Springham, Ross

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ross Springham,
a prisoner at HMP Wandsworth,
on 20 March 2021
A report by the Prisons and Probation Ombudsman
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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.
Our 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 Ross Springham died in hospital on 20 March 2021, after being found with a ligature
around his neck four days earlier at HMP Wandsworth. He was 29 years old. I offer my
condolences to Mr Springham’s family and friends.
Mr Springham arrived at Wandsworth on 22 February 2021. Staff started suicide and self-
harm monitoring (known as ACCT) the same day, as they were concerned about Mr
Springham’s odd behaviour and unkempt appearance. He was monitored under ACCT
throughout his three weeks at Wandsworth.
Mr Springham’s behaviour was bizarre, including his refusal to wear clothes for most of the
time. Healthcare staff assessed him for signs of psychosis, but it was unclear whether this
was the cause of his behaviour. Staff referred him to a Psychiatric Intensive Care Unit (a
secure mental health unit) for assessment.
The clinical reviewer was satisfied that the mental health care Mr Springham received at
Wandsworth was equivalent to that he could have expected to receive in the community.
We recognise that Mr Springham was a very challenging prisoner to manage safely. We
found some deficiencies in the prison’s management of the ACCT procedures, and we
consider that staff under-estimated the risk posed by Mr Springham’s unpredictable
behaviour. However, he was being observed at least hourly at the time he hanged himself
and we consider this was reasonable in the circumstances.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Elizabeth Moody
Deputy Prisons and Probation Ombudsman December 2021
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
Summary
Events
1. On 22 February 2021, Mr Ross Springham was remanded in prison custody,
charged with indecent exposure, and sent to HMP Wandsworth.
2. A prison GP in reception started suicide and self-harm prevention procedures
(known as ACCT), as he was concerned about Mr Springham’s odd behaviour and
unkempt appearance. Mr Springham remained on an ACCT until his death.
3. Mr Springham refused to wear clothes for most of the time. On 28 February, after
being asked to put a shirt on before leaving his cell, he stripped and jumped naked
onto the netting of the landing below.
4. On 1 March, Mr Springham was moved to the prison’s Addison Unit for assessment
of possible psychosis. However, healthcare staff were unable to reach a diagnosis.
On 15 March, they referred him for a transfer to a Psychiatric Intensive Care Unit
(PICU), a secure mental health unit, for assessment.
5. On 16 March, Mr Springham was unlocked for a shower, and grabbed a member of
staff around the neck. It was decided he would not be unlocked again without three
prison officers being present. Mr Springham had several interactions with staff
during the morning and was last seen at 11.30am when he declined lunch.
6. Just over half an hour later, during a roll check, a nurse saw Mr Springham lying
naked on his cell floor. This was not unusual but, as she was not sure if she could
see movement, she fetched another nurse and they asked officers to let them into
the cell. They realised that Mr Springham had a ligature around his neck and was
unresponsive.
7. Staff began cardiopulmonary resuscitation (CPR) which they continued until
paramedics arrived. Paramedics were able to restore Mr Springham’s circulation
and took him to hospital. He did not regain consciousness and died in hospital at
7.19pm on 20 March.
Findings
8. Mr Springham was a very challenging prisoner to manage safely.
9. He was appropriately managed under ACCT procedures, but we found some
deficiencies in the prison’s management of Mr Springham’s ACCT. These included
not holding an assessment interview within the prescribed timescale, not setting
caremap actions designed to keep a prisoner safe, and not involving healthcare
staff in all case reviews. We also consider that staff underestimated the risk posed
by Mr Springham’s unpredictability.
10. However, Mr Springham was being observed at least hourly at the time of his
hanging and we consider that this was reasonable and appropriate for the level of
risk he had shown.
11. The clinical reviewer found that Mr Springham’s mental health care was equivalent
to that he could have expected to receive in the community.
