natural causes in August 2022. In that
case, the prisoner was in possession of medication not prescribed to her (as well as
illicit drugs), although it was likely that she had smuggled them into the prison when
she first arrived.
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Assessment, Care in Custody and Teamwork
28. 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.
29. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of 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. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
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Key Events
30. On 22 December 2023, Ms Angela Montgomery was released on licence from HMP
Low Newton where she had been serving a 12-week sentence of imprisonment for
harassment of a neighbour in breach of a restraining order.
31. On 30 December, Ms Montgomery was remanded back to Low Newton for
breaching the terms of her licence through further alleged acts of harassment.
32. At a reception health screen on arrival at Low Newton, Ms Montgomery said that
she was ‘all right’ about being back in custody and had no thoughts of suicide or
self-harm. A doctor re-prescribed Ms Montgomery’s various medicines, including
two antidepressants, venlafaxine and nortriptyline. Ms Montgomery did not hold
these medicines in-possession, but attended a medication hatch each day where
she was required to swallow the tablets in front of a nurse. Ms Montgomery’s
medical record noted that she had been diagnosed with alcohol induced epilepsy in
2001. Healthcare staff did not discuss this with her or start a care plan.
33. Ms Montgomery then saw a reception officer and said that she had thoughts of
suicide following an upsetting Christmas and difficulties with her neighbours. The
officer started prison suicide and self-harm support and monitoring procedures,
known as ACCT.
34. On the morning of 31 December, Nurse A, saw Ms Montgomery for a secondary
health screen. The nurse noted that Ms Montgomery was being supported on an
ACCT and, in answer to a question about whether she had thoughts of suicide,
noted that Ms Montgomery said that she would drown herself if she had the chance.
35. A few minutes later, Mental Health Nurse B, recorded that she had received a
telephone call from Supervising Officer (SO) A asking for someone from healthcare
to attend an ACCT review that afternoon. The nurse noted that her shift was due to
finish at midday so she would not be able to attend (nor was any other mental
health nurse on duty that afternoon). The nurse told the investigator that she told
the SO that she could telephone healthcare later on to ask if someone from the
primary care team would be able to attend. The nurse could not recall seeing the
comment about Ms Montgomery drowning herself if she had the chance. Nurse A
did not tell prison staff about Ms Montgomery’s comment or record it in her ACCT
document.
36. SO A chaired an ACCT review with Ms Montgomery that afternoon. Ms
Montgomery said that she did not want to die, but felt hopeless and believed she
had been ‘set up’ by her neighbours. Ms Montgomery said that she wanted to see
the mental health team and wanted to move to A wing as that was where she felt
most comfortable. She said that she had a sense of loss about being back in prison.
37. SO A said that as there was no mental health nurse at the ACCT review it would not
be appropriate to close the ACCT. The SO kept the ACCT open and arranged for
Ms Montgomery to be observed three times during the day and four times through
the night. The SO wrote a care plan that included for Ms Montgomery to preferably
move to A wing and for her to receive appropriate support in coming to terms with
being back in prison.
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38. In email correspondence, the SO told the investigator that she spoke to two nurses
in the morning about Ms Montgomery. She said that Nurse B told her that there
were no mental health nurses on duty to attend the ACCT review, but she gave her
the name of a nurse with whom Ms Montgomery had worked in the past. The SO
thought it would be helpful if the same nurse could work with her again during this
sentence. The SO said that the other nurse, Nurse C, told her that Ms Montgomery
was having a medication review with the pharmacist in a few days’ time. The SO
said that neither of the nurses told her that Ms Montgomery had spoken about
drowning herself. She said that she would have explored the comment at the review
had she been told. (The investigator was not able to check Nurse C’s recollection
as she was no longer employed at Low Newton.)
39. On 5 January, staff discussed Ms Montgomery at the safety intervention meeting
(SIM) due to her being a new reception being supported by ACCT. The minutes of
the SIM did not detail any discussion about plans for Ms Montgomery’s support.
40. SO B chaired Ms Montgomery’s next ACCT review later that day. SO C also
attended. SO B noted that there was no representative from the mental health team
as Ms Montgomery was not on their caseload. At the review Ms Montgomery said
that she was feeling much better and was hoping to see the mental health team that
week. She also said that she was hoping to start working again as a wing cleaner,
as she had done the last time she was in Low Newton. SO B kept the ACCT open
with the same level of observations.
