Degg, Paul

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Paul Degg,
a prisoner at HMP Risley,
on 29 September 2018
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Paul Degg was found hanged in his cell at HMP Risley on 29 September 2018. He
was 46 years old. I offer my condolences to Mr Degg’s family and friends.
Mr Degg had significant mental health issues, including self-harming behaviour, and was
managed under Prison Service suicide and self-harm prevention procedures (known as
ACCT) on six occasions at Risley. He also had a history of substance misuse and was
found under the influence of psychoactive substances (PS) on several occasions.
We found that, overall, Mr Degg was well-supported by ACCT procedures and the mental
health team at Risley. However, we found that mental health staff did not always have
input into Mr Degg’s ACCT reviews as they should have done.
Mr Degg received appropriate support with his substance misuse, although he did not
always want to engage with it. We found some instances where staff did not follow the
prison’s policy on PS by failing to submit intelligence reports when Mr Degg was
suspected of being under the influence.
The officer who found Mr Degg did not call a medical emergency code as he should have
done. Although this did not cause a delay in treating Mr Degg or affect the eventual
outcome, I am concerned that staff at Risley are not following the correct medical
emergency procedures, an issue we have raised before.
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 June 2019
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
Summary
Events
1. Mr Paul Degg was sentenced to 32 months in prison for wounding with intent on 19
June 2017. He was moved from HMP Manchester to HMP Risley on 30 June 2017.
2. Mr Degg had schizophrenia and dissocial personality disorder, as well as a history
of illicit substance misuse and self-harm. He was supported by the prison’s mental
health and substance misuse teams.
3. Staff monitored Mr Degg under suicide and self-harm prevention procedures
(known as ACCT) on six occasions at Risley after he had self-harmed. He made
serious attempts to take his life on 4 March, 5 August and 13 August 2018,
requiring hospital treatment on each occasion. At times, due to his high level of
risk, Mr Degg was placed under constant supervision.
4. Mr Degg was found under the influence of psychoactive substances (PS) on several
occasions at Risley. Staff warned him of the dangers of using PS and the effects
they could have on his mental health. His substance misuse worker attempted to
engage him in psychosocial work to address his PS use, but he did not want to
engage.
5. On 29 September at around 6.40pm, an officer carrying out an ACCT check found
Mr Degg hanging from his cell window. The officer called for assistance, then
entered the cell, cut down Mr Degg and started cardiopulmonary resuscitation
(CPR). Other officers arrived and assisted with CPR until healthcare staff arrived
shortly afterwards and took over.
6. Ambulance paramedics arrived at 6.58pm but were unable to resuscitate Mr Degg
and he was declared dead at 7.15pm. Toxicology tests found that Mr Degg had PS
in his system when he died.
Findings
7. Mr Degg had complex needs which resulted in him regularly self-harming, including
three serious attempts to take his life. Overall, we found that he was well-supported
by prison and healthcare staff and that his risk was appropriately managed.
8. However, we found that some of his ACCT reviews were not multidisciplinary as
they should have been, in that some lacked input from the mental health team.
9. Given Mr Degg’s complex needs, we are concerned that at the ACCT review four
days before his death, his risk was reassessed as low and the frequency of his
observations was reduced without input from the mental health team.
10. We found that Mr Degg received appropriate medication for his mental health
conditions and had regular reviews with a psychiatrist.
11. We found some occasions where staff did not submit intelligence reports, in
accordance with their own policy, when Mr Degg was suspected to be under the
influence of PS.
Prisons and Probation Ombudsman 1
12. Mr Degg told staff that he was under threat from other prisoners on 27 November
2017 and 19 September 2018. We found that staff acted in accordance with the
prison’s Violence Reduction Policy in submitting intelligence reports about Mr
Degg’s allegations and that he was appropriately moved to another wing on the
second occasion.
13. The officer who found Mr Degg did not call a medical emergency code as he should
have done. While this did not cause a delay in the emergency response or affect
the eventual outcome for Mr Degg, it could be crucial in future incidents.