Prisons and Probation Ombudsman 1
Recommendations
• The Governor should ensure that staff manage prisoners at risk of suicide and self-
harm in line with national guidelines, including ensuring that:
• A trained ACCT assessor completes an assessment within 24 hours of the
ACCT being opened and attends the first case review.
• Case reviews are multidisciplinary and include all relevant people involved in
a prisoner’s care, including mental health staff where appropriate.
• Staff set specific and meaningful ACCT caremap actions that are aimed at
reducing prisoners’ risks to themselves and review them at each case review.
• Staff consider holding an ACCT review following a restraint.
2 Prisons and Probation Ombudsman
The Investigation Process
12. The investigator issued notices to staff and residents at HMP Wandsworth 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 Springham’s prison
and medical records.
14. NHS England commissioned an independent clinical reviewer to review Mr
Springham’s clinical care at the prison. The investigator interviewed nine members
of staff. Some interviews were conducted jointly with the clinical reviewer, and the
clinical reviewer interviewed one nurse on her own. The interviews were completed
by video and telephone due to the restrictions imposed by the COVID-19 pandemic.
15. We informed HM Coroner for Inner West London 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. One of the Ombudsman’s family liaison officers contacted Mr Springham’s family to
explain the investigation and ask if they wanted to raise any issues. They asked:
• What psychological assessments did Mr Springham have in prison and what
was the outcome?
• Why was the family not contacted by the prison between 22 February and 16
March?
• Why was his heart not donated?
These questions are covered in this report and the clinical review.
17. We shared our initial report with HM Prison and Probation Service (HMPPS).
There were no factual inaccuracies.
18. We provided Mr Springham’s next of kin with a copy of our initial report. They
raised some inaccuracies and issues which have been addressed in separate
correspondence.
Prisons and Probation Ombudsman 3
Background Information
HMP Wandsworth
19. HMP Wandsworth is a local Category B prison in London, with a Category C unit. It
holds up to 1,452 men in eight residential wings. Oxleas Foundation Trust provides
physical healthcare services at the prison. There is an inpatient unit for up to six
prisoners. Mental health services are provided by South London and Maudsley
NHS Foundation Trust. The Addison Unit is a 12- bed mental health unit, staffed by
prison officers and a multi-professional team of medical, nursing and occupational
therapy staff, with 24-hour nursing cover.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Wandsworth was in March 2018. Inspectors
found the demand for mental health beds in the prison remained high and there was
a waiting list for admission to the Addison Unit. Delays occurred in transferring
patients to mental health beds in the community. Assessment and care planning
was good, and inspectors saw some positive care in the unit. The environment was
adequate. Patients had satisfactory access to showers and exercise. Weekly art
therapy and a hearing voices group were positive initiatives, but there were still too
few therapeutic activities and many patients spent too long locked in their cells.
21. HMIP also conducted a Short Scrutiny Visit of Wandsworth in April 2020 to report
on the treatment and conditions of prisoners during the COVID-19 pandemic. They
found that the prison had adopted clear plans to manage the pandemic at the start
of the lockdown, identifying those who were most vulnerable so they could protect
them and limit the spread of the virus. Health and safety protocols were in place
and the prison remained calm, well ordered and safe. Most healthcare clinics had
been suspended, but managers had implemented a triage system to ensure that
urgent cases were dealt with appropriately.
Independent Monitoring Board
22. 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 31 May 2020, the IMB said they
remained very concerned that the Addison Unit was unfit for purpose. The Unit had
insufficient beds and cells were frequently out of use awaiting repair. The waiting
time for beds was up to seven days. The Board was also concerned about the poor
condition of the Unit’s showers and toilets, one toilet having an obvious ligature
point.
23. Delays in transfers to secure psychiatric accommodation remained a problem,
which the Board had reported on since 2009.
Previous deaths at HMP Wandsworth
24. Mr Springham was the tenth prisoner to die at Wandsworth since March 2019. Of
the previous deaths, four were from natural causes, one was drug related and four
4 Prisons and Probation Ombudsman
were self-inflicted. There were no notable similarities in these cases to the death of
Mr Springham, although we have not yet completed our investigation into one of the
self-inflicted deaths.