41. On 9 January, a psychological wellbeing practitioner saw Ms Montgomery for a
mental health assessment. Ms Montgomery had asked to see the psychological
wellbeing practitioner as she had offered her support the previous time she was in
Low Newton. Ms Montgomery had declined help at that time as she was on the
point of being released from custody. The psychological wellbeing practitioner
noted that Ms Montgomery had harmed herself in the past by cutting, the last time
had been a year earlier and also said that she often thought that she would be
better off dead. Ms Montgomery said she had had such thoughts for a long time but
also said that she had no present plans to act on those thoughts. At the end of the
assessment Ms Montgomery agreed to a programme of low intensity cognitive
behavioural therapy (CBT) sessions (CBT entails the patient talking through their
problems to gain awareness and to derive solutions to problematic thinking).
42. On 11 January, SO C chaired Ms Montgomery’s next ACCT review. She said that
she continued to have some good days and some bad days, but that was
completely normal for her. She said that she was keeping herself busy by
completing distraction packs (such as puzzles and colouring exercises), which she
enjoyed. She said that she had no thoughts of suicide or self-harm. The SO noted
that the ACCT could be closed. The SO made no reference to any healthcare
attendee. He told the investigator that he always contacted healthcare for their
input, but if the prisoner was not on the mental health team workload, they would
not normally attend reviews. The SO said that in future he would record this contact
with healthcare including the name of the person to whom he had spoken.
43. On 15 January, Ms Montgomery moved to a single cell on the ground floor on A
wing.
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44. On 18 January. SO D saw Ms Montgomery for an ACCT post-closure review (a
check one week after an ACCT has been closed to review the prisoner’s wellbeing).
Ms Montgomery said that she was depressed and suicidal. She said that she was
due to attend court on 29 January and was unsure what she might do if she was
remanded back in custody. The SO reopened Ms Montgomery’s ACCT.
45. On 19 January, Ms Montgomery was again discussed at the SIM due to her ACCT
being re-reopened.
46. Later that day, SO C chaired an ACCT review with Ms Montgomery. Nurse D also
attended. The SO asked Ms Montgomery about the events that led to her ACCT
being reopened the previous day. Ms Montgomery said that she was ‘pissed off’ as
she believed that she had been ‘set-up’ by her neighbours leading to her being
remanded back into custody. She said though that she was due in court at the end
of the month and was hopeful that she would be released from custody. She said
that she was not suicidal and dealt with unpleasant thoughts by hitting her mattress.
Staff present closed the ACCT.
47. Nurse D did not make an entry in Ms Montgomery’s medical record about the ACCT
review and acknowledged that she should have done. She told the investigator that
she recalled the review and Ms Montgomery did not report any thoughts of suicide
or self-harm, although she was bored from not having a job and was also frustrated
about being in prison.
48. On 30 January, Ms Montgomery attended a video-link plea and trial preparation
hearing and was remanded in custody until her next hearing on 19 March. Officer A
noted that Ms Montgomery had been in tears during the hearing and at the
conclusion. Ms Montgomery’s solicitor said that he was concerned that she might
harm herself. The officer spoke to Ms Montgomery, who then started crying and
said, ‘I don’t want to be here, I don’t know how much more I can take’. The officer
re-opened Ms Montgomery’s ACCT.
49. On 31 January, SO E chaired an ACCT review with Ms Montgomery and Officer B.
The SO said that before the review she went to the healthcare unit to ask if a
mental health nurse would attend the review, but she was told that Ms Montgomery
was not on the mental health team workload so one would not attend. The SO said
that Ms Montgomery engaged in the review. She said that she was due in court in
six weeks’ time and was hopeful that she would be released from custody. She also
said that she was going to apply for a job to keep herself busy. She said that she
felt safe in prison and was content on A wing as the prisoners there focused on their
own issues and left one another alone. The SO closed Ms Montgomery’s ACCT.
50. On 7 February, SO E saw Ms Montgomery for an ACCT post-closure review. Ms
Montgomery said that she had good days and bad days and dealt with the bad days
by either keeping busy or sleeping. She said that she was seeing the mental health
team and was looking forward to getting a job. The SO noted that the ACCT did not
need to be re-opened.
51. On 13 February, Ms Montgomery started working as a wing cleaner.
52. Officer C was Ms Montgomery’s key-worker and he saw her several times for key-
worker sessions (the key-worker scheme allocates officers dedicated time to spend
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with individual prisoners, focussing on their development). The officer’s last keywork
meeting with Ms Montgomery was on 15 February. The officer noted that Ms
Montgomery was pleased that she had started working. He noted that keeping busy
helped her frame of mind and the pay also allowed her to buy items from the prison
shop. The officer told the investigator that he was shocked when he learned of Ms
Montgomery’s death as he had expected her to get on with her sentence until her
release.
