Rowntree, Kevin

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Independent investigation into
the death of Mr Kevin Rowntree,
a prisoner at HMP Holme House,
on 16 December 2021
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, 2024
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Kevin Rowntree was found dead on the floor of his cell at HMP Holme House on 16
December 2021. He had hanged himself from the light fitting. He was 41 years old. I offer
my condolences to Mr Rowntree’s family and friends.
Mr Rowntree gave no indication to staff that he was at risk of suicide. Although information
came to light after Mr Rowntree’s death that he was struggling and was considering taking
his life, I am satisfied that staff were unaware. I consider that staff at Holme House could
not have foreseen Mr Rowntree’s actions.
I am concerned, however, that the officer who unlocked Mr Rowntree on the morning of 16
December did not notice that he was dead on the floor and that another prisoner
discovered him. There was a lack of clear guidance to staff on how to check prisoners’
welfare during the unlock process. This needs to be addressed.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
.
Sue McAllister CB
Prisons and Probation Ombudsman July 2022

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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8

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Summary
Events
1. On 30 November 2020, Mr Kevin Rowntree was remanded in prison custody,
charged with various offences, including robbery, common assault and breach of a
non-molestation order. He was sent to HMP Durham.
2. Mr Rowntree had a history of anxiety and depression and was prescribed
antidepressant medication. In March 2021, he asked to see someone from the
mental health team. However, when an appointment was offered to him, he failed to
engage with the support offered.
3. On 4 October, Mr Rowntree was sentenced to six years and six months in prison.
On 29 October, he was moved to HMP Holme House. Reception staff noted that he
had a history of anxiety and depression and a prison GP prescribed his
antidepressant medication. Mr Rowntree declined input from the mental health team
and no further concerns were noted.
4. Mr Rowntree had three sessions with his allocated keyworker on 12 November, 27
November and 14 December. His keyworker noted that he did not seem to want to
engage with her but she had no concerns about him.
5. At around 4.40am on 16 December, an operational support grade (OSG) looked
into Mr Rowntree’s cell as part of the standard morning roll check. He saw nothing
of concern. At approximately 8.52am, an officer unlocked Mr Rowntree’s cell but
she did not look in. Around a minute later, a prisoner alerted the officer that Mr
Rowntree was lying on the floor of his cell.
6. The officer called an emergency code blue, an ambulance was called and
healthcare staff attended. However, staff quickly realised that Mr Rowntree had
been dead for some time. He had hanged himself from the light fitting. Staff
therefore did not continue with attempts to resuscitate him. Ambulance paramedics
confirmed Mr Rowntree’s death at approximately 9.15am.
7. Mr Rowntree left a suicide note which said that his mental health was at its worst
and he could no longer cope. After Mr Rowntree’s death, a prisoner told staff that
Mr Rowntree had said he was going to kill himself because he was worried that it
had got out that he had been accused of mugging a pensioner.
Findings
8. We are satisfied that Mr Rowntree gave no indication to staff that he was at risk of
suicide and that they could not have foreseen his actions. Although information
came to light after Mr Rowntree’s death that he had been struggling with his mental
health, we are satisfied that staff were unaware of this.
9. We are satisfied that the morning roll check was carried out properly and that the
night OSG saw nothing of concern. However, we are concerned that the officer who
unlocked Mr Rowntree’s cell four hours later did not notice that he was dead on the
floor.
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10. We found that there was no clear unlock guidance in place at the prison at the time
of Mr Rowntree’s death. The officer who unlocked Mr Rowntree should have tried to
get a verbal response from him and then she would have realised that he was
unresponsive on the floor. It was unacceptable that another prisoner discovered
him.
11. The clinical reviewer concluded that Mr Rowntree’s clinical care was equivalent to
that which he could have expected to receive in the community.
Recommendations
• The Governor should ensure that, in line with PSI 75/2011, staff are issued with
clear guidance on how to check on the welfare of prisoners when unlocking cells.
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The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Holme House
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Rowntree’s prison and
medical records.
14. NHS England commissioned an independent clinical reviewer to review Mr
Rowntree’s clinical care at the prison. The investigator and clinical reviewer
interviewed three members of Holme House staff on 23 February and 8 March
2022. The interviews were conducted by telephone because of the restrictions in
place during the COVID-19 pandemic.
15. We informed HM Coroner for Teesside of the investigation. The coroner gave us
the results of the post-mortem examination. We have sent the coroner a copy of this
report.