25. Since Mr Springham’s death, there have been a further four self-inflicted deaths at
Wandsworth, all of which are currently being investigated by the Ombudsman.
Assessment, Care in Custody and Teamwork
26. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011. After an initial assessment of the prisoner’s main concerns, levels of
supervision and interactions are set according to the perceived risk of harm.
Checks should be irregular to prevent the prisoner anticipating when they will occur.
There should be regular multi-disciplinary review meetings involving the prisoner.
27. As part of the process, a caremap (plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
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.
Prisons and Probation Ombudsman 5
Key Events
28. On 22 February 2021, Mr Ross Springham was remanded in prison custody,
charged with indecent exposure, and sent to HMP Wandsworth. Police had
arrested him wandering the streets naked the day before. This was Mr Springham’s
first time in prison. (Mr Springham had previously been found naked in a public
place before, in January 2021. On that occasion, he was assessed in hospital and
they found evidence of paranoia and psychosis, possibly due to drug or alcohol
use.)
29. A nurse completed Mr Springham’s initial health screen in reception. He told her he
had no mental health issues and no thoughts of suicide or self-harm. He said he
had no history of taking drugs (this was untrue) but that he drank around 85 units of
alcohol a week. He showed no alcohol withdrawal symptoms. She referred him to
a GP.
30. A prison GP saw Mr Springham in reception shortly afterwards. He noted that Mr
Springham was unkempt, with messy hair, dirty nails and no shoes. Mr Springham
told him that he had been detained under the Mental Health Act for ten days in 2020
and that he sometimes heard voices “saying bad things”, but that he had no mental
health problems and no thoughts of suicide or self-harm.
31. The prison GP noted that Mr Springham’s behaviour was strange, and his mood
was flat. He recorded that Mr Springham needed to be assessed in the prison’s
Addison Unit (a 12-bed mental health unit) but thought there was no space for him
at that time. He told Mr Springham he would refer him to see a psychiatrist. He
noted that in response Mr Springham said repetitively six times, “I will not see a
psychiatrist”. He noted that Mr Springham showed no signs of alcohol withdrawal.
32. The prison GP made a mental health referral and started suicide and self-harm
monitoring (known as ACCT) due to Mr Springham’s vulnerability and poor mental
health. Staff put him on hourly observations.
33. An officer tried to carry out an ACCT assessment interview with Mr Springham the
next day, but he refused to engage and said he did not need it. Another officer
noted that Mr Springham also refused to take part in the first ACCT case review.
34. On 24 February, Westminster Magistrates Court Liaison and Diversion Team sent
the Healthcare Department at Wandsworth an email asking for further information
about Mr Springham before they decided whether he could be bailed. They asked
the prison to assess Mr Springham’s mental health before his next court
appearance on 15 March.
35. The same day, a nurse went to see Mr Springham in his cell as part of the in-reach
mental health team’s triage. Mr Springham was sitting on his bed, naked, but then
put on his trousers. Mr Springham said he felt fine, had no mental health issues
and refused to discuss it further.
36. Shortly afterwards, a psychiatrist met Mr Springham. He was naked again and
initially refused to engage but spoke briefly about how he liked being naked and had
intended to go for a swim in the canal when he was arrested. The psychiatrist
noted that Mr Springham should be assessed in the Addison Unit to identify
6 Prisons and Probation Ombudsman
whether he had an underlying psychosis. In the meantime, Mr Springham remained
on the wing, monitored by ACCT and by mental health staff.
37. On 26 February, staff tried again to complete an ACCT assessment interview with
Mr Springham, but he refused to engage. He was sitting in bed naked and, when
asked to get dressed so he could attend the ACCT meeting, he refused.
38. On 28 February, an officer unlocked Mr Springham and asked him to put on a shirt
before he left his cell. In response, Mr Springham stripped, ran out of his cell and
jumped from the landing onto the netting of the landing below. He refused to let a
nurse carry out a thorough examination, told her he felt alright and denied it was a
suicide attempt.
