Esson, Stuart

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Stuart Esson,
a prisoner at HMP Rochester,
on 12 February 2022
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
© Crown copyright, 2024
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.
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 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 Stuart Esson died in hospital on 12 February 2022, after he was found hanging in his
cell in the Care and Separation Unit (CSU) at HMP Rochester on 10 February. He was 41
years old. I offer my condolences to his family and friends.
Mr Esson had a history of self-harm and suicidal thoughts and had been managed under
suicide and self-harm monitoring procedures (known as ACCT) while serving previous
prison sentences. He also had a history of poor mental health and substance misuse.
Mr Esson was at Rochester for six weeks and spent all of that time in the CSU. He could
be difficult to manage, including that he started more than one dirty protest, and refused to
move to a normal wing.
Staff began suicide and self-harm monitoring procedures (known as ACCT) on 8 February,
when he tied a ligature around his neck. I am concerned that the decision to reduce the
frequency of checks two days later was premature and did not take into account his
presentation.
I am also very concerned that an officer failed to complete ACCT checks on Mr Esson on
10 February as they should have done and falsified the record.
The clinical reviewer concluded that the care Mr Esson received at Rochester was of a
reasonable standard and equivalent to that which he could have expected to receive in in
the community. She was, however, concerned that nursing staff were not sufficiently
trained in ACCT procedures. They failed to review Mr Esson’s medical information before
attending his ACCT case reviews and failed to make relevant entries in his ACCT
document.
It is disappointing that a number of the recommendations made in this report relate to
record keeping and following required Prison Service policies and procedures.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman November 2023
Prisons and Probation Ombudsman 1
Contents
Summary ......................................................................................................................... 3
The Investigation Process ................................................................................................ 7
Background Information ................................................................................................. 11
Key Events ..................................................................................................................... 10
Findings ......................................................................................................................... 18
2 Prisons and Probation Ombudsman
Summary
Events
1. Mr Stuart Esson had a history of mental health problems (and was prescribed
antipsychotic medication) and substance misuse. He had been in prison several
times before.
2. On 24 October 2021, Mr Esson was remanded to HMP Nottingham. He had a
history of starting dirty protests (where a prisoner chooses to defecate or urinate
without using the facilities provided and sometimes covers their surroundings,
clothing and body in faecal waste). He began one in the transport vehicle on his
way to prison and so was taken straight to the prison’s Care and Separation Unit
(CSU – previously known as the segregation unit).
3. Mr Esson spent the majority of his time in the prison’s CSU. He started dirty
protests on several occasions. He said that he felt unsafe and asked to be
transferred closer to his family in Scotland.
4. On 18 January, Mr Esson transferred to HMP Rochester, which he was angry and
disappointed about. He refused to move to a standard wing and so he was again
taken to the CSU.
5. At 7.30am on 8 February, an officer found Mr Esson with a ligature around his neck.
Mr Esson was conscious but was taken to hospital as a precaution. Prison staff
started suicide and self-harm monitoring procedures (known as ACCT). At around
lunchtime, Mr Esson discharged himself from hospital and returned to Rochester.
He returned to the CSU and staff placed him under constant supervision.
6. On 9 and 10 of February, staff held ACCT case reviews. Mr Esson had been
displaying paranoid and impulsive behaviour, but staff reduced his level of
observations to four observations per hour on 9 February, and two observations per
hour on 10 February.
7. At 1.00pm on 10 February, an officer checked on Mr Esson. She saw him sitting
under the sink with a ligature around his neck. The officer radioed an emergency
medical code, staff went into the cell and began CPR. Paramedics arrived within
ten minutes and took over his care and treatment. At 1.35pm, they took Mr Esson
to hospital by emergency ambulance.
8. In hospital, Mr Esson was placed on life support. At 10.20pm on 12 February, it
was confirmed that Mr Esson had died.
Findings
Management of ACCT procedures
9. Prison staff appropriately started ACCT procedures on 8 February, after Mr Esson
tied a ligature around his neck. However, we consider that the decision to reduce
his observations to two an hour on 10 February was inappropriate given ongoing
concerns about his presentation, his increased anxiety and his impulsive behaviour.
Prisons and Probation Ombudsman 3
10. We are concerned that a prison officer failed to complete ACCT checks on Mr
Esson on 10 February as she should have done. She also falsified entries in Mr
Esson’s ACCT document to indicate that checks had been completed when they
had not been.
Location in the Care and Separation Unit (CSU)
11. Segregation is known to negatively impact a prisoner’s mental state and can
increase the risk of suicide or self-harm. Mr Esson was often accommodated in the
CSU while serving previous sentences in prison and he had also engaged in dirty
protests dating back as far as 2011. His reasons for refusing location on a
residential unit were not always clear, but evidence suggests that he used dirty
protests as a way of remaining in the CSU.
12. Mr Esson spent the whole of his six weeks at Rochester in the CSU. He refused to
move to a wing and staff were attempting to arrange a transfer for him. On the
evidence available, it does not seem that being segregated – in itself – negatively
impacted on his mental state or level of risk and we concluded it was not
inappropriate to house him there.
Mr Esson’s Primary and Mental Healthcare
13. The clinical reviewer concluded that the clinical care Mr Esson received at HMP
Rochester was of a reasonable standard and equivalent to that which he could have
expected to receive in the community. She did, however, identify some areas of
concern.
14. The clinical reviewer was concerned that nursing staff were not sufficiently trained
in ACCT procedures. They failed to review Mr Esson’s medical information before
attending his ACCT case reviews and failed to make relevant entries in his ACCT
document.
