Perry, Jared

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Jared Perry,
a prisoner at HMP Parc,
on 3 November 2019
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Jared Perry died in hospital on 3 November 2019 after being found hanging in his cell
at HMP Parc four days earlier. He was 32 years old. I offer my condolences to Mr Perry’s
family and friends.
Mr Perry had significant mental health problems. Staff managed him under suicide and
self harm prevention procedures (known as ACCT) from January 2019 onwards. He often
behaved bizarrely and was aggressive to staff. He was due to transfer to a secure
psychiatric hospital the day after he died.
Staff recognised that he was mentally ill, and I am satisfied that they treated him with care
and compassion. However, while there was much good practice, we have also identified
some areas of concern.
Mr Perry’s mental health needs were generally responded to in a timely and appropriate
way. However, our investigation found that he should have been referred to the prison’s
mental health team when he first arrived at Parc, and that it took some time before the
community mental health inreach team accepted him onto their caseload (possibly
because of resource issues). These may have been missed opportunities to identify and
meet his mental health needs sooner.
I am also concerned about the length of time it took to transfer Mr Perry to hospital once it
had been identified that he had serious mental health needs that could not be met in
prison. I recognise that this was not the fault of prison or healthcare staff and was probably
due to a lack of available hospital beds. We cannot know whether an earlier transfer to
hospital might have prevented Mr Perry’s death.
I am concerned that just hours before Mr Perry was found hanging, an officer failed to
remove a piece of material from his cell. Although we cannot be certain that this was the
piece of material Mr Perry used as a ligature, we consider it highly likely.
I am also concerned that the officer who completed Mr Perry’s ACCT observations by
CCTV in the 30 minutes before he was found hanging, recorded that Mr Perry was
standing by the door, even though he was not in fact visible on the camera. We cannot
know if Mr Perry’s death could have been prevented if the officer had acted more quickly,
but Mr Perry would at least have been discovered earlier.
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 April 2021
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 18
Summary
Events
1. On 6 August 2018, Mr Jared Perry was remanded to HMP Parc, charged with
sexual offences.
2. At an initial reception screen, Mr Perry told a healthcare assistant that he had a
history of drug-induced psychosis. She obtained his consent to request his
community GP records but did not refer him to the mental health team. The prison
received Mr Perry’s GP summary on 8 August but did not prescribe his
antipsychotic medication until 11 August. There is also no record that Mr Perry had
a secondary health screen.
3. On 18 January 2019, Mr Perry was sentenced to 17 years in prison and returned to
Parc. At his reception screen, a mental health nurse recorded that Mr Perry was
tearful and had thought about taking his life. Prison staff started suicide and self-
harm prevention procedures (known as ACCT). He continued to be managed
under ACCT procedures for the remainder of his time at Parc.
4. Over the next seven months, Mr Perry’s mental health deteriorated. He refused to
take his medication and displayed strange behaviour and aggression towards staff.
He was moved to the Safer Custody Unit (SCU) for additional support on several
occasions. Primary care mental health staff reviewed Mr Perry regularly and twice
referred him to the community mental health inreach team. However, the inreach
team concluded that the prison’s primary healthcare services could manage him.
5. On 16 August, a nurse referred Mr Perry to the mental health inreach team for the
third time after his mental health deteriorated further. On 29 August, a consultant
psychiatrist from the inreach team reviewed Mr Perry and referred him for
assessment for a transfer to a secure psychiatric hospital.
6. On 10 September, a consultant forensic psychiatrist assessed Mr Perry and
concluded he was psychotic and required a transfer to hospital. On 22 October, the
psychiatrists completed the required medical recommendations to enable a transfer
to take place. On 24 October, the Ministry of Justice issued a transfer warrant, and
it was agreed that Mr Perry would transfer to hospital on 4 November.
7. At 10.17am on 30 October, three officers unlocked Mr Perry for a shower and some
time out of his cell. In the meantime, an operational manager asked an officer to
clear the rubbish from Mr Perry’s cell. The officer picked up a piece of material but
did not remove it from the cell.
8. At 11.28am and 11.41am, an officer used the in-cell CCTV to conduct an ACCT
observation. He recorded that Mr Perry was standing by the door, but CCTV shows
that Mr Perry was out of the camera’s view from 11.26am onwards.
9. At around 11.50am, the officer noticed that he could not see Mr Perry. He went to
his cell and looked through the cell door observation panel but could not see him.
He asked another officer for assistance, who saw Mr Perry’s feet by the door. At
11.52am, they opened the door and found Mr Perry hanging from the back of the
door. An officer cut the ligature from Mr Perry’s neck and started cardiopulmonary
Prisons and Probation Ombudsman 1
resuscitation (CPR). At 11.53am, the other officer radioed a medical emergency
code blue.
1. Shortly afterwards, members of healthcare staff arrived. Ambulance paramedics
arrived at the cell at 12.09pm. At 12.17pm, they detected a pulse and at 12.27pm,
they took Mr Perry to hospital, unrestrained, where he remained in a critical
condition on life support.
2. On 3 November, Mr Perry died in hospital, with his family present.
Findings
Risk management
3. Mr Perry had a history of mental health problems and this made him challenging to
manage. We are satisfied that prison and healthcare staff showed concern and
compassion and tried to support his best interests.
4. His mental health deteriorated after he received a long prison sentence in January
2019. Staff recognised that he posed a risk to himself as a result and appropriately
managed him under ACCT procedures for the remainder of his time at Parc.
5. While staff managed much of Mr Perry’s ACCT well, we are concerned that they did
not always set clear and meaningful caremap actions or record whether they were
complete. There was also no co-ordinated plan for monitoring the progress of Mr
Perry’s transfer to a secure psychiatric hospital.
6. We are concerned that an officer failed to consider the risk posed by the piece of
material he found in Mr Perry’s cell on the day he hanged himself. While removing
the material may not have prevented Mr Perry’s death, it would have stopped him
accessing it. If the officer had reported it, it is also likely that there would have been
an ACCT case review and additional support measures put in place.
7. We are concerned that the officer who completed Mr Perry’s ACCT observations
that day recorded that he was standing by the door, even though he was not visible
on CCTV. While we cannot know whether Mr Perry’s death would have been
prevented if the officer had checked him sooner, he would have discovered him
earlier. The officer has since resigned from his job at Parc.
Clinical care
8. The clinical reviewer concluded that, overall, the clinical care that Mr Perry received
at Parc was equivalent to that which he could have expected in the community, and
that his mental health needs were general met in a timely and appropriate way.
9. However, there were some failings: healthcare staff failed to refer him to the mental
health team at his initial reception screen, to prescribe medication promptly or to
conduct a secondary health screen. Although he was first referred to the
community mental health inreach team in February 2019, and again in July, they did
not accept him onto their caseload until August (possibly because of inadequate
resources). These were missed opportunities to identify his mental health needs
earlier.