14. We found that some staff did not feel supported after Mr Degg’s death and that a
hot debrief was not held immediately after the incident.
Recommendations
• The Governor and Head of Healthcare should ensure that prison staff manage
prisoners at risk of suicide and self-harm in line with PSI 64/2011, in particular that
there is a multi-disciplinary approach for all case reviews with relevant healthcare
staff and other keyworkers providing detailed input if they are unable to attend.
• The Governor should ensure that staff adhere to the requirements of the prison’s
PS policy when prisoners are suspected of using PS.
• The Governor and Head of Healthcare should ensure that all staff are aware of the
correct medical emergency codes and have appropriate training in the use of
emergency call signs.
• The Governor should:
• ensure that, in accordance with PSI 64/2011, a manager holds a hot debrief
promptly after a death in custody, that all those involved in the incident are
invited to attend, and that an accurate written record of attendees is kept; and
• undertake a review of post-incident processes to ensure that all staff involved in
an individual’s care are offered support following an unexpected death.
2 Prisons and Probation Ombudsman
The Investigation Process
15. The investigator issued notices to staff and prisoners at HMP Risley informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
16. The investigator obtained copies of relevant extracts from Mr Degg’s prison and
medical records.
17. NHS England commissioned an independent clinical reviewer to review Mr Degg’s
clinical care at the prison.
18. The investigator and clinical reviewer jointly interviewed eight members of staff at
Risley. The investigator also separately interviewed one member of staff and one
prisoner. The interviews took place between October 2018 and February 2019.
19. We informed HM Coroner for Greater Manchester West District of the investigation.
The coroner gave us the results of the post-mortem examination. We have sent the
coroner a copy of this report.
20. The investigator contacted Mr Degg’s daughter to explain the investigation and to
ask if the family had any matters they wanted the investigation to consider. His
daughter wanted to know if Mr Degg’s mental health and medication were
appropriately managed; whether prison was the right environment for him, given his
mental health issues; whether he was observed appropriately under ACCT
procedures; how his substance misuse issues were managed; and whether her
previous complaints and concerns had been acknowledged by the prison.
21. We cannot comment on whether prison was the right place for Mr Degg as that is a
matter for the courts and outside the Ombudsman’s remit. We have addressed Mr
Degg’s daughter’s other concerns in this report.
22. Mr Degg’s family received a copy of the initial report. They did not raise any
concerns regarding factual accuracy of this report.
Prisons and Probation Ombudsman 3
Background Information
HMP Risley
23. HMP Risley is a medium security training prison which holds over 1,000 convicted
men. Bridgewater Community Healthcare NHS Trust provides healthcare services
in the prison. Greater Manchester West Mental Health Foundation Trust provide
mental health services and substance misuse services are provided by Change,
Grow, Live (CGL). There is 24-hour healthcare cover.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Risley was conducted in June 2016. Inspectors
found that the daily regime was not being delivered. Inspectors were told that
difficulties in industrial relations had led to significant regime cuts in recent months.
They found that about a third of prisoners remained in their cells during the working
day. They noted that Risley did not provide enough full-time activity to meet the
needs of the population, and attendance and punctuality in learning and skills
activities were poor.
25. There was evidence to suggest that the availability and threat of psychoactive
substances (PS) at Risley was undermining prisoner wellbeing and was a major
challenge to the stability of the prison. Nearly two-thirds of prisoners said it was
easy to obtain drugs, including PS, at Risley. Inspectors found that health services
were reasonable but the requirement to respond to PS-related incidents placed
significant additional demands on the services. They noted that substance misuse
services were good, with a range of excellent recovery-focused interventions
delivered by a well-integrated and skilled drugs team.
26. Inspectors noted that levels of violence and self-harm were comparable to other
prisons and that useful and effective work was in place to support prisoners in
crisis. However, around one fifth of prisoners said they felt unsafe at the time of the
inspection.