53. On 16 February, Ms Montgomery met the psychological wellbeing practitioner for a
CBT session. The psychological wellbeing practitioner told the investigator that Ms
Montgomery was tearful at the start of the session as she had heard that people in
the community had been posting negative comments on Facebook about her and
her deceased mother. The psychological wellbeing practitioner said that she asked
Ms Montgomery about options for dealing with these issues and she said that she
wanted to get back into the community and to repair her relationships with people.
The psychological wellbeing practitioner said that she advised Ms Montgomery
about ‘grounding’ techniques, including mediation and her mood lifted. At the end of
the session Ms Montgomery said that was looking forward to taking a bath.
54. The psychological wellbeing practitioner went to see Ms Montgomery on 23
February for another CBT session but Ms Montgomery said that she did not want to
talk that day. However, she also said that she was fine, was not thinking about
harming herself and they agreed to meet again the following week.
55. A prisoner told the investigator that she had met Ms Montgomery before at Low
Newton. She said they had a good relationship and while Ms Montgomery was quite
reserved when in a group, she would open up in one-to-one situations. She said
that Ms Montgomery never said anything to suggest she intended to take her life.
56. Ms Montgomery made no telephone calls while at Low Newton and she received no
visits.
Events of 25 February
57. The investigator watched CCTV footage, body worn video camera footage (BWVC)
and listened to radio transmissions relating to the emergency response. The
following account is based on these sources, in addition to the written accounts
from staff and staff interviews.
58. A second prisoner told the investigator that she had heard Ms Montgomery sobbing
in her cell the previous evening and she asked her on 25 February if she was okay.
She said that Ms Montgomery looked terrible and said that she had chest pain.
59. The second prisoner told the investigator that she also spoke to Ms Montgomery
that morning. She said that Ms Montgomery was chatty and she asked to borrow
some skin oil.
60. At around 9.50am on 25 February, Officer D went to Ms Montgomery’s cell while
making routine security checks of all cells. Ms Montgomery said that she wanted to
have a bath and the officer told her that she would unlock her in around 10 minutes
time. The officer briefly re-locked Ms Montgomery’s door and carried on making
security checks on the other cells.
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61. At around 10.00am, Officer D unlocked Ms Montgomery’s cell and told her she
could use the bath. The officer noted that there was nothing about Ms
Montgomery’s demeanour that was unusual or out of character for her. (Prisoners
without any specific risk factors were allowed unsupervised use of the baths.)
62. CCTV shows that Ms Montgomery went into the bathroom at 10.07am. At 10.32am,
another prisoner went into the bathroom and came out again one minute later. She
told the investigator that she had gone into the bathroom to ask Ms Montgomery for
a vape. Ms Montgomery told her that she would give her a vape after she had had
her bath. She said that she did not walk around the privacy screen, so she did not
see Ms Montgomery. (The privacy screen obscures the bath from the rest of the
bathroom.)
63. At around 11.55am, Officer D and Officer E started locking up prisoners on the A-
1 landing for the lunch-time routine check. Ms Montgomery was not in her cell
and another prisoner said that she thought she was in the bathroom. Officer D
looked into the bathroom, but she did not see Ms Montgomery. The officer told
the investigator that she was going to check if Ms Montgomery had gone to
another landing but realised that that would be unusual behaviour for her, so she
immediately returned to the bathroom. As she walked into the bathroom she saw
clothing to the side of the privacy screen and then saw Ms Montgomery
submerged under water in the bath. The officer called to Officer E and radioed a
medical emergency code blue (to signal a prisoner with breathing difficulties).
Staff in the control room noted that the code blue call was made at 11.59am and
they immediately requested an ambulance.
64. BWVC footage shows that Officer D lifted Ms Montgomery from the bath without
delay and placed her on the floor. Officers checked for a pulse and found none,
so started CPR. Nurses arrived within around a minute and gave Ms
Montgomery oxygen. On several occasions staff can be heard on the recording
saying that there was water coming out of Ms Montgomery’s mouth. Staff can
also be heard discussing whether to use a defibrillator, but concluded that they
could not do so as there were puddles of water on the bathroom floor.
65. Paramedics arrived at 12.11pm. They asked staff to move Ms Montgomery from the
bathroom to the landing and they took charge of her care. At around 12.38pm, the
paramedics ceased efforts to resuscitate Ms Montgomery and pronounced that she
had died.