15. Healthcare staff failed to record on the segregation safety algorithm that Mr Esson
was prescribed antipsychotic medication, and this was not updated during his time
at Rochester. She was also concerned that healthcare staff were not always able
to read the prisoner’s medical records before completing a safety algorithm.
16. Mr Esson was under the care of the Mental Health Team at HMP Nottingham but
there was no formal handover of care between HMP Nottingham and HMP
Rochester as there should have been.
Response to Mr Esson’s concerns about his safety
17. Mr Esson believed that he was under threat from other prisoners on the CSU.
Although this issue was recorded in the ACCT case reviews, we found no evidence
that staff investigated Mr Esson’s concerns.
Record Keeping
18. We found various examples of poor record keeping at Rochester, including in
important segregation paperwork, contrary to national guidance.
4 Prisons and Probation Ombudsman
Mr Esson’s transfer from HMP Nottingham to HMP Rochester
19. Prison staff failed to carry out the correct procedures when transferring Mr Esson
from HMP Nottingham to HMP Rochester.
Recommendations
• The Governor at HMP Rochester should ensure that staff manage prisoners at
risk of suicide and self-harm in line with national guidelines, including that:
• staff understand the need to consider a prisoner’s risk factors when
assessing risk and that the level of observations is agreed by all those
present at the review and reflects the immediate concerns; and
• staff conduct ACCT observations in line with what is set out in the
prisoners individual ACCT document and record these appropriately.
• The Governor should inform the PPO of the outcome of the disciplinary
investigation into the actions of Officer A.
• The Head of Healthcare at HMP Rochester should ensure that:
• healthcare staff read the prisoner’s medical history prior to attending
ACCT case reviews;
• healthcare staff record their involvement with the ACCT case review in
the ACCT document in accordance with PSI 64/2011; and
• all healthcare staff complete the full two-day ACCT training course
(version six).
• The Head of Healthcare at HMP Rochester should ensure that healthcare staff:
• receive appropriate training to competently carry out segregation
safety algorithm assessments; and
• read any available medical history prior to undertaking a segregation
safety algorithm.
• The Heads of Healthcare at HMP Rochester and HMP Nottingham should
ensure there is a formal mental health handover when a prisoner is transferred
between prisons.
• The Head of Healthcare and Mental Health In-Reach Manager should review
and ensure that:
• the roles and responsibilities of newly qualified nurses are appropriate
to their level of experience and competency, and
• newly qualified nurses receive appropriate ongoing support and
supervision from managers and a mentor.
Prisons and Probation Ombudsman 5
• The Governor of Rochester should ensure that any concerns raised by a
prisoner about their safety are properly investigated and recorded appropriately.
• The Governor at HMP Rochester should:
• review the current process for recording daily interactions, visits from
other agencies and the regime for prisoners in the Care and
Separation Unit and satisfy themselves that it fully adheres to the
guidance set out in PSO 1700 Segregation;
• review the current process for storing documentation and ensure it
complies with PSO 1700 Segregation,
• ensure CSU staff notify the Independent Monitoring Board when a
prisoner is located in the Care and Separation Unit and that the safety
algorithm is completed correctly to indicate that this action has been
completed, and
• ensure that dirty protests are managed in accordance with PSO 1700
Segregation, the Health and Safety at Work Act 1974 and COSHH
Regulations 1999.
• The Governors of HMP Rochester and HMP Nottingham must ensure that when
a prisoner located in the CSU is to be transferred every aspect of the process
follows the guidance as set out in PSO 1700 Segregation.
6 Prisons and Probation Ombudsman
The Investigation Process
20. The investigator issued notices to staff and prisoners at HMP Rochester informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
21. The investigator visited Rochester on 22 February 2022. He obtained copies of
relevant extracts from Mr Esson’s prison and medical records.
22. The investigator interviewed 13 members of staff at Rochester and Nottingham
between 22 March and 26 May.
23. NHS England commissioned a clinical reviewer to review Mr Esson’s clinical care at
the prison. The investigator and clinical reviewer completed a joint interview with
the Head of Healthcare on 17 May.
24. We informed HM Coroner for Kent and Medway of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
25. The Ombudsman’s family liaison officer contacted Mr Esson’s family to explain the
investigation and to ask if they had any matters, they wanted the investigation to
consider. They did not ask any questions.
26. Mr Esson’s family were provided with a copy of our initial report but did not respond
to our findings.
27. HMPPS responded to our initial finding and accepted the recommendations made.
28. An inquest into Mr Esson’s death was concluded on 22 January 2024. A jury found
the cause of death to be suicide, but made the following comments:
‘… On the 10th of February 2022 at 13.05 (approx) Stuart Esson was discovered in
cell 108 of the CSU at H.M.P. Rochester with a ligature around his neck which was
secured to the wash basin. He was transferred to Medway Maritime Hospital in
Gillingham where he was put on life support. On the 12th of February 2022, he was
taken off life support and he was declared deceased, In addition, we are satisfied
that the following circumstances are relevant to the death of Mr Esson: (i) Prison
officers not having received sufficient information regarding his history, complexity
and needs (ii) Independent Monitoring Board was not contacted which should have
been paramount (iii) Segregation paperwork was apparently not managed in
accordance with national guidance (iv) Falsification of records in relation to
observations undertaken on 10th February 2022 (v) Lack of investigations into Mr
Esson's concerns of threats from other prisoners which must have been a constant
frustration and a known trigger (vi) The jury agreed that the prescribed antipsychotic
medication was not recorded.