Independent Monitoring Board
27. 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 March 2017, the IMB was
greatly concerned with the use of illicit drugs in the prison and the additional
problems caused by PS. The Board noted that the high levels of substance misuse
were a challenge for staff and that there was a lack of drug dogs. The Board noted
that there were problems running the prison due to the reduction in staffing levels.
They said that this had an adverse effect on the welfare of prisoners who were
locked in their cells for unacceptable periods.
Previous deaths at HMP Risley
28. Mr Degg was the eighth prisoner to die at Risley since August 2015. Of the
previous deaths, two were self-inflicted, two were drugs related and three were from
4 Prisons and Probation Ombudsman
natural causes. There have been four deaths since Mr Degg’s, three from natural
causes, one homicide and one awaiting classification. We have previously made
recommendations about ensuring healthcare staff attend ACCT case reviews and
staff using the correct medical emergency code.
Assessment, Care in Custody and Teamwork
29. 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.
30. 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.
31. 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.
Psychoactive substances (PS)
32. PS (formerly known as ‘new psychoactive substances’ or ‘legal highs’) are a serious
problem across the prison estate. They are difficult to detect and can affect people
in a number of ways including increasing heart rate, raising blood pressure,
reducing blood supply to the heart and vomiting. Prisoners under the influence of
PS can present with marked levels of disinhibition, heightened energy levels, a high
tolerance of pain and a potential for violence. Besides emerging evidence of such
dangers to physical health, there is potential for precipitating or exacerbating the
deterioration of mental health with links to suicide or self-harm.
33. In July 2015, we published a Learning Lessons Bulletin about the use of PS (still at
that time NPS) and its dangers, including its close association with debt, bullying
and violence. The bulletin identified the need for better awareness among staff and
prisoners of the dangers of PS, the need for more effective drug supply reduction
strategies, better monitoring by drug treatment services and effective violence
reduction strategies.
34. HMPPS now has in place provisions that enable prisoners to be tested for specified
non-controlled PS as part of established mandatory drugs testing arrangements.
Prisons and Probation Ombudsman 5
Key Events
35. On 19 June 2017, Mr Paul Degg was sentenced to 32 months in prison for
wounding and grievous bodily harm with intent. He had been in prison before. Mr
Degg was sent to HMP Manchester where reception staff identified that he had a
history of self-harm and substance misuse, as well as a diagnosis of dissocial
personality disorder and schizophrenia. Mr Degg said that his mood was low as he
had been unable to contact his daughter. Reception staff started suicide and self-
harm prevention procedures (known as ACCT) and arranged for Mr Degg to be
supported by the mental health in-reach team and the substance misuse team.
36. On 26 June, staff at Manchester stopped ACCT monitoring after Mr Degg said he
had contacted his daughter and he was engaging with the substance misuse and
mental health teams. Staff assessed his risk as low and arranged a post-closure
review for 3 July. However, Mr Degg was transferred to HMP Risley before the
ACCT post-closure review took place.
37. Mr Degg arrived at HMP Risley on 30 June. Reception staff identified that he was
in the ACCT post-closure stage and an offender supervisor interviewed him about
his risk of suicide and self-harm. The offender supervisor wrote in Mr Degg’s prison
record that he said he was happy to be at Risley as it was closer to home and his
nephew was also there. Mr Degg said he had no thoughts of suicide or self-harm.
38. A nurse completed Mr Degg’s reception healthcare screening. She noted he had
no thoughts of suicide or self-harm but referred him to the mental health team due
to his history and recent ACCT. A GP prescribed Mr Degg with the same
medication he had received at Manchester. Staff placed Mr Degg on C Wing.
39. On 3 July, a GP saw Mr Degg and reviewed his substance misuse medication. Mr
Degg told the GP that he was being victimised on the wing because he was using
buprenorphine (used to treat opioid addiction). The GP noted that Mr Degg’s mood
was up and down, he was experiencing auditory hallucinations and he was feeling
paranoid, but Mr Degg said that he currently felt stable. The GP changed Mr
Degg’s substance misuse medication from buprenorphine to methadone.