10. We are also concerned about the length of time it took to transfer Mr Perry to a
secure psychiatric hospital once it had been identified in August that his severe
2 Prisons and Probation Ombudsman
mental health needs could not be met in prison. This was not the fault of prison
healthcare staff. Communication between healthcare and prison staff about Mr
Perry’s hospital transfer could have also been more effective.
Recommendations
• The Director should ensure that staff manage prisoners at risk of suicide and self-
harm in line with national guidelines, including that staff:
• set effective caremap actions that are specific and meaningful, aimed at
reducing risk, and update them at each review; and
• accurately record details of ACCT observations in the ongoing record and
physically review prisoners who are not visible on in-cell CCTV.
• The Director should ensure that staff are extra vigilant about the care of prisoners
who are being considered for or are awaiting transfer to a secure hospital.
• The Director should ensure that prison staff remove items which potentially pose a
risk from a prisoner’s cell and escalate their concerns.
• The Director should commission an investigation into PCO A’s failure to remove an
item of risk from Mr Perry’s cell, with a view to considering whether disciplinary
action is appropriate.
• The Head of Healthcare should ensure, in line with PSO 3050, that healthcare staff:
• refer prisoners who report mental health problems to the mental health team;
• prescribe medication promptly once a GP has confirmed a prisoner’s existing
prescription;
• rearrange outstanding hospital appointments if necessary; and
• offer all prisoners a full general health assessment within a week of their arrival.
• The HMPPS Executive Director for Wales should:
• satisfy himself that the mental health needs of the prisoner population at Parc
have been established;
• satisfy himself that there is prompt assessment and timely access to integrated
support and a full range of interventions for prisoners with complex mental
health needs; and
• write to the Ombudsman to confirm that he is so satisfied.
• The Head of Healthcare should ensure that:
• local guidance is developed setting out the process for transferring prisoners to
a secure hospital under Section 47 of the Mental Health Act 1983; and
• prisoners with complex needs are reviewed weekly as part of a multidisciplinary
team and decisions set out in an agreed written plan.
Prisons and Probation Ombudsman 3
The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Parc informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
12. The investigator visited Parc on 15 November 2019 and obtained copies of relevant
extracts from Mr Perry’s prison and medical records. He interviewed six members
of staff at Parc on 18 December.
13. Healthcare Inspectorate Wales (HIW) commissioned a clinical reviewer to review Mr
Perry’s clinical care at the prison. The investigator and clinical reviewer jointly
interviewed 12 members of staff at Parc between 20 January and 4 February 2020.
14. We informed HM Coroner for Cardiff, Bridgend and Glamorgan Valleys of the
investigation and have sent him a copy of this report. No post-mortem examination
was conducted.
15. One of the Ombudsman’s family liaison officers contacted Mr Perry’s mother to
explain the investigation and to ask if she had any matters she wanted the
investigation to consider. Mr Perry’s mother wanted to know:
• why Mr Perry had to wait for months to see two psychiatrists; and
• what support he was offered after his father died.
We have addressed these concerns in this report and in separate correspondence.
16. Mr Perry’s mother received a copy of the initial report. She raised a number of
issues/questions that do not impact on the factual accuracy of this report and have
been addressed through separate correspondence.
17. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
4 Prisons and Probation Ombudsman
Background Information
HMP Parc
18. HMP Parc is a medium security prison run by G4S, which holds around 1,600
convicted men and young adults on remand or convicted. It also has a unit for
around 60 young people under the age of 18.
19. G4S Medical Services provide primary physical and mental health care services.
There are 24-hour general healthcare and palliative care facilities. A local GP
practice provides GP services, including a daily clinic and out-of-hours cover.
20. The mental health inreach team (MHIT) and secondary mental health services are
provided by Swansea Bay University Health Board (SBUHB).
HM Inspectorate of Prisons
21. The most recent inspection of HMP Parc was in November 2019. Inspectors found
that the level of self-harm remained high despite some improvement over the
previous 12 months and, combined with the relatively large number of self-inflicted
deaths, continued to cause serious concern. Recommendations made by the
Prisons and Probation Ombudsman were taken seriously and regularly reviewed by
safer custody staff, as well as being monitored at the monthly safer custody strategy
meeting. Although quality assurance measures were in place for prisoners
assessed at risk of suicide or self-harm, weaknesses in the quality of recording,
observational checks and caremaps were identified.
22. Inspectors found that the demand for mental health services was high and service
provision did not meet demand. Although the support available for mild to moderate
problems had improved, the range of specialist interventions and support for
prisoners with more complex needs was inadequate and too many patients waited
too long to access existing services. Secondary mental health services for those
with complex mental health issues were provided by the Swansea Bay University
Health Board. Inspectors found that the team was under-resourced, and also
covered another prison (HMP Swansea).
23. Inspectors found that in the previous six months, three out of four transfers under
the Mental Health Act had taken place promptly, with one slightly delayed and
another - Mr Perry’s transfer - cancelled as he had died on the day before transfer.
Independent Monitoring Board
24. 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 28 February 2019, the IMB
reported that although incidents of violence and self-harm remained high, the safer
custody team had expanded, with several caseworkers developing and delivering a
range of interventions to prisoners at risk.
Prisons and Probation Ombudsman 5
25. The mental health pathway for access to primary care services was working well,
but the lack of secondary psychiatric care, particularly for elderly prisoners,
continued to be a major concern.
Previous deaths at HMP Parc
26. Mr Perry’s death was the seventeenth at Parc since November 2017, two of which
were self-inflicted. There has been one death since. We have previously made a
recommendation about the use of medical emergency codes, and about the need to
ensure adequate mental health service provision for prisoners with dementia.
Assessment, Care in Custody and Teamwork
27. 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.
28. 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 (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.
29. All decisions made as part of the ACCT process and any relevant observations
about the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction (PSI) 64/2011.
Transfer of prisoners to hospital under the Mental Health Act
30. When a prisoner has a mental illness that requires detention in a hospital for
medical treatment, and the prisoner urgently needs that treatment, the prison can
arrange for them to transfer to a secure hospital under section 47, 48 or 49 of the
Mental Health Act 1983. PSI 50/2007, Transfer of Prisoners to and From Hospital
Under Sections 47 and 48 of the Mental Health Act 1983, and the Mental Health Act
1983 Code of Practice for Wales (updated in 2016), set out the process.
31. Before the prisoner can be transferred to hospital, two doctors (one of whom must
be a mental health specialist) must provide reports stating that the prisoner meets
the criteria for transfer. The reports must not be more than two months old. The
mental health inreach team then sends the reports to the Ministry of Justice’s
Mental Health Casework Section, who review the request and issue a transfer
warrant. The transfer warrant, which is valid for 14 days, allows the prisoner to be
transferred to hospital under the direction of the Secretary of State.