39. The same day, a prison manager held an ACCT review with Mr Springham. A
nurse also attended. The manager noted that Mr Springham was quite despondent
and disorientated, and that he had been like this since arriving at Wandsworth. He
asked Mr Springham if he intended to take his own life and he said he did not. He
noted that he had discussed Mr Springham with nurses who considered that the act
of jumping onto the netting below was linked to his mental health condition rather
than an attempted suicide. He noted that Mr Springham would be moved to a lower
landing to limit the risk of him jumping again. He kept observations at one an hour.
He did not complete a caremap.
40. On 1 March, staff moved Mr Springham to the Addison Unit. Just before, a
Custodial Manager (CM) held Mr Springham’s second case review. No other staff
were present. Mr Springham was naked in his cell but got dressed when asked. Mr
Springham said he did not believe he needed to move to the Addison Unit, but he
walked there compliantly.
41. When Mr Springham arrived at the Addison Unit, staff set his observations at every
15 minutes for 72 hours, in line with the new patient admission protocol. After 72
hours, if there were no concerns regarding a new or increased risk, the
observations would be reduced to hourly.
42. On 2 March, a psychiatrist met Mr Springham. Mr Springham was lying naked on
the cell floor and mainly answered, “Leave me alone” in response to the
psychiatrist’s questions. He noted that Mr Springham should continue to be
assessed in the unit.
43. Later that day, an officer held an ACCT review with Mr Springham. A nurse also
attended. Mr Springham was naked in his cell. He said he liked to be naked but
understood he should not be naked in public. He said he was not suicidal and did
not self-harm. Mr Springham said he did not want his parents “told”, although it is
unclear whether he meant about his offence, that he was in prison, or that he was
on ACCT. He did not give staff managing the ACCT any next of kin details. The
officer did not add any caremap actions.
44. On 3 March, a consultant forensic psychiatrist saw Mr Springham. He spoke to him
through his cell hatch. Mr Springham was naked and crouching on the floor. He
later moved to his bed but remained naked. Mr Springham told the psychiatrist he
was not mentally ill, did not feel depressed, was not hearing voices and said he just
did not want to wear clothes. He said he was happier on the Addison Unit as it was
quieter, and knew he was due to appear in court for sentencing on 15 March. The
Prisons and Probation Ombudsman 7
psychiatrist asked Mr Springham if he was autistic, and he said that he had never
been told he was and did not think so. He noted that Mr Springham’s behaviour
might be as a result of autism or he might have a psychotic illness and was trying to
hide his psychotic symptoms.
45. On 5 March, staff put Mr Springham on hourly observations.
46. The psychiatrist saw Mr Springham again on 8 March. Mr Springham declined to
leave his cell and speak privately, so they spoke through the hatch. Mr Springham
was naked, but a blanket covered his genitals. The psychiatrist noted that Mr
Springham was polite, but his responses were vague and brief. The psychiatrist
said that prison did not seem to be the right place for him, and Mr Springham
shrugged his shoulders. The psychiatrist asked if he could visit him again later, but
Mr Springham did not respond.
47. Another psychiatrist also reviewed Mr Springham on 8 March. He recorded that Mr
Springham was naked, appeared perplexed and distracted, and did not make much
eye contact. Mr Springham said he was worried that he posed a risk to other
people. When the psychiatrist asked for details, Mr Springham refused to engage
further. The psychiatrist noted that Mr Springham had a probable underlying
psychosis and planned to refer him to a Psychiatric Intensive Care Unit (PICU – a
secure mental health unit for people experiencing an acute period of mental illness).
(This was discussed further at a meeting on 11 March, and the psychiatrist made
the referral on 15 March.)
48. A Supervising Officer (SO) held an ACCT review on 9 March. An officer also
attended, but Mr Springham declined to attend. He told staff he did not want to kill
himself and then went back to sleep. The SO noted that Mr Springham had not
shown any thoughts of self-harm and she assessed his risk of self-harm as low.