Contact with Ms Montgomery’s family
66. Ms Montgomery had given as next of kin the neighbour with whom she had been in
dispute and who had filed a restraining order against her. Low Newton asked the
police to help identify Ms Montgomery’s biological family and on 28 February, they
confirmed that she had a brother who lived in Leeds. One of Low Newton’s family
liaison officers, telephoned Ms Montgomery’s brother at 11.00am. He confirmed
that the police and the Coroner’s officer had already told him about his sister’s
death. He also said that there were two other brothers and he had informed them of
the news.
67. Low Newton contributed to the cost of Ms Montgomery’s funeral in line with national
instructions.
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Support for prisoners and staff
68. After Ms Montgomery’s death, Custodial Manager (CM) A debriefed the staff
involved in the emergency response to ensure they had the opportunity to discuss
any issues arising, and to offer support. Staff were offered further support from the
care team and the Trauma Risk Management (TRiM) team.
69. Staff spent time with prisoner A as she was very upset at Ms Montgomery’s death.
Low Newton’s managing chaplain spoke to all of the prisoners from Ms
Montgomery’s landing, and they were all then taken to reception where they were
given hot drinks and offered support from Listeners (prisoners trained by the
Samaritans to provide confidential peer support). Staff made welfare checks on all
the prisoners on the other landings on A wing. All prisoners assessed as being at
risk of suicide or self-harm were reviewed in case they had been adversely affected
by Ms Montgomery’s death and observations on all these prisoners were raised to
four times an hour pending further review.
Post-mortem report
70. Ms Montgomery’s toxicology report noted that 24 venlafaxine tablets were found
in her stomach at post-mortem examination. The report noted that the level of
venlafaxine in Ms Montgomery’s blood was well above the level expected with
therapeutic use, but was also significantly below concentrations reported in
fatalities attributed to venlafaxine toxicity (therapeutic use means a level
consistent with that given to successfully treat an illness). The toxicology report
also noted that Ms Montgomery’s blood sample contained a level of nortriptyline
that substantially exceeded that expected with therapeutic use. The report noted
however that nortriptyline is prone to post-mortem redistribution (post-mortem
redistribution refers to changes in drug concentrations after death so that the
levels detected might not accurately represent the dose taken by the patient).
71. The pathologist noted that his principal findings included that Ms Montgomery
had bleeding into her lungs, had 24 venlafaxine tablets in her stomach and had
evidence of brain damage caused by interrupted blood flow to the brain. The
pathologist explained that his post-mortem findings were consistent with death by
drowning due to the effects of venlafaxine. The pathologist added that his
conclusion on cause of death was largely based on the circumstances of Ms
Montgomery’s death, rather than on any positive post-mortem findings. He
explained that typical post-mortem findings of drowning are froth in the main
airways and over-expanded lungs. However, both of these presentations are
eliminated by CPR.
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Findings
Management of Ms Montgomery’s risk of suicide and self-harm
72. 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 self-harm or suicide posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under ACCT procedures. 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.
73. Ms Montgomery made various comments while at Low Newton indicating that she
was at potential risk of suicide. She specifically said on 31 December that she
would drown herself if she had the chance, she said on 9 January that she had had
long term thoughts that she would be better off dead, she said that she felt
depressed and suicidal on 18 January, and when she was remanded back into
custody at a court hearing on 30 January, said she did not know how much more
she could take.
74. However, at her ACCT reviews Ms Montgomery generally assured staff that she
had no suicidal intentions and at her final ACCT review on 31 January said that she
was hopeful about being released from custody at her next court appearance in six
weeks’ time.
75. While the psychological wellbeing practitioner’s evidence might indicate that Ms
Montgomery’s final ACCT would have been closed on 31 January even had she
attended the review, we are very concerned about the clear failures in
communication between healthcare and discipline staff throughout Ms
Montgomery’s time in Low Newton. The first omission was on 31 December when
healthcare staff failed to tell discipline staff that Ms Montgomery had said that she
would drown herself if she could. The Head of Healthcare, told the investigator that
he had spoken to both Nurse A and Nurse B about the actions they should have
taken. He said that Nurse B was receiving ongoing supervision about her future
practice.
76. There was then no healthcare representative at Ms Montgomery’s next two ACCT
reviews on 5 January and 11 January. On 5 January, SO B noted that he had been
told that Ms Montgomery was not on the mental health workload, and SO C said
that he was told the same for the review on 11 January, although he made no
record of this at the time.
77. Nurse D did attend the ACCT review on 19 January, but she failed to make an entry
about the review in Ms Montgomery’s medical record.
78. For the ACCT review on 31 January, SO E again noted that she was told (we do not
know by who) that Ms Montgomery was not on the mental health team workload.
This was despite the fact that Ms Montgomery was seeing the psychological
wellbeing practitioner.