16. We wrote to Mr Rowntree’s nominated next of kin, his mother, to explain the
investigation and to ask if she had any matters she wanted the investigation to
consider. Mr Rowntree’s family wanted to know:
• How long was he dead before he was found?
• What medication was he prescribed?
• Was he on suicide watch?
• What mental health support did he get?
• Had the police told him he would be charged?
• Is there any evidence of why he would take his own life?
We have answered the family’s questions in this report.
17. We shared our initial report with Mr Rowntree’s mother who identified a factual
inaccuracy on the clinical review which has been amended. Mr Rowntree’s mother
raised other issues which did not affect the factual accuracy of the report and these
have been addressed in separate correspondence.
18. We shared our initial report with the Prison Service. The Prison service pointed out
some factual inaccuracies with our report and the clinical review which have been
amended. The action plan has been annexed to this report.
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Background Information
19. HMP Holme House HMP Holme House is a category C training and resettlement
prison holding a maximum of 1159 men. Spectrum provides health services at the
prison. There is a 24-hour healthcare unit with 16 beds.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Holme House was in February and March 2020.
Inspectors reported that the prison was not sufficiently good in a number of areas,
including prisoner safety, although they acknowledged that the safer custody team
had undertaken some recent work to improve the quality of the ACCT case
management process. Incidents of self-harm had doubled since the last inspection
in 2017 and there had been three further self-inflicted deaths. Positively, inspectors
reported that all prisoners now had an allocated keyworker and 67% of prisoners
found them to be helpful. Mental health services were good and delivered
responsive, evidence-based treatments.
Independent Monitoring Board
21. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year ending 31 December 2020, the IMB
reported that staff referred 638 prisoners for ACCT monitoring during 2020. This
was significantly higher than in 2019. Inspectors reported that incidences of self-
harm had increased significantly, particularly in the second half of their reporting
year. Despite the challenges, prisoners who self-referred to the mental health team
were seen within four to five days with urgent cases being seen within 24 hours.
There was no waiting list for GP services and prisoners received an overall
responsive service.
Previous deaths at HMP Holme House
22. Mr Rowntree was the 13th prisoner to die at Holme House since December 2019.
Of the previous deaths, eight were from natural causes, two were self-inflicted, and
two are awaiting classification. There are no similarities between our findings from
our investigation into Mr Rowntree’s death and our investigation findings from the
previous deaths.
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Key Events
23. On 30 November 2020, Mr Kevin Rowntree was remanded in prison custody
charged with various offences, including robbery, common assault and breach of a
non-molestation order. He was sent to HMP Durham. Mr Rowntree had been in
prison many times before and had last been released in September 2020.
24. A nurse carried out a reception healthcare screening and noted that Mr Rowntree
had a history of anxiety and depression for which he was prescribed an
antidepressant (mirtazapine). She noted that he had no current thoughts of suicide
or self-harm and he declined any input from the mental health team. Although he
said he used cannabis occasionally and had a previous history of alcohol misuse,
Mr Rowntree declined any intervention from the substance misuse service. The
nurse referred Mr Rowntree to the prison GP who prescribed mirtazapine.
25. On 3 March 2021, Mr Rowntree told a nurse that he needed support from the
mental health team. He said he was low in mood because of problems in the
community with his partner and children. He told the nurse that he did not feel
suicidal at that time, but that he had tried to hang himself in his cell the previous
November. This information was not known to staff at the time. The nurse passed
his referral to the primary care mental health team (Rethink) so that he could be
assessed for low intensity cognitive behavioural therapy. Rethink sent him an
introductory letter and placed him on the waiting list for assessment.
26. On 31 March, Mr Rowntree failed to attend his appointment with Rethink. Staff
discussed his case the following day at a multi-disciplinary team meeting and he
was offered a further appointment with them on 1 April. However, he declined to
engage with the support on offer. Mr Rowntree did not report any further mental
health concerns while at Durham and there were no concerns about his wellbeing.
27. In August, Mr Rowntree was interviewed by police as part of their investigation into
further alleged burglary offences. He was not charged with any further offences.
28. On 4 October, Mr Rowntree was sentenced to six years and six months in prison.
On 29 October, he was moved to HMP Holme House. At his healthcare reception
screening, the nurse noted that he had a history of anxiety and depression for which
he was prescribed mirtazapine. She noted that he had no current thoughts of
suicide and self-harm and that he engaged well throughout the assessment. In line
with standard COVID-19 procedures at the time, Mr Rowntree was located on the
Reverse Cohorting Unit (RCU – where newly arrived prisoners are kept separate
from the main prison for at least 14 days to limit the spread of COVID-19).