32. When a prisoner is identified as suitable for transfer to hospital, the local health
board within which the prisoner is registered with a community GP is responsible for
arranging a secure mental health bed.
6 Prisons and Probation Ombudsman
33. The Department of Health for Wales’s guidance, published in 2011, recommends
that all prisoners who need to be transferred are moved within 14 days.
Prisons and Probation Ombudsman 7
Key Events
August to December 2018
34. On 6 August 2018, Mr Jared Perry was remanded to HMP Parc for sexual offences.
35. At an initial reception screen, Mr Perry told a healthcare assistant that he had a
history of drug-induced psychosis and had recently seen a GP for a medication
review. He also said he had an appointment with a psychologist booked for that
day. She obtained Mr Perry’s consent to request his community medical records
but did not refer him to the mental health team.
36. The prison received Mr Perry’s GP summary on 8 August and a prison GP reviewed
it on 11 August. The community summary confirmed that Mr Perry was prescribed
olanzapine (an antipsychotic) and diazepam (to treat anxiety), and had received
intermittent input from a private psychiatrist in the community for the past three
years, with a current referral to an NHS psychiatrist. The GP re-prescribed
olanzapine and diazepam.
37. There is no record that Mr Perry had a secondary health screen.
38. On 20 August, a prison pharmacist reviewed Mr Perry’s medication and recorded
that he said that he had stopped taking olanzapine due to timing issues. She noted
that Mr Perry was tearful, and she referred him to the primary care mental health
team for an assessment.
39. Over the next four months, prison and healthcare staff monitored and reviewed Mr
Perry frequently. Mental health staff conducted an initial assessment, issued him
with self-help guidance and arranged for him to attend depression-focussed group
sessions.
January to March 2019
40. On 10 January 2019, a nurse conducted a follow-up mental health assessment and
Mr Perry reported hearing voices. He said that his medication helped manage the
voices but that he continued to struggle. She recorded that Mr Perry did not report
any thoughts of suicide or self-harm and suggested that he should receive one-to-
one support.
41. On 18 January, Mr Perry was sentenced to 17 years in prison and returned to Parc.
At a reception screen, a mental health nurse noted that Mr Perry was tearful and
had thought about taking his life. She told prison staff who started ACCT
procedures.
42. On 19 January, a Prison Custody Officer (PCO) carried out an ACCT assessment
and noted that Mr Perry appeared upset about his sentence. Shortly afterwards, an
Operational Manager (OM) chaired an ACCT review in which a mental health nurse
attended. Mr Perry told attendees that he had been expecting “10 years” and that
his “head was all over the place”. They assessed his risk as raised and recorded
on his caremap that he should remain active and have access to a music class.
43. Staff continued to monitor Mr Perry under ACCT procedures until his death.
Healthcare staff attended 56 out of 58 ACCT case reviews.
8 Prisons and Probation Ombudsman
44. On 8 February, a nurse attended a multidisciplinary case conference and recorded
that Mr Perry’s mental state had deteriorated over the weekend. Staff conducted a
Threshold Assessment Grid assessment (TAG - a brief assessment of the severity
of an individual's mental health problems) and agreed to check if Mr Perry had been
referred to the mental health inreach team.
45. On 14 February, Mr Perry cut his thumb with a razor and was noted to be very
agitated and restless.
46. On 18 February, a nurse attended a case conference and recorded that staff had
decided to move Mr Perry to the Safer Custody Unit (SCU – for prisoners who
require additional monitoring and support) for an assessment. On 19 February, an
OM chaired an ACCT case review and noted that Mr Perry was acting in a ‘bizarre
and unusual fashion’. There is no record that staff reviewed or updated his
caremap.
First referral to MHIT
47. On 20 February, a pharmacist reviewed Mr Perry’s medication and he agreed to
take olanzapine again. The next day, a nurse referred Mr Perry to the mental
health inreach team.
48. On 22 February, an OM chaired an ACCT case review, which several prison
managers and a nurse attended. Mr Perry reported feeling guilty for his crimes and
said that he had spoken to a chaplain about his standing with God. Attendees
questioned whether Mr Perry’s state of mind was due to substance misuse, but he
denied taking anything illicit.
49. On 14 March, a mental health Inreach nurse visited Mr Perry to conduct an initial
assessment. However, he refused to engage or to consent to the nurse requesting
his community mental health records. The nurse noted that Mr Perry appeared
emotional and concluded that his presentation could have been due to substance
misuse or the reaction to a long sentence. He tried again to complete the initial
assessment on 3 April, but Mr Perry again refused to engage.
18 April to 7 June 2019
50. On 18 April, the nurse tried to see Mr Perry for a third time. He still refused to
engage in the assessment, citing his religious beliefs as a Jehovah’s Witness, but
agreed to an informal discussion. He told the nurse that his thoughts had spiralled
out of control recently and that he may have been ‘spiked’ as he had not willingly
taken illicit drugs for two years. He also said that he had reduced olanzapine and
was not having any auditory or visual hallucinations. The nurse felt Mr Perry’s
mental health could be managed under primary care but said he would discuss him
at a single point of access meeting (SPAM) before discharging him. (The SPAM
meeting considers referrals to the mental health inreach team and decides whether
to accept them.)
51. On 4 May, a prison chaplain noted that Mr Perry had spoken to his mother the
previous night and she had told him that his father had died. The same day, an OM
chaired an ACCT case review and recorded that although Mr Perry was upset, he
did not report thoughts of suicide or self-harm.
Prisons and Probation Ombudsman 9
52. On 8 May, a nurse reviewed Mr Perry following his father’s death. He said that he
had spoken to officers and Listeners (prisoners trained by the Samaritans to
support other prisoners) and did not feel like talking anymore. She recorded that he
remained subject to ACCT monitoring and did not report any thoughts of suicide or
self-harm.
53. On 10 May, an OM chaired an ACCT case review. Mr Perry told attendees that he
had mixed feelings and the OM encouraged him to take his medication. Mr Perry
did not report any thoughts of suicide or self-harm and said that he was hoping to
go to his father’s funeral. On 15 May, a probation officer recorded that Mr Perry’s
application to attend his father’s funeral was not supported, as the victims of his
offences were family members.
54. On 22 May, a pharmacist reviewed Mr Perry’s medication. He told her that he had
had a breakdown after his father’s death. He said that he did not feel that he was
being punished enough for what he had done, that his thoughts were disordered
and that he had not been taking his medication. She encouraged Mr Perry to do so
and recorded that he should remain on olanzapine.