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79. The head of healthcare told the investigator that a mental health nurse will attend
initial ACCT reviews if there is a nurse available and will attend future ACCT
reviews if the prisoner is on the mental health team caseload. He said that if the
prisoner’s is not on the mental health team caseload, but they have primary health
needs, a primary care nurse will attend future ACCT reviews. He said that
attendance at following ACCT reviews should be discussed at the end of each
review. He also said that where healthcare staff are contacted by an SO for
attendance at an unscheduled ACCT review, he would expect the nurse to check
the prisoner’s records to advise the SO of the prisoner’s medical issues and to
document that contact.
80. As none of the SOs noted any names of healthcare staff to whom they might have
spoken, we were unable to verify their evidence. We also note that their evidence is
in clear contradiction to the head of healthcare’s evidence. We make the following
recommendation:
The Governor and Head of Healthcare should ensure that:
• ACCT reviews are multidisciplinary,
• healthcare staff adequately consult clinical records before contributing to
an ACCT review and record their contribution afterwards, and
• ACCT case managers accurately record the name of healthcare staff from
whom they gain input before an ACCT review.
81. After Ms Montgomery’s final ACCT was closed on 31 January, she said nothing
further to staff to suggest she might be at risk and, in general, seemed happy that
she had started working again as a wing cleaner. However, her actions in
apparently accumulating an extensive amount of medication would suggest that she
had been planning to harm herself. Staff were unaware of this and we consider that
overall there was little to indicate that Ms Montgomery was at imminent risk of
suicide when she died.
Medication distribution
82. As already noted, Ms Montgomery was found at post-mortem examination to have
24 venlafaxine tablets in her stomach. She was prescribed this medication but did
not have it in her possession. She attended the medication hatch daily to be given
her tablet by a nurse who would then ask her to drink a cup of water. However, the
head of healthcare said that HMPPS policy stresses that the mouth is deemed an
intimate area and with the exception of just two opiate based medicines, prisoners
were not routinely asked to open their mouths to check they had swallowed
prescribed medication. He said that if the nurse was concerned that a prisoner had
not swallowed her medication, the nurse would alert the officer supervising the
medication queue. It is common practice for prisoners to attempt to conceal
medication, often with the intention of trading the medication with other prisoners.
Similarly, prisoners are also known to trade medication they hold in possession.
83. It is possible that Ms Montgomery obtained the tablets from another prisoner who
had the medication in possession, although given the number of tablets, it seems
more likely that Ms Montgomery was able to divert the tablets when issued them
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each day. If this was the case, it demonstrates substantial weaknesses in the
supervision of medication. Following Ms Montgomery’s death, Low Newton has
started using two officers to supervise medicine distribution, one officer to manage
the queue and one officer to view each prisoner as they receive and take their
medication. We make the following recommendation:
The Head of Healthcare and the Governor should ensure that staff adhere
closely to protocols to limit prisoners’ ability to conceal and divert supervised
medication.
Access to baths
84. The investigator spoke to the Governor about access to baths at Low Newton. He
said that he had learned that prisoners with healthcare needs were assessed and
supervised in using the bath in the healthcare unit but there was no similar system
for prisoners on standard wings who had no apparent disabilities or other
healthcare needs. In response, the Governor removed access to the baths at Low
Newton other than the bath in healthcare. In light of the action already taken by Low
Newton, we make no recommendation of our own.
Clinical care
85. The clinical reviewer found that the care Ms Montgomery received at Low Newton
was not of a satisfactory standard and was not equivalent to that which she would
have received in the community. The clinical reviewer noted that Ms Montgomery
had alcohol induced epilepsy, but this condition was not fully assessed, and no care
plan was constructed to mitigate any risks. The clinical reviewer also noted that Ms
Montgomery had no mental health care plan.
86. The clinical reviewer was also concerned about aspects of the healthcare input in
Ms Montgomery’s ACCT management including poor communication, inconsistent
attendance at ACCT reviews and a failure to document attendance. The clinical
reviewer was also concerned about the robustness of medicine distribution at Low
Newton (and about which we have already made a recommendation). The clinical
reviewer made five recommendations which the Head of Healthcare will need to
address.
Good practice
87. We commend Low Newton for the efforts made to support other prisoners following
Ms Montgomery’s death. We consider this to be an example of best practice.
Inquest
88. An inquest into Ms Montgomery’s death held between 24 to 28 August 2026
concluded that her cause of death was suicide from drowning. The inquest jury
found that a contributory factor was that Mr Montgomery’s statement to a nurse that
she would drown herself if she could was not shared with officers and no action was
taken upon the statement.
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