40. On 4 July, a psychiatric nurse from the mental health team at Manchester,
contacted Risley’s mental health team by phone to let them know that Mr Degg had
an outstanding psychiatric appointment to review his medication. The psychiatric
nurse noted in Mr Degg’s medical record that he had handed over Mr Degg’s care
to Risley who agreed to follow up this action. Mr Degg was allocated a mental
health keyworker on 11 July.
41. On 13 July, Mr Degg had a second healthcare screening with a nurse. He said he
was feeling better on methadone.
42. On 17 July, Mr Degg was suspected of being under the influence of psychoactive
substances (PS). He was assessed by healthcare staff but he denied using
anything. He was not given his methadone that evening. Staff did not submit an
intelligence report.
43. On 18 July, Mr Degg made superficial cuts to his arm and an officer started ACCT
monitoring. The first ACCT review was chaired by a custodial manager (CM) and
attended by a supervising officer (SO), an officer and a nurse from the mental
6 Prisons and Probation Ombudsman
health team. Mr Degg said that he had self-harmed as a coping mechanism but he
did not want to die. He said he was unhappy that his methadone was withheld the
previous evening and denied that he had been under the influence, saying he was
affected by his prescribed medication. Staff assessed his risk as raised and
observed him twice an hour. Mr Degg had four further multidisciplinary ACCT
reviews until staff stopped ACCT monitoring on 14 August.
44. On 17 August, healthcare staff withheld Mr Degg’s medication after he was
suspected of being under the influence of an illicit substance. A nurse noted that he
was unsteady on his feet and slurring his words. We found no evidence that prison
staff were made aware that Mr Degg was under the influence and no intelligence
report was submitted.
45. On 18 August, Mr Degg had his anti-psychotic medication by depot (slow-release)
injection, as prescribed. He told the nurse that he found the medication to be
beneficial and he reported no side effects. Mr Degg was due to see a doctor for a
mental health review on 24 August but he did not attend. His medication continued
as prescribed.
46. On 25 September, Mr Degg was involved in a fight and placed on basic regime.
Later that day he was found to be under the influence of PS. He was seen by
healthcare staff who submitted an intelligence report. Mr Degg was moved to D
Wing. By 3 October, Mr Degg was back on standard regime.
47. On 30 October, Mr Degg attended the healthcare unit for his depot injection. A
nurse wrote in Mr Degg’s medical record that he did not think his medication dose
was correct and he wanted to see his mental health keyworker. The nurse also
said that Mr Degg was concerned that he would need to go into a hostel on release
from prison. His mental health keyworker subsequently arranged an appointment to
see Mr Degg on 31 October but he did not attend.
48. Mr Degg was found to be under the influence of PS on 1 November. Healthcare
staff saw him and submitted an intelligence report. The following day, he was found
in possession of drug paraphernalia and hooch (illicitly brewed alcohol). Staff put
him on basic regime and submitted an intelligence report. On 3 November, when a
SO went to speak to Mr Degg to tell him that he would be on basic regime, she
found him to be in a low mood and he expressed thoughts of self-harm. The SO
started ACCT monitoring.
49. The first ACCT review on 4 November was chaired by a CM and attended by a
nurse. Mr Degg said that he was frustrated that he had not received his medication
after staff thought he was under the influence. He continued to deny that he had
taken anything. Staff completed a caremap with actions for Mr Degg to engage with
the substance misuse and mental health teams. Mr Degg had two further
multidisciplinary reviews before staff stopped ACCT monitoring on 13 November.
Staff recorded that he had made good progress, was abstaining from using PS and
had acknowledged the impact his substance misuse was having on his mental
health.
50. On 27 November, Mr Degg’s daughter contacted the prison’s safer custody team to
say that her father wanted to move to another wing. She was worried that he would
not tell staff but would end up harming himself instead. A SO spoke to Mr Degg
about his daughter’s concerns. Mr Degg said he was being intimidated by other
Prisons and Probation Ombudsman 7
prisoners on D Wing but he did not give any further information. The SO submitted
an intelligence report.