55. On 23 May, a nurse told Mr Perry that his case had been discussed at a SPAM and
that it had been decided that primary care could manage his symptoms. Mr Perry
said that he had deep-rooted issues to work through and blamed himself, others
and drugs for how he presented. The nurse recorded that Mr Perry did not show
signs of psychosis and referred him to primary care with recommendations for
counselling or psychological therapies.
56. On 28 May and 30 May, a mental health nurse tried to conduct a primary care
mental health assessment. However, Mr Perry refused to engage on both
occasions.
57. On 31 May, an OM chaired an ACCT enhanced case management review which
several members of staff, including a nurse, attended. The OM recorded that Mr
Perry had not been taking his medication and was displaying bizarre behaviour. As
Mr Perry’s mental health appeared to have deteriorated, attendees decided that he
should move to the SCU for observation. Later that day, the probation officer
contacted a substance misuse manager to enquire about a counselling referral for
Mr Perry.
58. On 3 June, a prison chaplain saw Mr Perry who reported struggling with lots of
different thoughts. Later that day, the substance misuse manager advised the
probation officer that it would not be appropriate to start counselling as Mr Perry
was subject to ACCT monitoring and needed a period of stability.
59. On 7 June, an OM chaired an ACCT case review and a nurse attended. Mr Perry
did not report thoughts of suicide or self-harm but said that he was concerned about
the noise on the wing. The OM added a caremap action to look at the possibility of
moving Mr Perry.
1 July to 29 August
60. On 1 July, a locum GP saw Mr Perry for a medication review. He told her that he
had a lot of issues to work through. She recorded that Mr Perry did not display any
psychotic symptoms and had agreed to continue taking olanzapine.
10 Prisons and Probation Ombudsman
61. On 9 July, an OM chaired an ACCT case review and recorded that Mr Perry came
across as very bizarre. Mr Perry did not report any thoughts of suicide or self-harm
but said he felt like he was “going backwards”, despite taking his medication. The
OM noted that he did not update Mr Perry’s caremap, as the case manager was not
available to chair the review.
Second referral to the MHIRT
62. On 15 July, a mental health nurse reviewed Mr Perry and recorded that he was
pacing up and down his cell and was unable to sit still. She noted that he appeared
to be responding to unseen stimuli and that it was difficult to assess his mental state
as he refused to engage. Two days later, she re-referred Mr Perry to the mental
health inreach team.
63. On 18 July, an OM chaired an enhanced ACCT case management review and case
conference. Mr Perry told attendees that he did not have any thoughts of suicide or
self-harm but wanted to return to the SCU as he felt the house block was too busy.
Staff discussed the possibility of Mr Perry moving to another part of the house block
to ensure he complied with his medication first. At that point, Mr Perry stopped
engaging with the review and tried to assault the OM.
64. On 24 July, a mental health nurse recorded that following a discussion at a SPAM
the previous day, it was felt Mr Perry’s needs could be managed under primary care
and the referral to the inreach team was not therefore accepted.
65. On 30 July, Mr Perry was moved to the segregation unit for trying to assault a
member of staff during a disciplinary hearing. Later that day, an OM chaired an
ACCT case review, in which a nurse attended. The OM recorded that although Mr
Perry seemed more relaxed than earlier, attendees had decided to increase his
level of ACCT monitoring to five observations an hour, with four conversations
during the day and one at night.
66. On 1 August, a prison manager chaired an ACCT case review and Mr Perry told the
attendees that he was okay and had no thoughts of suicide or self-harm. The
prison manager noted that Mr Perry’s behaviour had been very strange since he
had arrived in the segregation unit. He did not expand on this.
67. On 2 August, a prison manager tried to chair an ACCT case review, but Mr Perry
refused to engage. He added to the caremap an action for Mr Perry to engage in
case reviews. Later that day, staff moved Mr Perry to the SCU and assigned him a
safer cell (a cell specifically designed to minimise ligature points) with 24 hour in-
cell CCTV surveillance.
68. On 5 August, an OM chaired an ACCT case review, in which a nurse attended. Mr
Perry refused to engage and lunged at the OM. Staff used force to restrain him so
they could exit the cell. A prison paramedic reviewed Mr Perry and recorded that
he did not have any injuries.
69. On 7 August, staff discussed Mr Perry’s recent presentation at the weekly
multidisciplinary meeting for prisoners with complex needs and noted that a nurse
would refer him to the inreach team. However, there is no record that she did so.
That day, another nurse visited Mr Perry for a review, but there were not enough
staff available to meet the requirement to have two officers present to unlock him.
Prisons and Probation Ombudsman 11
70. On 13 August, a nurse recorded that Mr Perry had been allocated to her caseload
for mental health support. She visited Mr Perry, but he refused to engage. The
next day, staff discussed Mr Perry at the weekly healthcare meeting to discuss
prisoners with complex needs and recorded that his unlock requirement had been
increased to three officers due to his challenging behaviour.
Third referral to the MHIT
71. On 16 August, an OM chaired an ACCT case review, in which a Senior Operational
Manager (SOM) and a nurse attended. He recorded that Mr Perry seemed pre-
occupied and tried to push his way out of his cell door when staff tried to facilitate a
phone call to his mother. The attendees agreed that as Mr Perry’s mental health
appeared to have deteriorated, he should be referred to the inreach team again.
They assessed Mr Perry’s risk as raised but reduced his ACCT monitoring to two
observations an hour, with two conversations daily and one at night, as they felt he
presented more of a risk to staff than to himself. That day, a nurse referred Mr
Perry to the mental health inreach team again.
72. On 19 August, the mental health Inreach team manager and a mental health
inreach nurse assessed Mr Perry. They spoke to staff in the SCU, who said that
they had observed a deterioration in Mr Perry’s behaviour and that they were now
managing his unlock requirements to include three officers and a shield. The
Inreach team manager questioned whether Mr Perry had psychotic depression
following his father’s death and tasked a GP to prescribe a short course of
diazepam, which a GP did on 21 August.
73. On 22 August, an OM chaired an ACCT case review, in which a complex case
manager, a nurse and two officers attended. The OM talked to Mr Perry through
the door and asked him to move to the back of the cell. Once the door was open,
My Perry kept edging towards the door and staff left the cell. After the review,
attendees decided that although Mr Perry’s behaviour was concerning, he did not
present a significant risk to himself and could continue to be managed under two
observations an hour.
74. On 27 August, an OM chaired a case conference attended by Mr Perry’s mother, a
nurse from the Inreach team, a SOM, the complex case manager, a nurse and a
prison chaplain. Mr Perry’s mother told the attendees that he had a history of
mental health and substance misuse problems and did not take his medication
consistently in the community. She also gave staff a psychiatric report from 2018,
which indicated that Mr Perry had schizophrenia and would need intense
antipsychotic treatment.