We the jury believe that Stuart Esson did suspend himself by fashioning a ligature
from his bedsheet. It was his intention to take his own life. It is possible that these
issues contributed to Stuart Esson's death: (i) The evaluation of risk of self-harm to
Stuart Esson on 10th of February 2022 (ii) the levels of observation put in place
Prisons and Probation Ombudsman 7
after the ACCT review on 10th of February 2022 (iii) The level of training and
experience involved in the ACCT review on 10th of February 2022 …’
8 Prisons and Probation Ombudsman
Background Information
HMP Rochester
29. HMP/YOI Rochester is a Category C resettlement prison, holding up to 695 adult
and young male prisoners across seven residential units, and a separate Care and
Separation Unit (CSU.) Oxleas NHS Foundation Trust provides healthcare services
at the prison.
HM Inspectorate of Prisons
30. The most recent inspection of HMP/YOI Rochester was in October 2021.
Inspectors reported that the documented reasons for segregation were generally
adequate, but behaviour targets were generic, healthcare staff did not always
attend segregation reviews, and little attention was paid to reintegration planning,
with objectives which were not tailored to the individual prisoner. Some useful data
was presented at the segregation monitoring and review group, but inspectors said
that it was not clear how this information was used to effect change.
Independent Monitoring Board
31. 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 March 2021, the IMB reported
that the way in which Good Order and Discipline reviews were handled had
changed and had taken some time to settle in. The Board found that most reviews
and adjudications were conducted carefully, fairly and appropriately.
Previous deaths at HMP Rochester
32. Mr Esson was the third prisoner to die at Rochester since April 2018. Of the
previous deaths one was self-inflicted, and one was from natural causes. There are
no similarities between the findings in this investigation and previous ones.
Assessment, Care in Custody and Teamwork
33. Assessment, Care in Custody and Teamwork (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.
34. 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 multi-disciplinary review meetings involving the prisoner. As part of the
process, a caremap identifying support actions is put in place. The ACCT plan
should not be closed until all the support actions on the caremap have been
completed.
Prisons and Probation Ombudsman 9
Key Events
35. On 6 August 2018, Mr Stuart Esson was sentenced to 40 months in prison for
burglary. On 9 April 2020, he was released from prison but a year and a half later,
he was recalled to HMP Nottingham for burglary and driving offences.
1. HMP Nottingham
36. On 24 October 2021, on his way from court to HMP Nottingham, Mr Esson started a
dirty protest in the transport vehicle. As a result, when he arrived at the prison, he
was taken straight to the Care and Separation Unit (CSU), and he did not go
through the normal reception procedures.
37. In the CSU, an officer completed Mr Esson’s first night interview. He recorded that
Mr Esson had a history of self-harm and suicidal thoughts and had previously been
managed under suicide and self-harm monitoring procedures (known as ACCT).
Mr Esson denied any current thought or intent to harm himself. The officer also
recorded that Mr Esson had mental health issues and had a history of substance
misuse. He noted that he had been assessed as being a high risk to other
prisoners because he had a history of assaulting other prisoners and using
unauthorised weapons.
38. Because Mr Esson was on a dirty protest and refused to comply with staff
instructions, nursing staff were unable to complete his initial health screening (which
should take place on the day the prisoner arrives). A nurse completed a
segregation safety algorithm and concluded Mr Esson was medically fit to be held in
the CSU and referred him to the prison’s mental health team for assessment.
39. On 28 October, a nurse completed Mr Esson’s initial health screen. Mr Esson said
that he had self-harmed within the past twelve months and had previously
overdosed with medication. His current medication was recorded as pregabalin
(used to treat anxiety) and olanzapine, an antipsychotic medication used in the
treatment of schizophrenia and bi-polar disorder. Mr Esson had been prescribed
this medication to treat his diagnosed complex personality disorder (PD).
40. Later that day, Mr Esson agreed to move from the CSU to G wing.
41. On 9 November, a mental health worker completed a mental health assessment.
Mr Esson engaged well and was pleasant and polite. She recorded that there was
no evidence that Mr Esson was at risk from himself. Mr Esson told her that he had
been diagnosed with generalised anxiety disorder and personality disorder and had
experienced significant paranoia. He said that he started dirty protests in prison
because he was told that prison officers would not assault him if he was covered in
faeces. He also said that he liked covering himself in faeces and admitted that this
was unusual. He said that he always overthought situations which led to frustration
and occasionally self-harm, including banging his head against walls or solid
objects and punching objects, and said that he would like to address this. She
recorded that Mr Esson was under the care of the mental health team and that a
further appointment was booked for the following week.
42. Mr Esson spent some time on G wing, but staff found his behaviour challenging,
and, on 13 November, he was moved back to the CSU.
10 Prisons and Probation Ombudsman
43. On 24 November, Mr Esson was sentenced to a further two years and four months
in prison for the offences that led to his recall.
44. Over the following weeks, Mr Esson engaged in several dirty protests. He told staff
that he would only end his protests if staff arranged for him to transfer to another
prison.
45. On 31 December, a Senior Probation Officer (SPO) and the Deputy Governor saw
Mr Esson in the CSU. The Deputy Governor told Mr Esson that she would pass on
his request for a transfer to the relevant department and acknowledged that he said
he wished to go to HMP Oakwood because he had previously said that he felt safe
there. Mr Esson said that his home was in Aberdeen and that he intended to live
there after his release.
46. Over the weeks that followed, Mr Esson began to settle in the CSU. Staff continued
to explore the possibility of his transfer to another prison, but Oakwood refused to
take him. On the 18 January, arrangements were made for his transfer to
Rochester prison, but no one discussed this with him.