51. On 14 December, a consultant forensic psychiatrist assessed Mr Degg. She noted
that Mr Degg was hearing voices and had thoughts of harming others. She noted
his mood was irritable but difficult to assess. She recorded that Mr Degg should not
share a cell with anyone. She increased his depot injection dose from 80mg to
100mg.
52. On 18 December, a SO started ACCT monitoring again after Mr Degg opened
wounds on his wrists. A nurse and the SO were concerned as they had not seen
Mr Degg in such an agitated state before and he made clear statements that he
wanted to kill himself. As a result, he was placed on constant supervision on 20
December. Staff identified a trigger as the birthday of his daughter (25 December)
who had died, so he remained on constant supervision until 28 December.
53. On 6 January 2018, Mr Degg was found to be under the influence. He was seen by
healthcare staff and placed on basic regime. Staff submitted an intelligence report.
54. On 24 January, Mr Degg made cuts to his wrist so was again placed on constant
supervision.
55. On 29 January, Mr Degg had a mental health review with the consultant forensic
psychiatrist who noted that Mr Degg reported low mood, poor appetite, weight loss
and poor sleep pattern. He admitted to using PS in prison but said he had not used
any in the last three weeks. She noted that Mr Degg reported hearing voices telling
him to hit people and he said he self-harmed when he felt stressed. She increased
Mr Degg’s fortnightly depot injection from 100mg to 140mg and also prescribed
medication to help him sleep. Staff took Mr Degg off constant supervision on 30
January.
56. Mr Degg’s methadone dose was reduced on 7 February and he told, a substance
misuse worker that he was not happy about this. She saw him again on 13
February and he said he was not feeling well because of the methadone reduction.
She gave him a relapse prevention booklet and harm reduction advice, but she
noted in his record that he walked away while she was talking to him so he did not
fully engage with her. Mr Degg completed his methadone detox programme on 15
February.
57. Staff stopped ACCT monitoring on 20 February, after a total of 23 ACCT case
reviews between 18 December 2017 and 20 February 2018.
58. On 4 March, Mr Degg made severe cuts to his arm which resulted in him being
admitted to hospital for surgery to repair an artery. Staff started ACCT monitoring
and he was placed on constant supervision while at the hospital and this continued
when he returned to the prison on 8 March.
59. On 12 March, Mr Degg met with a nurse and the consultant forensic psychiatrist.
Mr Degg said that he cut himself to relieve tension but he had no thoughts of self-
harm or harming others. The nurse noted that his mood was low and he appeared
anxious. Mr Degg said he had issues from his past that he needed to address but
he did not feel able to talk about them. The consultant forensic psychiatrist
increased his amitriptyline (antidepressant) medication from 150mg to 200mg, and
8 Prisons and Probation Ombudsman
his promethazine (sleeping pills) from 25mg to 50mg and agreed to review him in
four to six weeks to consider increasing the dose of his depot injection.
60. Staff stopped constant supervision on 15 March and reduced Mr Degg’s
observations to five an hour.
61. On 19 March, Mr Degg was found to be under the influence and was seen by
healthcare staff. A substance misuse worker spoke to him and he denied using any
illicit substances. Staff submitted an intelligence report.
62. By 25 March, staff had reduced Mr Degg’s ACCT observations to two an hour. At
around 5.15pm, he cut his wrist and said he needed an ambulance. A nurse
attended his cell and treated his wounds. She noted that Mr Degg was
disappointed that he had not severed an artery again. Staff increased his
observations to five an hour. Shortly afterwards, Mr Degg cut his wrist again, this
time severing the artery, and he had to return to hospital for treatment. On return to
the prison later that evening, staff placed him on constant supervision. He
remained on constant supervision until 29 March when he was moved to B Wing.
63. On 4 April, while on hourly observations, Mr Degg cut his arm again so staff moved
him to a constant supervision cell. Mr Degg said he harmed himself because there
were cockroaches in his cell on B Wing and he did not want to stay there. Staff
moved him to E Wing and maintained hourly observations. Mr Degg said he was
happy to move to E Wing and said he no longer needed to be on an ACCT.