75. Later that day, the OM chaired an ACCT case review and recorded that Mr Perry
was distressed and tearful. He told Mr Perry that he had spoken to his mother and
offered to facilitate a phone call. However, shortly after agreeing to speak to his
mother, Mr Perry assaulted the OM by punching him in the head. Staff stopped the
review and used force to secure Mr Perry. An action was added to the caremap for
staff to encourage Mr Perry to have regular contact with his family.
76. On 29 August, a consultant psychiatrist from the mental health Inreach team and a
nurse reviewed Mr Perry in the presence of three officers with a shield. The
psychiatrist recorded that Mr Perry’s bizarre behaviour, poor engagement, non-
compliance with medication and possible diagnosis of psychotic illness meant that
12 Prisons and Probation Ombudsman
he could not assess him in a prison environment. He noted that he would refer Mr
Perry to Hywel Dda Health Board’s forensic psychiatry team to be assessed for a
secure hospital transfer.
2 September to 29 October
77. On 2 September, an OM chaired an ACCT case review which prison staff and a
mental health nurse attended. The OM recorded that Mr Perry refused to engage
and ‘approached staff in an aggressive manner’ when he tried to explain the reason
for the review. He noted that a shield was used to push Mr Perry away and added
a caremap action which was to speak to the use of force co-ordinator for
suggestions on how to manage Mr Perry’s behaviour.
78. On 6 September, an OM chaired an ACCT case review and recorded that Mr Perry
agreed to phone his mother, before changing his mind. A nurse asked the OM to
ask Mr Perry if he was hearing voices and he replied, “Yes and no.” He then
proceeded to move towards staff, and they left the cell. The attendees decided to
continue with two ACCT observations an hour and noted that Mr Perry’s compliance
and engagement was better than it had been for a considerable time.
79. On 8 September, a nurse reviewed Mr Perry and recorded that he presented as
unkempt, appeared to be responding to unseen stimuli and lacked capacity to make
rational decisions. He asked the inreach team to prioritise their assessment as he
did not feel that staff could sufficiently meet Mr Perry’s needs.
Assessment for a transfer to a secure hospital
80. On 10 September, a PCO recorded that Mr Perry refused to have his breakfast and
became aggressive. She noted that he continuously banged on his cell door and
told staff to go away when they spoke to him. That day, a consultant psychiatrist
from Hywel Dda Health Board conducted an assessment. The ongoing ACCT
record indicates that Mr Perry’s observations continued to take place twice an hour.
81. On 11 September, an OM chaired an ACCT case review through Mr Perry’s cell
door as he was aggressive towards staff. He told her that he did not want to go to
hospital but refused to say more. The attendees assessed Mr Perry’s risk as raised
and kept his ACCT observations at five an hour. There is no record to indicate
when the observations were increased.
82. Later that day, a nurse made a retrospective entry in Mr Perry’s medical record
which noted that the consultant psychiatrist felt Mr Perry presented as psychotic
and needed a hospital transfer under section 47 of Mental Health Act 1983. She
noted that he would prepare a report and liaise with the inreach team.
83. On 26 September, a nurse contacted the consultant psychiatrist to ask for an
update on his assessment. He informed her that he had completed a section 47
report and a nurse assessor from Hywel Dda Health Board added that they would
start the process of identifying a bed in a mental health hospital. That day, the
nurse spoke to Mr Perry through his cell door as officers could not meet his unlock
requirement. He said he was not feeling too bad but did not want to speak to her.
84. On 30 September, an OM looked through Mr Perry’s cell observation panel and saw
him huddled up on his bed. He told him that he was going to conduct an ACCT
case review and asked Mr Perry to stay on his bed. Staff entered the cell and Mr
Prisons and Probation Ombudsman 13
Perry told them that he was “not good” and “needed to be punished for the things
he has done”. Mr Perry then asked staff to beat him and began to get up. At this
point, the OM instructed all staff to leave the cell.
85. On 2 October, a SOM emailed the mental health Inreach team manager to ask for
an update about several prisoners, including Mr Perry. That day, the Operational
Head of Safety also emailed the Inreach team manager for an update about Mr
Perry’s hospital transfer as prison staff were becoming increasingly concerned
about him. The Inreach team manager contacted the consultant psychiatrist, who
informed him that Mr Perry was almost certainly schizophrenic and required
admission to a Psychiatric Intensive Care Unit (PICU). He said that there were
currently four people waiting for a bed and that a nurse manager would visit the
prison to assess Mr Perry.
86. On 3 October, the mental health Inreach team manager informed the SOM that the
hospital offering Mr Perry a bed had arranged a nursing assessment for the
following week. Later that day, an OM met several staff before an ACCT enhanced
case management review. They discussed the difficulty staff had minimising the
amount of force used on Mr Perry and the SOM asked staff to contact the use force
co-ordinator. This action was added to the caremap. The OM recorded that when
staff entered Mr Perry’s cell to conduct the review, he approached them
aggressively and they used a shield to enable them to leave the cell safely.
87. On 8 October, two members of hospital staff assessed Mr Perry’s suitability for a
psychiatric hospital admission. The mental health Inreach team manager
accompanied them and recorded that Mr Perry tried to attack an officer shortly after
leaving his cell. He also noted that Mr Perry was pre-occupied and reported
hearing voices and a radio playing in his head. Hospital staff assessed Mr Perry as
suitable for a PICU and advised that a bed should be available within two weeks.
The Inreach team manager recorded that he would liaise with the consultant
psychiatrist and prepare the relevant paperwork.
88. On 11 October, a PCO recorded that Mr Perry’s behaviour had improved over the
last few days. Later that day, an OM chaired an ACCT case review and recorded
that Mr Perry repeatedly said, “I’m sick”. The OM noticed that Mr Perry was holding
a letter from his mother and offered to help him read it but there is no record to say
whether he accepted.
89. On 15 October, an OM chaired an ACCT case review and recorded that Mr Perry
had attended to his personal hygiene. Later that day, a psychiatrist visited Mr Perry
for a review, but he charged at him and an officer had to stop him. He noted that
Mr Perry remained psychotic and that he was waiting for the consultant
psychiatrist’s medical recommendation to complete the second recommendation.
90. On 22 October, the consultant psychiatrist visited Mr Perry again and completed the
first medical recommendation for a transfer to a secure hospital. The prison
psychiatrist completed the second medical recommendation shortly afterwards.
The next day, healthcare staff submitted the section 47 application to the Ministry of
Justice Mental Health Casework Section (MoJ MHCS). MoJ MHCS gave the prison
a transfer warrant on 24 October, and staff scheduled the hospital transfer for 4
November.