They reduced his ACCT observations to five observations during the night. They
did not add any caremap actions.
49. A psychiatrist wrote to Westminster Magistrates Court on 10 March. He said that
Mr Springham could be suffering from a psychosis and was being referred to a
PICU in his home area of Nottingham. He said Mr Springham was not fit to attend
his court hearing on 15 March and that a report from the PICU was needed before
sentencing. He requested a minimum two-week adjournment.
50. The next day, 11 March, Mr Springham seemed more settled, but still did not
engage with staff.
51. On 13 March, Mr Springham asked a nurse for some hot water, but when he
passed it to him through the hatch, he lunged and tried to grab his chest. The nurse
noted that this was the second time this had happened and that an officer should be
present before opening the hatch in view of Mr Springham’s unpredictability. Mr
Springham later tried to grab a chaplain’s arm.
52. A SO held an ACCT review with Mr Springham on 15 March. A mental health
nurse, a clinical support worker and an ACCT assessor attended. She noted that
Mr Springham refused to engage with her. She said that every time she tried to
engage with him, Mr Springham kept trying to grab her and when she asked why,
Mr Springham did not respond. She noted that Mr Springham would not say
whether he had any concerns or how staff could help him. Staff assessed his risk
8 Prisons and Probation Ombudsman
of self-harm remained low, and his ACCT observations were altered to once during
the morning, afternoon and evening (although healthcare staff continued to observe
him hourly in line with the standard policy in the Addison Unit). She noted that a
psychiatrist would be invited to attend the next review on 18 March. She did not
add any caremap actions.
53. On 15 March, a psychiatrist tried to review Mr Springham, but Mr Springham
suddenly pushed both his hands through the hatch and tried to grab him. Mr
Springham could not explain why. The psychiatrist told Mr Springham he had
referred him to Northampton Hospital PICU. He noted that Mr Springham did not
understand the reason for the referral.
16 March
54. Between 7.00am and 12.09am on 16 March, prison and healthcare staff interacted
with Mr Springham on 20 separate occasions.
55. At approximately 10.11am, staff unlocked Mr Springham so he could take a shower.
As he left the cell, he lunged at a SO and grabbed her around the neck. Staff
restrained Mr Springham and returned him to his cell. The unit’s manager
increased Mr Springham’s unlock level to three officers due to the increased risk of
assaulting staff. Healthcare staff did not assess Mr Springham for injuries following
his restraint, due to his level of risk. However, they observed him through the spy
hole in the cell door.
56. A healthcare assistant observed Mr Springham for his hourly check. At 11.31am,
Mr Springham was offered lunch, but declined.
57. At 12.09pm, a nurse was completing the unit’s roll check. She saw through the
door’s spy hole that Mr Springham was lying naked on the cell floor, which was not
unusual. She called him but was unable to get a response. She asked an officer to
unlock the hatch in the cell door so she could observe Mr Springham better. She
could only see Mr Springham’s back but thought she detected some movement to
indicate he was breathing. Both staff members walked away from the cell, but she
was concerned so asked the ward manager for advice.
58. At 12.12pm, the nurse and the ward manager returned to Mr Springham’s cell. Mr
Springham remained unresponsive, so the ward manager asked officers to unlock
the cell door. Three officers, in full personal protection equipment (PPE),
responded and unlocked Mr Springham’s door at 12.15pm, and they went in.
59. The ward manager saw that Mr Springham had a ligature, made from a torn
bedsheet, tied around his neck. An officer immediately radioed an emergency code
blue call (indicating a life-threatening medical emergency). The nurse passed her
anti-ligature knife to an officer who cut the ligature, while the ward manager
checked Mr Springham and started chest compressions. The nurse collected
emergency equipment, including a defibrillator. When she returned, she took over
chest compressions. Two nurses attached the defibrillator and managed Mr
Springham’s airway. The defibrillator did not recommend Mr Springham was
shocked.