HMP Rochester
47. Mr Esson transferred to Rochester on 20 January 2022. On his arrival, Mr Esson
told staff that he would not move to the wing and so he was placed in the CSU. The
duty manager that day told the investigator that his first knowledge of Mr Esson was
when he refused to move on to the wing. Staff gave him a brief background
including that Mr Esson had thought he would be moving north to be nearer his
family in Scotland. The duty manager was not aware of Mr Esson’s challenging
behaviour and dirty protests or that he had spent the majority of his time in the CSU
at Nottingham.
48. The duty manager said that he signed the paperwork confirming that Mr Esson
would be held in the CSU under prison rule 53 (where a prisoner is to be charged
with an offence against discipline at an adjudication hearing), for his refusal to move
on to a wing. He told the investigator that he would have gone to the CSU to
complete the documentation and would also have completed a section of the safety
algorithm. However, the safety algorithm was not signed by a manager until the
next day. Prison staff also failed to notify the Independent Monitoring Board (IMB)
that Mr Esson had been located in the CSU as they should have done.
49. A nurse saw Mr Esson in the CSU to complete the medical section of the safety
algorithm. He told her that he had just been transferred, that he was fine and just
wanted his medication. She administered his medication. She then completed the
safety algorithm paperwork but wrongly answered ‘no’ to the question whether the
individual was in receipt of or had been prescribed antipsychotic medication.
50. The following day, a senior nurse saw Mr Esson to complete his initial health
screen. Mr Esson was angry that he had been transferred to Rochester. He said
that he would be starting a dirty protest that day. Mr Esson said that he did not
have any thoughts or intent to harm himself. She recorded that Mr Esson was
anxious, agitated and very on edge, but that he was polite and had engaged in
conversation. She also noted that Mr Esson had previously used illicit drugs but
declined any support from the prison’s substance misuse team.
Prisons and Probation Ombudsman 11
51. The senior nurse noted that Mr Esson had previous contact with mental health
services and that he had a history of personality disorder and schizophrenia
(although there was no evidence of a formal diagnosis of the latter). She completed
a routine referral to the mental health team, due to both his history of mental health
issues and because she knew that time in the CSU could cause further mental
health problems.
52. On 21 January, a duty governor completed the CSU daily duty governor rounds and
saw Mr Esson. He signed the safety algorithm and recorded that that Mr Esson had
presented as a really angry individual. He told Mr Esson that if he agreed to move
to a residential wing it would be easier to deal with his issues, but Mr Esson said
that he would not leave the CSU. The duty governor spoke to the Head of the
Offender Management Unit (OMU) to get more information about why Mr Esson
had been transferred to Rochester. He said that he was told that Mr Esson was
transferred there because of his previous poor behaviour and that Nottingham had
accepted two prisoners from Rochester in return. There is no evidence to indicate
that a review took place to explore the reasons why Mr Esson refused to move to
the wing.
53. On 24 January, a mental health nurse completed a desktop triage on the mental
health referral the senior nurse had submitted. She reviewed Mr Esson’s medical
record. She told the investigator that she had no immediate concerns about Mr
Esson’s well-being and that, as a result of her triage, he would be seen weekly as a
part of the mental health team’s CSU rounds, rather than being added to the mental
health in-reach team’s caseload. She said that she was not aware of any handover
of Mr Esson’s care from the mental health or healthcare team at Nottingham.
54. Nursing staff and senior prison staff continued to see Mr Esson daily in the CSU,
but they did not record all the contact they had with him in his electronic prison
record as they should have done. The prison said that this was an oversight.
55. On 2 February, an officer recorded that Mr Esson’s behaviour was beginning to
deteriorate because he only wanted to transfer to two other prisons. She noted that
he said he had assaulted staff in the past and was refusing to listen to staff who
tried to offer him advice. He said that he would start a dirty protest soon and had
asked for bags to put his clothing and property in.
56. The officer told the investigator that she knew very little about Mr Esson. She said
that after a couple of days, a member of the mental health team telephoned the
CSU to inform them that they had looked at Mr Esson’s mental health history, that
he had a number of mental health issues and staff should be aware of him (the
same information was recorded in Mr Esson’s medical record). She said that after
receiving this information, staff were wary of Mr Esson when unlocking him because
his behaviour could be ‘up and down’.
57. On 3 February, a Custodial Manager (CM) recorded on Mr Esson’s record that he
had read the previous entry by the officer and following previous conversations that
he had with Mr Esson, he found his mood increasingly erratic and unpredictable.
He recorded that he had instructed CSU staff that they should only unlock Mr Esson
when three officers were present. He recorded no concerns about Mr Esson’s risk
of suicide or self-harm.
12 Prisons and Probation Ombudsman
58. On 6 February, an officer recorded that Mr Esson had declined all activities offered
to him, including exercise, his lunch and dinner. He told staff that he believed
everyone in the CSU was after him. He had also passed notes to staff saying that
he believed that both he and his family were under threat and that he was fearful for
his and his family’s safety. There is no evidence to indicate that staff explored or
followed up his concerns.
59. On 7 February, the prison held a complex case review meeting to discuss Mr Esson
because he continued to refuse to move to a wing. Those who attended expressed
concern about Mr Esson’s mental state and noted that he had requested a transfer
to either a Category C or B prison or a forensic psychiatric hospital. Staff recorded
that Mr Esson was refusing to engage and that he had been writing letters of
concern about his family’s safety. A nurse considered that his behaviour was in line
with his diagnosis of personality disorder. She recorded that Mr Esson was to be
added to the mental health team’s referral caseload and that the Mental Health In-
Reach Team (MHIRT) would review him.