14 Prisons and Probation Ombudsman
91. The prison told us that between 8.15am and 8.46am on 26 October, in-cell CCTV
footage shows that Mr Perry is out of view of the camera. The ACCT observation
record indicates that Mr Perry was stood by his door, but CCTV footage covering
the SCU does show an officer going to his cell during this time. At 3.28pm, in-cell
CCTV shows Mr Perry ripping what appears to be bedding and placing it under his
duvet.
92. At 10.30am on 28 October, an OM chaired an ACCT case review, in which a nurse
and two officers attended. She asked Mr Perry how he felt, and he said, “This isn’t
me”. She asked him if he understood that he would be going to hospital, but he did
not respond. At 6.14pm, in-cell CCTV shows Mr Perry pick up a piece of material
from his bedside table and appear to tear it several time before putting it back
down.
93. On 29 October, the accommodation fabric check box (AFC, a visual inspection of
the cell to ensure it is safe) in the SCU ledger was signed ‘staff’ instead of the name
of the individual who conducted the AFC, as the document requires. However, the
ongoing ACCT record states that Mr Perry refused to leave his cell throughout the
day and told staff taking his food into his cell that he wanted to “punch someone”.
Events from 30 October to 3 November
94. At 8.00am on 30 October, an OM chaired a morning meeting in the SCU and asked
staff to encourage Mr Perry to leave his cell as he had not been out for a day. At
10.17am, three PCOs unlocked Mr Perry and took him to the shower. Shortly
afterwards, CCTV footage shows that Mr Perry went to the unit’s exercise yard for
around 30 seconds before he returned inside. At this point, the OM arrived and
asked PCO A, who was monitoring the cameras to clear the rubbish from Mr Perry’s
cell.
95. PCO A entered Mr Perry’s cell and gathered rubbish and leftover food. While doing
so, he picked up a piece of material next to some used polystyrene plates on Mr
Perry’s bedside table. He inspected the piece of material before putting it back
where he found it.
96. In the meantime, Mr Perry spoke to the OM and asked him why he looked down or
depressed. The OM told him that he been ill recently. Mr Perry stood up and
walked towards him saying, “I’m going to punch him”. The OM encouraged Mr
Perry to stay out of his cell a while longer before leaving the unit to avoid
antagonising him further.
97. At 10.47am, officers informed Mr Perry that he had to return to his cell. Mr Perry
began to move towards a PCO, who used a shield to hold him against a wall. A
PCO grabbed Mr Perry’s left arm while another PCO dropped the shield and they
guided him back to his cell. CCTV shows that Mr Perry did not resist staff. Both
PCOs told the investigator that Mr Perry did not report thoughts of self-harm or
display any behaviour that may have indicated an increased risk of suicide.
98. At 11.01am, a nurse reviewed Mr Perry through his cell observation panel and
recorded that Mr Perry did not report sustaining any injuries in the earlier restraint.
At 11.24am, a PCO conducted an ACCT check and recorded that Mr Perry was
lying on his bed.
Prisons and Probation Ombudsman 15
99. At 11.18am, Mr Perry pressed his emergency cell bell and spoke to a member of
staff. Although it has not been possible to establish who answered the cell bell, a
PCO told us that Mr Perry often used the intercom to ask staff to let him out of his
cell shortly after he had spent time in the unit.
100. At 11.26am, in-cell CCTV footage shows that Mr Perry walked into a blind spot
behind the door, with a piece of material in hands. At 11.28am and 11.41am, a
PCO said that he used the in-cell CCTV monitor in the staff office to conduct the
ACCT observations. He recorded that Mr Perry was standing by the door on both
occasions. However, CCTV footage shows that Mr Perry remained out of view of
the camera.
101. At around 11.50am, a PCO conducted Mr Perry’s ACCT check by looking at the
CCTV monitor and noticed that he could not see him. He went to Mr Perry’s cell
and looked through the observation panel but still could not see him. He asked
another PCO for assistance due to Mr Perry’s unlock level and he too looked into
the cell. The PCO told us that he could not see Mr Perry initially, but then saw his
feet by the door.
102. A PCO suggested that they unlock the cell to check Mr Perry as this was not his
usual behaviour. At 11.52am, they opened the door and found Mr Perry hanging by
a piece of bed linen attached to an exposed rivet holding the inundation point to the
door. The PCO cut the ligature from Mr Perry’s neck, placed him on the floor and
started cardiopulmonary resuscitation (CPR). At 11.53am, another PCO pressed
his personal alarm and radioed a medical emergency code blue (indicating that a
prisoner is unconscious or has breathing difficulties).
103. At 11.54am, a nurse arrived and saw that officers were performing CPR. He
radioed for all nurses to attend and obtained an emergency medical bag from the
medication hatch in the SCU. In the meantime, several members of healthcare staff
arrived while a PCO collected a defibrillator. A prison paramedic inserted an airway
and asked nurses to use the defibrillator, which analysed Mr Perry’s heart rhythm
but advised not to issue a shock. Prison and healthcare staff continued CPR.
104. An ambulance arrived at the prison at 12.03pm and the first paramedic reached Mr
Perry’s cell at 12.09pm. At 12.17pm, paramedics detected a pulse and at 12.27pm
they took Mr Perry, unrestrained and escorted by two officers, to the Princess of
Wales Hospital, Bridgend.
105. At 1.10pm, a hospital consultant told prison staff that Mr Perry was on life support
and in a critical condition. Healthcare staff remained in daily contact with the
hospital for updates on Mr Perry.
106. On 3 November, after consulting with Mr Perry’s family, hospital staff decided to
turn off his life support. Mr Perry died at 3.50pm, with his family present.
Contact with Mr Perry’s family
107. At 1.30pm on 30 October, Parc appointed the complex case manager as the family
liaison officer. She phoned Mr Perry’s mother and told her that he had been taken
to hospital. At 4.25pm, complex case manager and a prison manager met Mr
Perry’s mother and sister at the hospital. They offered their support and remained
in daily contact with Mr Perry’s mother.
16 Prisons and Probation Ombudsman
108. At 8.30am on 3 November, the complex case manager met Mr Perry’s mother at
the hospital and offered support. She stayed at the hospital until 12.30pm. At
5.30pm, Mr Perry’s mother phoned the complex case manager and told her that Mr
Perry had died.
109. The complex case manager provided ongoing support to Mr Perry’s mother until his
funeral on 20 November. The prison contributed toward the cost in line with
national policy.
Support for prisoners and staff
110. On 26 September, a prison manager debriefed staff involved in the emergency
response to ensure that they had the opportunity to discuss any issues arising, and
to offer support. After Mr Perry died, a prison manager offered support to the staff
present at the hospital.
111. The prison posted notices informing other prisoners of Mr Perry’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 Perry’s death.