60. At 12.22pm, ambulance paramedics arrived at the cell and Mr Springham was
moved on to the landing. Paramedics took over Mr Springham’s care and managed
Prisons and Probation Ombudsman 9
to restore his circulation, although he remained deeply unconscious throughout.
The paramedics took Mr Springham to St George’s Hospital where he was taken to
the Intensive Care Unit (ICU).
61. A psychiatrist spoke to hospital staff and then telephoned Mr Springham’s mother at
approximately 3.00pm to explain what had happened. He remained in contact with
Mr Springham’s family over the next few days. Staff telephoned St George’s daily
for updates on Mr Springham’s condition. On 17 March, hospital staff said that Mr
Springham had suffered irreversible brain damage. Further scans verified this and
with the family’s agreement, Mr Springham’s life support was removed, and he died
at 7.19pm on 20 March.
Contact with Mr Springham’s family
62. An officer was appointed as the family liaison officer (FLO). Mr Springham had not
provided any next of kin details and prison staff did not have access to Mr
Springham’s medical records (where a psychiatrist had found his mother’s details),
so police located and broke the news to his family. These details were passed to a
SO, who telephoned Mr Springham’s mother and kept in contact with her.
63. The prison contributed to the cost of Mr Springham’s funeral, in line with national
guidelines.
Support for prisoners and staff
64. After Mr Springham’s death, the Deputy Governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
65. The prison posted notices informing other prisoners of Mr Springham’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 Springham’s death.
Post-mortem report
66. The post-mortem report concluded that Mr Springham’s cause of death was
compression of the neck. The toxicology report noted that Mr Springham had
tested positive only for the medication administered to him in hospital, although
analysis of his hair suggested he had used cocaine in the six months before his
death.
10 Prisons and Probation Ombudsman
Findings
Management of Mr Springham’s risk of suicide and self-harm
67. 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.
68. A prison GP started ACCT procedures for Mr Springham on 22 February 2021, the
day he arrived. He was concerned about Mr Springham’s strange behaviour and
his unkempt appearance. This was good practice. The ACCT remained open
throughout Mr Springham’s three weeks at Wandsworth. Although this was
appropriate, we have some concerns about how the ACCT was managed.
69. PSI 64/2011 says that the ACCT assessment interview should take place within 24
hours of the ACCT being opened. We are aware that an officer noted in Mr
Springham’s prison record that he had tried to hold the ACCT assessment interview
on 23 February, but Mr Springham refused to engage. The ACCT paperwork
shows that staff tried to interview Mr Springham again on 24 and 25 February, but
he still refused to engage. The ACCT assessment interview form was completed
on 26 February, but Mr Springham still refused to engage. We do not understand
why there was this delay. PSI 64/2011 says, ‘…if the prisoner refuses to be
interviewed or is unable to participate in the interview, the ACCT assessor must
undertake the assessment based on all available information e.g., pre-sentence
reports, OASys, health care information, NOMIS case notes and previous ACCT
documents’. Given this, the ACCT assessment should have been completed on 23
February.
70. PSI 64/2011 says that the first case review should be held within 24 hours of the
ACCT being opened. Mr Springham refused to take part in the first ACCT review
on 23 February, and it appears it did not go ahead until 28 February. PSI 64/2011
says that the first case review should be timely and not unduly delayed to ensure
full attendance. It also says that the prisoner should attend but if they do not, their
reasons for non-attendance should be recorded on the case review document. The
first case review should not have been delayed by four days.
71. PSI 64/2011 says that at the first case review, the prisoner’s most pressing needs in
respect of their risk of suicide and self-harm should be identified and a caremap
should be completed, giving detailed and time-bound actions aimed at reducing the
risk posed by the prisoner. We are concerned that no caremap actions were
identified at the first case review, nor indeed at any subsequent case review. The
caremap of the ACCT document was left blank throughout.
72. We acknowledge that it was challenging trying to engage Mr Springham in the
ACCT process. We also recognise that healthcare staff were frequently trying to
engage with him and trying to understand his behaviour and concerns.