Events of 8 and 9 February
60. At 7.05am on 8 February, an officer began checking prisoners on the CSU. She
looked through the observation panel of Mr Esson’s cell and saw him sitting on the
floor with a ligature around his neck. She radioed a code blue (indicating a prisoner
is unconscious or is having breathing difficulties) and control room staff called an
ambulance immediately. Staff attended, entered Mr Esson’s cell and released the
ligature from his neck. Mr Esson was conscious and breathing but was gasping for
air. As a precaution, staff sent him to hospital, accompanied by officers. They also
started suicide and self-harm prevention procedures (ACCT).
61. Mr Esson was in hospital for a few hours. He refused further treatment and
discharged himself from hospital and returned to the prison around lunchtime.
62. Prison staff placed Mr Esson under constant supervision in a safe cell (a cell with a
gate instead of solid door to allow for additional monitoring, and sometimes with
reduced ligature points) in the CSU. He was unhappy about this and at 12.10pm,
he started a dirty protest. He smeared faeces over his body and on the inside of
the gate of his cell. He stopped his dirty protest at around 1.30pm and cleaned up
his faeces.
63. At 3.00pm that afternoon, a senior manager chaired an ACCT case review. Mr
Esson said that he did not want to be under constant supervision and that he did
not mean to harm himself when he tied the ligature around his neck. The meeting
recorded that Mr Esson was very paranoid about other prisoners on the unit
attacking him. He denied any previous suicide attempts or self-harm, but staff
checked his prison record and noted that ACCT procedures had been started
thirteen times in the past. The manager recorded that Mr Esson’s suicide attempt
was significant and that his mood had not stabilised enough to reduce the level of
observations. The meeting agreed that Mr Esson should remain under constant
supervision.
64. A mental health nurse attended the review and recorded on Mr Esson’s medical
record that Mr Esson came to the meeting asking to be taken off constant
supervision. He recorded that the ligature mark around Mr Esson’s neck was very
Prisons and Probation Ombudsman 13
prominent and red. Mr Esson continued to request a transfer north. Mr Esson was
not willing to hear about the difficulties in securing a transfer for him. Staff told him
that it would take time and that they were doing their best.
65. Mr Esson said that he was under threat from other prisoners who had labelled him a
"grass” and that they had a plan to steal keys from staff and enter his cell and attack
him. Mr Esson said that he would sit with his back to the cell door to prevent it from
opening. Despite Mr Esson voicing his concerns about his safety and believing that
he was under threat, there is no evidence that staff investigated his concerns or
looked into the matter further.
66. Despite his protests about being under constant supervision, Mr Esson settled
down and no issues were recorded for the remainder of the day.
67. At 2.20pm on 9 February, a senior manager chaired a multidisciplinary constant
supervision review meeting. Mr Esson presented as much better, and the manager
recorded that he was calm and not agitated. Mr Esson had been engaging well with
the officer covering his constant supervision, had eaten, and had slept for around 8
hours. Mr Esson said that he had not intended to take his own life the day before,
but it was a ‘moment of madness’.
68. A nurse attended the review and recorded on Mr Esson’s medical record that he
was calm and kempt in his appearance, was feeling much better in his mental state
and that he had said that he had not been in a good place the previous day. Staff
told Mr Esson that he needed to be open to engaging with the mental health team,
which he agreed to do. The review team agreed that the frequency of observations
would be gradually reduced from constant supervision to observations every fifteen
minutes (four per hour).
Events of 10 February
69. On 10 February, a duty governor visited the CSU that morning. When she went to
speak to Mr Esson, he talked very quietly, almost whispering, and said, ‘I really
need to speak to you on your own’. She said that such requests are not unusual
and that she told Mr Esson she would come back to speak to him when she had
completed her duty governor rounds.
70. At around 11.00am, when she had completed her rounds, the duty governor asked
an officer to bring Mr Esson to the adjudication room to speak to her. However,
while she was waiting, other staff arrived to attend Mr Esson’s ACCT case review.
She said that she wanted to stay for the review because Mr Esson had asked to
speak to her. When Mr Esson came into the room, he told her that he was ‘under
terrible threat’ on the unit. She said that she tried to reassure him that the other
prisoners had not been unlocked at the same time as him and that he was safe, but
she said that this seemed to do little to alleviate his anxiety. She said that she did
not stay for the entire ACCT case review as she was needed elsewhere.
71. A SO chaired the ACCT case review. Staff from the safer custody team, chaplaincy
and a nurse also attended. The SO recorded that Mr Esson was very paranoid and
spoke about other prisoners trying to gain access to his cell and attack him. The
meeting tried to reassure him that he was safe on the unit. However, Mr Esson
spoke about other prisoners overpowering staff to get their keys to open his cell.
14 Prisons and Probation Ombudsman
The SO said that he tried to move the conversation forward to find out how Mr
Esson was doing, but Mr Esson kept going back to the belief that he was going to
be attacked.
72. After telling the review group about his fears, Mr Esson left the room and returned
to his cell. The meeting continued to discuss Mr Esson’s behaviour and
presentation without him and recorded that it was a concern. The nurse told the
meeting that the psychiatrist was visiting the following Monday and that she would
try and get them to see Mr Esson. The meeting recorded that Mr Esson could be
impulsive and as such, should remain on a high level of observations. They
reduced the frequency of observations from four per hour to two per hour. The
meeting did not feel that there was any indication that Mr Esson would attempt
suicide again or self-harm.