29. On 1 November, a prison GP prescribed a further supply of mirtazapine as well as
pain relief (celecoxib) for Mr Rowntree’s ongoing shoulder pain.
30. On 12 November, Mr Rowntree had his first keyworker session with his allocated
keyworker. He told his keyworker that he was fine and had no concerns with the
regime. He said he was hoping to move onto the main prison wing soon.
31. On 13 November, Mr Rowntree was moved from the RCU to a single-occupancy
cell on House Block 2.
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32. On 27 November, Mr Rowntree’s keyworker went to see him for his second
keyworker session. She noted in his record that he was asleep in his cell and,
although she tried to talk to him, he did not want to engage in conversation. She
said she would come back and see him another time.
33. On 14 December, Mr Rowntree was moved to a different cell on House Block 2.
His keyworker saw him for a keyworker session on the same day. She noted in his
record that he said he was fine and he was settled on House Block 2. He said he
did not have anything to discuss with her but he knew how to contact her if he
needed to.
34. Mr Rowntree’s keyworker told the investigator that she had no concerns about Mr
Rowntree when she met him for keyworker sessions. She said that he was not
particularly talkative and did not seem to want to engage with her but this was not a
worry for her. She said she would have flagged up concerns if she had any.
35. On the morning of 15 December, a prison GP saw Mr Rowntree as he was
complaining of ongoing shoulder pain. Mr Rowntree told the GP that previous pain
relief medication had negative side effects so the GP prescribed naproxen at his
request. The GP told him she would make a referral for further investigation at the
hospital.
Events of 16 December 2021
36. At around 4.40am on 16 December, an operational support grade (OSG) looked
into Mr Rowntree’s cell as part of the standard morning roll check. The OSG could
not specifically recall what he saw when he looked into Mr Rowntree’s cell but he
told the investigator he would at least have had a visual sighting of him. He was
confident that he checked all cells and that nothing was out of the ordinary,
otherwise he would have taken appropriate action.
37. At approximately 8.52am, an officer unlocked Mr Rowntree’s cell for morning
association. CCTV shows her opening the cell door but she does not look into the
cell. The officer told the investigator that she was aware of the need to get a visual
sighting or verbal response from prisoners at unlock. However, she said she would
give them time to wake up properly before going back to check on them if she did
not see them within a few minutes of unlock.
38. Almost immediately after the officer unlocked Mr Rowntree’s cell, a prisoner went
into the cell and saw Mr Rowntree lying on the floor. The prisoner came out of the
cell and shouted for the officer. CCTV shows she returned to the cell at 8.53am and
immediately called an emergency code blue (a medical emergency code used when
a prisoner is unconscious or having breathing difficulties) as she found Mr Rowntree
was cold to the touch with no pulse.
39. A nurse responded immediately to the emergency code blue and arrived at 8.56am.
She did not have an emergency bag with her as she was not the designated first
responder, but she attended as she was nearby. She said she could see signs that
Mr Rowntree had attached a ligature from the light fitting. She initially tried to carry
out chest compressions on him but soon realised there were signs of rigor mortis
(stiffening of the body that occurs two to six hours after death) and therefore further
attempts to resuscitate him would be futile. Another nurse arrived shortly afterwards
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with the emergency bag but the first nurse indicated to her that no further
intervention was necessary as Mr Rowntree was already dead. Paramedics arrived
shortly afterwards and confirmed Mr Rowntree’s death at approximately 9.15am.
Information received after Mr Rowntree’s death
40. Mr Rowntree left a suicide note in his cell addressed to his mother and his partner.
He said his mental health was at its worst and he could no longer cope. He
apologised to them and other family members, including his daughter, son and
sister, and asked everyone to have a party at his funeral.
41. After Mr Rowntree’s death, two prisoners said they had had concerns about him.
One said that he had smelt of alcohol on the night before he died. The other said Mr
Rowntree told him he was going to kill himself as he was worried it had got out that
he had been accused of mugging a pensioner. This information was not shared with
staff before Mr Rowntree took his life.
42. The police confirmed that Mr Rowntree had not been charged with any additional
offences at the time of his death.
Contact with Mr Rowntree’s family
43. The prison appointed a prison manager and an officer as the family liaison officers
and identified Mr Rowntree’s mother as his next of kin. At 10.45am, they visited Mr
Rowntree’s mother at her home and broke the news of his death.
44. The prison contributed towards the cost of Mr Rowntree’s funeral in line with Prison
Service guidance.