Post-mortem report
112. No illicit substances were identified in routine post-mortem toxicology tests.
Prisons and Probation Ombudsman 17
Findings
Management of Mr Perry’s risk of suicide and self-harm
113. For the most part, Parc managed the ACCT process well. The case reviews
indicate that staff made concerted efforts to work with Mr Perry to reduce his risk
and that healthcare involvement in the process was frequent. Both prison and
healthcare staff attempted to support Mr Perry by referring him to available support
networks. They encouraged Mr Perry to participate in ACCT reviews and involved
his mother in the process. Enhanced case reviews with senior managers took
place as his condition deteriorated and staff asked the mental health inreach team
for updates about his hospital transfer. Staff were aware that Mr Perry was
mentally unwell and demonstrated compassion and managed his aggression
appropriately.
114. Despite this positive work, we have identified some areas for improvement.
Caremaps
115. PSI 64/2011 states that completing a caremap is an integral part of the ACCT
process and that it must reflect the prisoner’s needs, level of risk and the triggers of
their distress. The caremap should set time-bound actions and be aimed at
reducing the risk the prisoner presents to themselves. Caremap actions should be
updated at future case reviews, with new actions added when appropriate.
116. Staff only updated Mr Perry’s caremap once between the first case review on 20
January and the 10th case review on 13 March. A date for completing the actions
was not set and staff did not sign them off as complete. The following two issues
added to the caremap were marked as complete, but staff failed to record at which
case reviews this took place.
117. At an ACCT case review on 2 August, staff recorded that Mr Perry’s engagement in
the process was an issue and set an action for him to engage in reviews. At an
ACCT review on 22 August, an action was added for staff to encourage Mr Perry to
contact his family and, on 6 September, an action was added for staff to encourage
Mr Perry to have a regime. Although we recognise that staff tried many times to
engage with Mr Perry, it would have been more meaningful to set out how staff
planned to encourage him to participate in ACCT reviews, maintain family ties and
have a regime.
118. Staff failed to update an action to seek advice from the use of force co-ordinator on
2 September. An OM told the investigator that he tried to chase it up, could not get
a response and left the action blank. While we are satisfied the action was later re-
visited, we are concerned that the original action was not updated and that a new
one was not added sooner.
119. We are also concerned that there was no co-ordinated plan for arranging and
monitoring the progress of Mr Perry’s hospital transfer. Prison staff requested
updates from the inreach team, but a more joined-up approach with a specific plan
may have helped to improve communication.
18 Prisons and Probation Ombudsman
ACCT checks
120. We also have concerns about the ACCT checks on 30 October.
121. PSI 64/2011 states that staff must follow the level of observations and
conversations stated on the ACCT document and must record these immediately or
as soon as reasonably practical. ACCT records indicate that staff conducted Mr
Perry’s observations but that the conversation aspect was not always fulfilled.
However, the ongoing record shows that staff frequently encouraged Mr Perry to
talk and participate in activities. Since Mr Perry had a psychotic illness and often
displayed aggression towards staff, we are satisfied this action was appropriate.
122. A SOM told us that staff are expected to go to a cell to check in person if they
cannot see a prisoner on an ACCT on CCTV. When a PCO conducted Mr Perry’s
ACCT observations at 11.28am and 11.41am on 30 October, he recorded that Mr
Perry was standing by the door, even though Mr Perry was not visible on the
camera. The PCO told the investigator that although he could not see Mr Perry, he
heard a banging noise coming from his cell. He said this was not unusual for Mr
Perry and he was not concerned. We are concerned that the PCO did not go to the
cell when he could not see Mr Perry, and that he did not do so until 11.50am, 22
minutes after Mr Perry was not visible on the CCTV.
123. We note that the PCO first recorded an inaccurate ACCT observation at 11.28am,
two minutes after Mr Perry had moved into the blind spot in the cell with a piece of
material. While we cannot know whether Mr Perry’s death could have been
prevented if the PCO had checked on him instead of relying on what he heard, he
would have discovered him earlier.
124. The PCO has subsequently resigned from his job at Parc.
Cell checks
125. PSI 64/2011 states that where there is information to suggest that prisoners have
acquired an item which they could use to harm themselves, and which has not been
agreed or its risk assessed, they must be searched and the item removed.
126. When PCO A went into Mr Perry’s cell on 30 October, he picked up a piece of
material but did not remove it or inform a member of staff. The PCO told us that he
did not think the material presented a significant risk as it did not appear long
enough to be used as a ligature. We disagree. Mr Perry was living in a cell with
24-hour CCTV surveillance, was assessed as at a raised risk of suicide and subject
to a high level of monitoring. We therefore consider that regardless of the ligature’s
length, the item presented a significant risk and should have been removed and
reported.
127. We cannot be certain that the piece of material that PCO A picked up was that
which Mr Perry used as a ligature, but we consider it highly likely. While removing
the material from the cell and informing another member of staff may not have
prevented Mr Perry’s death, Mr Perry would not have had access to the material. In
addition, reporting the finding may have resulted in an ACCT case review and
additional support could have been put in place for Mr Perry.
Prisons and Probation Ombudsman 19
128. Previous PPO investigations have identified that prisoners who are being
considered for or awaiting a transfer to a secure hospital are at particular risk of
suicide. It is, therefore, a particular concern that two PCOs were not as vigilant as
they should have been.
129. We make the following recommendations:
The Director should ensure that staff manage prisoners at risk of suicide and
self-harm in line with national guidelines, including that staff:
• set effective caremap actions that are specific and meaningful, aimed at
reducing risk, and update them at each review; and
• accurately record details of ACCT observations in the ongoing record and
physically review prisoners who are not visible on in-cell CCTV.
The Director should ensure that staff are extra vigilant about the care of
prisoners who are being considered for or are awaiting transfer to a secure
hospital.
The Director should ensure that prison staff remove items which potentially
pose a risk from a prisoner’s cell and escalate their concerns.
The Director should commission an investigation into PCO A’s failure to
remove an item of risk from Mr Perry’s cell, with a view to considering
whether disciplinary action is appropriate.
Clinical care
Mental health care
130. The clinical reviewer concluded that prison healthcare staff generally responded to
Mr Perry’s mental health needs in a timely and appropriate way.
131. They completed appropriate assessments, attended ACCT reviews and reviewed
Mr Perry’s medication frequently. The chaplaincy also offered Mr Perry support
following his father’s death and probation staff explored bereavement counselling.
The clinical reviewer also considered that staff appropriately discussed his care at
healthcare meetings to review prisoners with complex needs.
132. He did, however, identify some areas for improvement.
Initial health screens
133. When Mr Perry arrived at Parc in August 2018, he reported a history of drug-
induced psychosis at his initial health screen, and an outstanding appointment with
a ‘psychologist’ (later confirmed by the community GP records to be an appointment
with a psychiatrist).