73. The SO told the investigator that they reduced the level of observations because
the meeting did not feel that there was any indication that Mr Esson was at risk of
suicide or self-harm. He said that Mr Esson was just focused on what would
happen to staff and how other prisoners would attack them to get to him. He said
that Mr Esson was paranoid, but that staff would carry out extra checks on him.
74. The nurse told the investigator that Mr Esson was more agitated during the review
than he had been the previous day. She said that he was showing more signs of
paranoia about what might happen to him, but staff constantly reassured him that
he was safe. She agreed that Mr Esson’s presentation was more negative than the
previous day. When asked whether she was happy with the decision taken to
reduce observations, she told the investigator that she could not recall any
discussion taking place on the level or frequency of the observations.
75. CCTV shows that at 11.09am, Mr Esson returned to his cell. At 11.27am, an
unidentified officer handed Mr Esson his lunch. At this time, staff did not update Mr
Esson’s ACCT document to indicate if they had any interaction with him, but at
12.00pm, Officer A made an entry in the ACCT document to say that she had
completed an observation check. CCTV footage shows that she did not check him.
During that morning, she made several entries in the ACCT document recording
that she had completed observation checks but, again, CCTV shows that she did
not do so.
76. At 12.30pm, Officer B arrived for her shift on the CSU and staff provided a
handover. She told us that she was not advised of any relevant issues with Mr
Esson and staff did not mention anything about the ACCT case review that took
place earlier that morning.
77. At 12.35pm, Officer B completed a routine count of all prisoners in the CSU. She
looked into Mr Esson’s cell, and he was sitting on the floor and appeared to be
writing. She asked him if he was all right and he said, ‘yes, thanks’. She continued
with the count.
78. At 1.00pm, Officer B said that she passed Mr Esson’s cell as she was leaving the
unit. She decided to look in on him because an ACCT observation was due. She
looked through the observational panel of his cell door and saw him sitting beneath
the sink with a ligature around his neck, attached to the taps. She said that she
Prisons and Probation Ombudsman 15
called to Mr Esson and kicked the door to try and get a response, but he did not
respond. She then radioed a code blue.
79. Officer B said that she remained at the door but did not immediately enter the cell.
She said that she completed her own dynamic risk assessment and took into
consideration that she was on her own and was aware that Mr Esson had a history
of threatening violence and unpredictable behaviour. Another officer attended
within a minute, and they immediately entered the cell and cut the ligature from
around Mr Esson’s neck then started CPR.
80. More prison and nursing staff arrived, and they moved Mr Esson from his cell onto
the landing. Staff attached a defibrillator while others continued with CPR.
Paramedics arrived ten minutes later and continued with Mr Esson’s care and
treatment. An air ambulance responded to the incident, but Mr Esson was not
stable enough to be taken to hospital by air and instead was taken by road.
81. On arrival at hospital, Mr Esson was placed on life support. As was routine at that
time, Mr Esson was tested for the COVID-19 virus and the result was positive. It
was agreed between the prison and hospital that Mr Esson’s next of kin would be
informed and allowed time to get to the hospital before any other decisions were
made. Further tests confirmed that Mr Esson had no brain activity and in
consultation with his next of kin, a decision was made to withdraw life support.
82. At 10.20pm on 12 February, it was confirmed that Mr Esson had died.
83. Following Mr Esson’s transfer to hospital, prison staff searched his cell and found a
note he had written which said that his next of kin details could be found on his
telephone account, that he loved his family, but had had enough of life.
Contact with Mr Esson’s family
84. An officer was appointed as the prison’s family liaison officer. She kept regular
contact with Mr Esson’s next of kin and offered support.
85. The prison contributed towards the costs of Mr Esson’s funeral in line with national
policy.
Support for prisoners and staff
86. After Mr Esson was taken to hospital, all staff including those from the healthcare
team were debriefed to ensure they had the opportunity to discuss any issues
arising and to offer support. The staff care team also offered support to staff.
87. The prison posted notices informing other prisoners of Mr Esson’s death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide and
self-harm in case they had been adversely affected by Mr Esson’s death.
16 Prisons and Probation Ombudsman
Post-mortem report
88. The post-mortem report gave Mr Esson’s cause of death as irreversible hypoxic
cerebral hypoxia caused by hanging. No illicit drugs were detected in Mr Esson’s
body.
Prisons and Probation Ombudsman 17
Findings
Management of Mr Esson’s risk of suicide and self-harm
89. Prison Service Instruction (PSI) 64/2011, Management of 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 a prisoner is assessed as being at risk of
suicide and self-harm.
90. Prison Service Order (PSO) 1700, Segregation states that a prisoner on an open
ACCT plan must only be kept in segregation under exceptional circumstances
whereby they are such a risk to other that no other suitable location is appropriate
and where all other options have been tried or are considered inappropriate.
91. Prison staff started ACCT procedures for Mr Esson on 8 February 2022, when they
found him with a ligature around his neck in his cell. ACCT procedures remained
open and on his return from hospital that afternoon, staff placed him under constant
supervision because of the perceived level of risk. A multidisciplinary review was
held the same day and it was decided to keep the same frequency of observations
in place. The next day, the review group reduced the level of observations to four
per hour. We have concluded that this first reduction in observations was
reasonable given that Mr Esson’s presentation had improved. We also consider it
was reasonable given Mr Esson’s continued refusal to relocate elsewhere, for him
to have remained on the segregation unit after the ACCT was opened.