Support for prisoners and staff
45. A prison manager held a debrief on the day of Mr Rowntree’s death to offer support
to the staff involved in the emergency response and to ensure they had the
opportunity to discuss any issues. The staff care team also offered support
46. The prison posted notices informing other prisoners of Mr Rowntree’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 Rowntree’s death.
Post-mortem report
47. The pathologist concluded that Mr Rowntree died as a result of asphyxiation due to
hanging. The toxicology report is still awaited.
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Findings
Management of Mr Rowntree’s risk of suicide and self-harm
48. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), requires all staff who have
contact with prisoners to be aware of the triggers and risk factors that might
increase the risk of suicide and self-harm, and take appropriate action. PSI 64/2011
sets out the procedures (known as ACCT) that staff must follow if they identify a
prisoner at increased risk. We found that appropriate measures were taken by staff
at both Durham and Holme House to explore potential risk factors and offer
appropriate support. Mr Rowntree was prescribed medication for depression and
anxiety and informed of support available if needed for mental health and substance
misuse.
49. Mr Rowntree was not monitored under ACCT procedures at either Durham or
Holme House. We accept that Mr Rowntree gave no indication that he was at risk of
suicide and self-harm and therefore there was no reason to start ACCT monitoring.
Although information came to light after Mr Rowntree’s death that he was struggling
with his mental health, we are satisfied that this information was not known to staff
at the time. We make no recommendation.
Morning unlock
50. An OSG carried out the early morning roll check at around 4.40am on 16
December. CCTV shows that he shone a torch through the observation panel to
look into Mr Rowntree’s cell. He could not remember exactly what he saw when he
looked into the cell but he told the investigator he was confident that there was
nothing of concern or he would have raised the alarm. We are satisfied that the
OSG carried out a proper check. It appears likely that Mr Rowntree hanged himself
a short time later. Mr Rowntree had rigor mortis when he was found, which
indicates that he had been dead for at least two hours at 8.52am.
51. We are concerned about the lack of a welfare check when Mr Rowntree was
unlocked on the morning of 16 December. CCTV shows that the officer just
unlocked the door and did not look into Mr Rowntree’s cell. She told the investigator
that she would have gone back and checked on him if she had not seen him after a
few minutes of opening the door. We accept that Mr Rowntree was already dead by
that time and a welfare check at that point would not have saved his life. However,
the officer’s failure to check that he was safe and well when she unlocked the cell
meant that another prisoner found Mr Rowntree dead. This is unacceptable.
52. Prison Service Instruction (PSI) 75/2011, Residential Services, notes that it is
unacceptable for staff unlocking a prisoner in the morning not to notice that the
prisoner has died overnight. It says, ‘The appropriate arrangements depend on the
local regime, but there need to be clearly understood systems in place for staff to
assure themselves of the wellbeing of prisoners during or shortly after unlock. For
example, if a prisoner is expected to leave their cell for an activity shortly after being
unlocked, then it will be sufficient for there to be a check on any prisoner who does
not do so. Where prisoners are not necessarily expected to leave their cell, staff will
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need to check on their wellbeing, for example by obtaining a response during the
unlock process.’
53. We found that there was no clear guidance to staff at Holme House about what they
should do to check on the welfare of prisoners when unlocking cells. We consider
that in the case of Mr Rowntree, the officer should have tried to get a verbal
response from him when she unlocked his cell. Had she done so, she would have
realised that he was dead on the floor. We are aware that a Governor’s Notice on
welfare checks has been issued to staff since Mr Rowntree’s death. Nevertheless,
we make the following recommendation:
The Governor should ensure that, in line with PSI 75/2011, staff are issued
with clear guidance on how to check on the welfare of prisoners when
unlocking cells.
Clinical care
54. The clinical reviewer concluded that Mr Rowntree’s mental and physical healthcare
was of a good standard and at least equivalent to that which he could have
expected to receive in the community.
55. Although Mr Rowntree mentioned in a suicide note to his family that his mental
health was very poor, we found no evidence that staff were aware of any issues
with his emotional wellbeing. The only time he requested help from the mental
health team was in March 2021 at Durham. We found that staff responded
appropriately to his request for support but he unfortunately did not engage with the
support on offer. He did not request support for his mental health at any time at
Holme House and no concerns were noted.
56. We consider that the decision by nurses to stop resuscitation attempts on Mr
Rowntree was appropriate given he was clearly dead when he was found.
Inquest
57. The inquest, held on 27 and 28 November 2023, concluded that Mr Rowntree died
by suicide.
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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