134. The clinical reviewer considered that as Mr Perry reported a mental health issue,
staff should have referred him for an assessment by the prison’s mental health
team and that the GP should have asked healthcare staff to re-arrange his
outstanding psychiatric appointment, in line with National Institute of Clinical
Excellence (NICE) guidance. He also considered that healthcare staff took too long
to prescribe Mr Perry’s medication following receipt of his community GP record.
20 Prisons and Probation Ombudsman
135. Prison Service Order (PSO) 3050 on the continuity of healthcare for prisoners
requires that newly arrived prisoners should be offered a general health
assessment in their first week. This did not happen. Given Mr Perry’s reported
medical history, it was particularly important for healthcare staff to have conducted
a secondary health screen to ensure he received prompt and appropriate support.
136. The clinical reviewer said that these were all missed opportunities to pick up on Mr
Perry’s mental health issues, and that taking these actions could have led to earlier
assessment and support in managing his existing mental health needs.
137. We make the following recommendation:
The Head of Healthcare should ensure, in line with PSO 3050, that healthcare
staff:
• refer newly arrived prisoners who report mental health problems to the
mental health team;
• prescribe medication promptly once a GP has confirmed a prisoner’s
existing prescription;
• rearrange outstanding hospital appointments if necessary; and
• offer all prisoners a full general health assessment within a week of their
arrival.
The involvement of the mental health inreach team
138. Healthcare staff first referred Mr Perry to the mental health inreach team in
February 2019 (in response to his bizarre behaviour) and again in July (when they
considered that his mental state and behaviour had deteriorated). On both
occasions the inreach team concluded that Mr Perry could be managed by the
prison’s primary care mental health team. Their reasons are not clearly recorded.
The inreach team finally agreed to accept Mr Perry onto their caseload in August
after a third, urgent referral.
139. We note that when HMIP inspected Parc very shortly after Mr Perry’s death, they
found that mental health services for prisoners with complex needs were
inadequate and that the mental health inreach team was under-resourced. We are
concerned that this may have influenced the inreach team’s decisions not to accept
responsibility for Mr Perry until August 2019, and that this may have been another
missed opportunity to support and manage his mental health needs.
140. We recommend:
The HMPPS Executive Director for Wales should:
• satisfy himself that the mental health needs of the prisoner population at
Parc have been established;
• satisfy himself that there is prompt assessment and timely access to
integrated support and a full range of interventions for prisoners with
complex mental health needs; and
Prisons and Probation Ombudsman 21
• write to the Ombudsman to confirm that he is so satisfied.
Transfer to a secure psychiatric hospital
141. The clinical reviewer is satisfied that both prison and healthcare staff appropriately
escalated their concerns about the deterioration in Mr Perry’s mental state and that
these were in turn escalated to staff within Hywel Dda Health Board.
142. On 29 August, a consultant psychiatrist from the mental health inreach team
referred Mr Perry to the Health Board’s forensic psychiatry team to be assessed for
a secure hospital transfer. As a result, a forensic consultant psychiatrist from Hywel
Dda assessed Mr Perry on 10 September and concluded that Mr Perry was almost
certainly psychotic and needed a hospital transfer under the Mental Health Act. He
said that he would prepare a report and liaise with the inreach team to arrange the
transfer.
143. However, despite repeated requests from prison and healthcare staff for urgent
action, there was then a delay until 22 October when the consultant forensic
psychiatrist completed the required recommendation for a transfer to a secure
hospital.
144. Thereafter, things moved quickly. Healthcare staff submitted the application to the
Ministry of Justice on 23 October, the Ministry of Justice issued a transfer warrant
on 24 October and the transfer was scheduled for 4 November.
145. We agree with the clinical reviewer that healthcare staff at Parc appropriately
emphasised the need to prioritise Mr Perry’s hospital transfer because staff were
becoming increasingly concerned about their ability to manage Mr Perry safely in
prison. We recognise that the delay in transferring Mr Perry appears to have been
caused by the difficulties in finding an available hospital bed for him. We are
satisfied that there was nothing more prison and the primary healthcare team could
have done to speed things up.
146. However, we have expressed concern over many years about the lengthy waiting
times for hospital transfers in England and Wales. The Mental Health Act does not
specify any waiting time limit for transfers from prison to secure hospital, and factors
such as the lack of bed availability can lead to prisoners with severe and complex
mental health needs having to spend significant amounts of time in prison, where
they cannot receive the level of care they need.
147. This problem was recognised by Lord Bradley in his 2009 Review of people with
mental health needs and learning disabilities in the criminal justice system. He
recommended that the Department of Health should develop a new minimum target
for the NHS of 14 days to transfer a prisoner with acute, severe mental illness to an
appropriate healthcare setting49. The Department of Health accepted this
recommendation, and in 2011 published a good practice guide about the transfer of
prisoners under the Mental Health Act, which included a suggested timescale of 14
days. However, it is still not a legal requirement.
148. An additional problem is that delays are not always well recorded. The recording of
the length of a waiting time does not generally begin until an assessment has taken
22 Prisons and Probation Ombudsman
place. This opens up the possibility of assessments being pushed back, until there
is the possibility of a bed becoming available. In this case, Mr Perry was initially
referred by the inreach team on 29 August and was first assessed on 10
September, but the necessary report was not completed until 22 October.
149. We cannot know whether an earlier transfer would have prevented Mr Perry’s
death, but where a secure hospital has been identified as the best environment to
deliver appropriate care for acutely ill prisoners, we would expect all possible steps
to be taken to ensure this takes place within the 14-day target.
150. We also note that although the clinical reviewer considered that the inreach team
did what they could to follow-up Mr Perry’s hospital transfer, he found that they did
not communicate this information effectively. This left prison and primary care staff
without a clear indication of what was happening.
151. The mental health Inreach team manager told us that although Inreach staff do not
have the resources to attend ACCT case reviews, prison healthcare staff could
access their notes through the shared clinical records. We agree with the clinical
reviewer that a more joined-up approach and guidance for staff on the transfer
process would have led to greater clarity and enabled staff to develop a formal plan
for managing Mr Perry while he waited for his transfer, accessible to all those
involved.
152. We make the following recommendation:
The Head of Healthcare should ensure that:
• local guidance is developed setting out the process for transferring
prisoners to a secure hospital under section 47 of the Mental Health Act
1983; and
• prisoners with complex needs are reviewed weekly as part of a
multidisciplinary team and decisions set out in an agreed plan.
Inquest
153. At the inquest, which took place on 27 March 2024, the Coroner concluded that Mr
Perry died of misadventure. To which a failure to undertake indicated observations;
a delay in his transfer to a secure mental health unit; and failure to remove material
as per procedure contributed.
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