92. However, we are concerned that, during the review meeting on 10 February, a SO,
the safer custody staff, chaplaincy and a nurse reduced the frequency of Mr
Esson’s observations to two per hour on the basis that there was no indication that
he would attempt suicide or self-harm. We consider that this was premature and
not based on an objective assessment of his risk. Mr Esson had ligatured on 8
February and repeatedly denied that he had any thoughts of doing so. He was a
complex man with challenging behaviour, housed in the CSU. Staff also had
ongoing concerns that he could be impulsive, was very paranoid and continued to
believe that he was going to be attacked despite assurances. Mr Esson had walked
out of the review and staff considered that his behaviour and presentation was a
concern. Despite these factors, and the group agreeing he should remain on a high
level of observations, the SO recorded that the frequency of observations would
reduce to two per hour. We do not consider this to be a high level of observations
and conclude that the reduction in the frequency of observations was premature.
93. Our investigation found that, on 10 February, Officer A falsified the ACCT
documents. She recorded that she had carried out Mr Esson’s ACCT observation
checks but CCTV footage shows that she did not do so. While the lack of
observations did not impact directly on Mr Esson’s death, in other cases, poor
practice and falsifying documents could have a far more serious outcome.
94. The Governor told us that he is conducting an internal disciplinary investigation into
Officer A’s actions. We make the following recommendation:
The Governor at HMP Rochester should ensure that staff manage prisoners at
risk of suicide and self-harm in line with national guidelines, including that:
18 Prisons and Probation Ombudsman
• staff understand the need to consider a prisoner’s risk factors when
assessing risk and that the level of observations is agreed by all those
present at the review and reflects the immediate concerns; and
• staff conduct ACCT observations in line with what is set out in the
prisoners individual ACCT document and record these appropriately.
The Governor should inform the PPO of the outcome of the disciplinary
investigation into the actions of Officer A.
Location in the Care and Separation Unit (CSU)
95. PSO 1700 Segregation, acknowledges the specific risks of holding vulnerable
prisoners in segregation. It notes that rates of suicide among segregated prisoners
is high, and that segregation should only be used as a last resort. Prisoners
monitored under ACCT procedures can be segregated but only when they are such
a risk to others that no other suitable location is appropriate and where all other
options have been tried or are considered inappropriate. We have considered
whether, in the circumstances, it was appropriate to hold Mr Esson in the
segregation unit when his risk of suicide and self-harm was raised, and he was on
an ACCT.
96. Mr Esson had spent a large amount of time in CSU’s while serving previous
sentences in prison and he had also engaged in dirty protests dating back as far as
2011. His prison record notes that he often asked to be segregated rather than
remain on a standard wing. His reasons for refusing location on a residential unit
were not always clear, but evidence suggests that he used dirty protests as a way
of remaining in the CSU.
97. Mr Esson was at Rochester for around six weeks and spent of that time in the CSU.
When he arrived at Rochester, Mr Esson immediately refused to move onto the
wing. Staff clearly found him challenging to manage and he engaged in at least one
dirty protest at Rochester. Staff were trying to arrange a transfer for Mr Esson, but
this was not easy due to his history of difficult behaviour. We consider that being
segregated did not seem, on the evidence available, to have added to Mr Esson’s
distress or risk and it is difficult to see how Rochester could have managed this
differently.
Mr Esson’s Primary and Mental Healthcare
98. The clinical reviewer concluded that the clinical care Mr Esson received at
Rochester was of a reasonable standard and equivalent to that which he could have
expected to receive in the community. She did, however, identify some areas of
concern.
99. The clinical reviewer was concerned about the lack of informed healthcare input into
Mr Esson’s ACCT. She considered that the decision to reduce Mr Esson’s ACCT
observations did not take into account the well-documented link in his medical
record between his episodes of emotional dysregulation and his increased risk of
suicide and self-harm, and that he had a very recent incident of ligaturing two days
Prisons and Probation Ombudsman 19
earlier. The Head of Healthcare told us that there were gaps in ACCT training for
healthcare staff.
100. The clinical reviewer also found that healthcare staff did not consistently record their
involvement with Mr Esson in his ACCT document as they should have done, which
is a mandatory requirement of PSI 64/2011.
101. She was also concerned that the nurse who attended most of Mr Esson’s ACCT
case reviews, was a newly qualified member of staff and had significant decision-
making responsibility at those reviews given his complex mental health history and
risk profile. The Head of Healthcare acknowledged that newly qualified staff
needed sufficient support and experience before managing complex prisoners. The
clinical reviewer considered that it was still early days in the nurse’s career at HMP
Rochester and she needed more training and support. We recommend:
The Head of Healthcare at HMP Rochester should ensure that:
• healthcare staff read the prisoner’s medical history prior to attending
ACCT case reviews;
• healthcare staff record their involvement with the ACCT case review in
the ACCT document in accordance with PSI 64/2011; and
• all healthcare staff have received ACCT training.
102. The clinical reviewer noted that another nurse made an error on the CSU safety
algorithm and failed to indicate that Mr Esson was on antipsychotic medication.
The error was not corrected during his time at Rochester. She was also concerned
that the nurse did not know that there was a section for recording antipsychotic
medication on the safety screen. She considered that while, on balance, this did
not have an adverse impact on Mr Esson’s care, the section on antipsychotic
medication forms part of the safety algorithm assessment for important reasons and
needs to be addressed for future cases. We recommend:
The Head of Healthcare at HMP Rochester should ensure that healthcare
staff:
receive appropriate training to competently carry out segregation
safety algorithm assessments; and
• read any available medical history prior to undertaking a segregation
safety algorithm.