Nevertheless, when an ACCT is opened, staff have a responsibility to manage
those procedures correctly and to identify and record the actions that might reduce
the prisoner’s risk of suicide and self-harm.
Prisons and Probation Ombudsman 11
73. PSI 64/2011 says that case reviews should be multidisciplinary where possible. We
identified two case reviews that did not have multidisciplinary input. One was
attended only by the case manager and the other by the case manager and one
officer. Given that Mr Springham was being assessed on the Addison Unit and
there were serious concerns about his mental health, we would have expected
healthcare involvement in every ACCT review.
74. We are also concerned that, at the second of these reviews, on 9 March, the case
manager and the officer assessed Mr Springham’s risk as low and reduced the
frequency of his ACCT observations on the basis that he had not shown any
thoughts of self-harm. We consider that this was premature. Although Mr
Springham had not self-harmed and repeatedly denied that he had any thoughts of
doing so, he did not share his thoughts with staff, his behaviour was bizarre and
unpredictable, and his mental health issues were undiagnosed and untreated. In
these circumstances we consider that Mr Springham’s unpredictability should have
been seen as a risk factor in itself, and that, by not doing so, staff under-estimated
his risk. We therefore consider that the decision to reduce his observations,
particularly without someone from mental health present, was unwise.
75. We recognise that Mr Springham was still being observed hourly by healthcare staff
in line with the standard policy in the Addison Unit, but we are concerned that his
risk to himself was underestimated by prison staff.
76. We also consider that an ACCT review should have been held on the morning of 16
March after Mr Springham was restrained. Although it is clear from the post-
mortem examination that Mr Springham did not suffer any significant physical
injuries, being restrained, even when all the correct procedures are followed, can be
a distressing experience, and we are concerned that this was apparently not
recognised even though Mr Springham was being managed under ACCT
procedures at the time.
77. However, Mr Springham had not self-harmed before this, and therefore, even if an
ACCT review had been held, we consider it unlikely that Mr Springham’s risk to
himself would have been assessed as so high as to require constant supervision.
He was seen alive at 11.31am and was found unresponsive 38 minutes later. We
think it is unlikely that an ACCT review would have resulted in more frequent
observations and, therefore unlikely that the outcome for Mr Springham would have
been different.
78. We make the following recommendation:
The Governor should ensure that staff manage prisoners at risk of suicide
and self-harm in line with national guidelines, including ensuring that:
• A trained ACCT assessor completes an assessment within 24 hours of
the ACCT being opened and attends the first case review.
• Case reviews are multidisciplinary and include all relevant people
involved in a prisoner’s care, including mental health staff where
appropriate.
• Staff set specific and meaningful ACCT caremap actions that are aimed
at reducing prisoners’ risks to themselves and review them at each case
review.
• Staff consider holding an ACCT review following a restraint.
12 Prisons and Probation Ombudsman
Clinical care
79. The clinical reviewer noted that in the last year of his life, Mr Springham was seen
and assessed by a range of clinicians in a variety of environments, all of whom
agreed that his behaviour was odd, but none were able to form a diagnosis. The
clinical reviewer said that Mr Springham’s presentation was perplexing and very
unusual, and even with the experience of the prison healthcare team, it was not
possible to form a clear diagnosis and thus develop a treatment plan.
80. The clinical reviewer was satisfied that the mental health care Mr Springham
received while at Wandsworth was equivalent to that he could have expected to
receive in the community. The clinical reviewer found that Mr Springham was
assessed by a nurse when he arrived at Wandsworth, followed up with a detailed
GP review shortly afterwards. He was referred to the prison’s mental health in-
reach team and was seen and assessed promptly. Once under the care of the
team, he was assessed very regularly by psychiatrists. The proposed transfer to a
secure mental health unit for further assessment was appropriate but could not be
achieved immediately.
Inquest
81. The inquest, held from 11 to 18 March 2024, concluded that Mr Springham died by
suicide.
Prisons and Probation Ombudsman 13
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