103. Based on his mental health history, a senior nurse appropriately made a routine
referral to the prison’s mental health in-reach team when Mr Esson arrived at
Rochester. The referral was triaged three days later by a nurse, who decided,
based on his history, that he did not need to be placed on the team’s caseload at
that time, or undergo a more detailed mental health assessment. However, the
nurse noted that Mr Esson would continue to be seen by nursing staff daily and a
member of the mental health team weekly as part of their routine CSU rounds.
104. Although he was not on the mental health team’s caseload, staff from the team
attended all ACCT reviews, and arrangements were made on 10 February for Mr
20 Prisons and Probation Ombudsman
Esson to be seen by a visiting psychiatrist the following week. The clinical reviewer
was satisfied that Mr Esson received appropriate mental health support at
Rochester.
105. At HMP Nottingham, Mr Esson was under the care of the mental health team but
there was no formal handover of care between the healthcare teams at HMP
Nottingham and HMP Rochester. A formal handover of care, as set out in PSO
3050 Continuity of healthcare for prisoners, would have informed a proactive
approach to the mental health care available to him at Rochester. We recommend:
2. The Heads of Healthcare at HMP Rochester and HMP Nottingham should
ensure there is a formal mental health handover when a prisoner is
transferred between prisons.
3. The Head of Healthcare and Mental Health In-Reach Manager should review
and ensure that:
• the roles and responsibilities of newly qualified nurses are appropriate
to their level of experience and competency, and
• newly qualified nurses receive appropriate ongoing support and
supervision from managers and a mentor.
106. The clinical reviewer made an additional recommendation about IT access for
healthcare staff which we do not repeat in this report but which the Head of
Healthcare will need to address.
Staff response to Mr Esson’s concerns about his safety
107. Mr Esson told staff that he feared for his and his family’s safety. He passed notes
to CSU staff saying that he believed that he was under threat from other prisoners
on the unit and voiced these concerns during the ACCT case reviews.
108. We accept that staff recognised that Mr Esson was showing signs of paranoia, in
keeping with his diagnosis of personality disorder. However, we found no evidence
that prison staff took any action to investigate Mr Esson’s concerns, such as
reviewing CCTV to see whether any prisoners had approached his door or speaking
with unit staff to assure themselves that he was not, indeed, under threat. We
make the following recommendation:
The Governor of Rochester should ensure that any concerns raised by a
prisoner about their safety are properly investigated and recorded
appropriately.
Record keeping
109. We found various examples of poor record keeping during the investigation,
including important segregation and dirty protest documentation. Prison Service
Order (PSO) 1700 Segregation sets out the processes that must be followed when
a prisoner is segregated, including how often and by whom records should be
updated, and how they should be stored.
Prisons and Probation Ombudsman 21
110. While Mr Esson’s NOMIS transfer record indicates that duty managers saw him
daily in the CSU, they did not always record their interaction with him in his
segregation file as they should have done.
111. The prison was unable to provide us with all of the documents relating to Mr Esson
time in the CSU. We received a copy of the safety algorithm, the authorisation for
Mr Esson’s initial segregation when he arrived at Rochester and the CSU daily
record sheets from 24 to 26 January. The prison was unable to locate paperwork
relating to Mr Esson’s segregation during February.
112. We found no documented evidence that the IMB had been informed when Mr
Esson arrived in the CSU at Rochester or that they had subsequently visited him
while he was segregated. The relevant section on the safety algorithm had not
been completed.
113. PSO 1700 Segregation also provides guidance on how dirty protests should be
managed, including the records that must be kept. Mr Esson engaged in dirty
protests at Rochester, but we found that processes for recording this were not
followed. We make the following recommendation:
The Governor at HMP Rochester should:
• review the current process for recording daily interactions, visits from
other agencies and the regime for prisoners in the Care and Separation
Unit and satisfy themselves that it fully adheres to the guidance set out
in PSO 1700 Segregation;
• review the current process for storing documentation and ensure it
complies with PSO 1700 Segregation,
• ensure CSU staff notify the Independent Monitoring Board when a
prisoner is located in the Care and Separation Unit and that the safety
algorithm is completed correctly to indicate that this action has been
completed, and
• ensure that dirty protests are managed in accordance with PSO 1700
Segregation, the Health and Safety at Work Act 1974 and COSHH
Regulations 1999.
Mr Esson’s transfer from HMP Nottingham to HMP Rochester
114. PSO 1700 Segregation clearly sets out guidance for the process that should be
followed when a prisoner located in a CSU is transferred to another prison,
including how decisions to transfer are made and information that should be shared
with a receiving prison.
115. While at Nottingham, Mr Esson made clear his wish to transfer, but said that he
particularly wanted to move closer to his home location of Aberdeen. The evidence
provided suggests that the decision to transfer Mr Esson to Rochester was made
following a meeting with a Deputy Governor and a SPO on 31 December. This was
not recorded as a review board and no other parties attended. We saw no
evidence that the correct process was followed when pursuing the transfer and we
found that little information about Mr Esson was shared with Rochester in advance
22 Prisons and Probation Ombudsman
of his arrival. This is particularly concerning given Mr Esson’s complex and
challenging presentation and his known mental health concerns.
116. Mr Esson had not been told he was moving to Rochester in advance and was
clearly angry and upset that he was no closer to Aberdeen.
117. We are concerned that the guidance set out in PSO 1700 was not followed in
respect of the transfer process or actions that followed. We make the following
recommendation:
The Governors of HMP Rochester and HMP Nottingham must ensure that
when a prisoner located in the CSU is to be transferred every aspect of the
process follows the guidance as set out in PSO 1700 Segregation.
Prisons and Probation Ombudsman 23
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