64. On 8 April, Mr Degg was found to be under the influence and healthcare staff
attended. His medication was withheld that evening for clinical reasons. Staff
submitted an intelligence report.
65. On 9 April, Mr Degg reopened the cut on his left wrist and refused to have his wrist
sutured by healthcare. He said he had done this because he did not get his
medication the previous evening. He said he would cut himself again so staff
resumed constant supervision. Mr Degg was assessed by the consultant forensic
psychiatrist and a nurse. He said he had thoughts of cutting himself but no
thoughts of other self-harm or of harming others. The nurse noted that he had
razors in his possession and she requested that staff remove these from him. Mr
Degg said he was feeling paranoid that others wanted to harm him and he was
worried that he was going to lose his flat in the community. The consultant forensic
psychiatrist suggested an increase in Mr Degg’s depot injection from 140mg to
160mg and to adjust his mood stabilising medication. However, a consultant
psychiatrist subsequently disagreed with the consultant forensic psychiatrist
suggested change in medication as he felt there were associated risks. As a result,
Mr Degg’s medication did not change. Staff stopped constant supervision on 11
April.
66. On 16 April, Mr Degg asked to move from E Wing so staff moved him back to B
Wing. He said he was happy with this and his ACCT observations were reduced to
three times an hour.
67. On 2 May, Mr Degg was moved to C Wing. Mr Degg agreed to this move as staff
considered it would facilitate his engagement with substance misuse services and
education. Staff continued ACCT monitoring until 18 May. Mr Degg had a total of
27 ACCT reviews between 4 March and 18 May.
Prisons and Probation Ombudsman 9
68. Staff started ACCT monitoring again on 12 June after Mr Degg said he felt his
medication was not working and he was having thoughts of taking his life. He said
that he was feeling paranoid and felt this was due to using PS. He said he felt safer
while being monitored on an ACCT.
69. On 18 June, Mr Degg had an assessment with the consultant forensic psychiatrist
and a nurse. The consultant forensic psychiatrist noted that her previous
suggestion to increase his depot injection and introduce an additional mood
stabiliser had not been agreed. Mr Degg said that he was experiencing paranoia
and that he tried to avoid other prisoners on the wing. Mr Degg appeared low in
mood but was happy when talking about his daughter who he said was expecting a
son in July. He was concerned that he might have to go into a hostel on release
and the consultant forensic psychiatrist suggested a meeting with his offender
supervisor and a further multidisciplinary meeting nearer to his release date.
70. On 30 June, staff found Mr Degg under the influence. He was seen by healthcare
staff but they did not submit an intelligence report.
71. Staff continued ACCT monitoring until 3 July. Mr Degg had four multidisciplinary
ACCT reviews between 12 June and 3 July.
72. On 5 August, Mr Degg attempted to hang himself and was taken to hospital. Staff
started ACCT monitoring and he was placed on constant supervision on D Wing.
Mr Degg said he had self-harmed because he was nervous about being released
from prison and he heard voices telling him to do this. He asked to be placed on
constant supervision. He remained on constant supervision until 8 August when
staff moved him to a different cell on D Wing and observed him five times per hour.
Staff recorded in his ACCT review paperwork that Mr Degg was happy to move to D
Wing as he had supportive friends there.
73. On 13 August, while Mr Degg was on hourly observations, he was found with a
ligature around his neck again and said he wanted to die. Staff moved him to A
Wing and placed him on constant supervision. Mr Degg was assessed by the
consultant forensic psychiatrist and a nurse. The consultant forensic psychiatrist
assessed Mr Degg’s risk as very high. She noted that he should continue with his
current medication and suggested a multidisciplinary meeting in a month’s time to
discuss his release plans. Staff kept Mr Degg on constant supervision until 17
August.
74. On 4 September, Mr Degg refused to attend a mental health review meeting with a
nurse but he did not give a reason. He did, however, attend an ACCT review later
that day.
75. On 6 September, Mr Degg refused to attend an ACCT review, saying he was tired.
A nurse and a CM went to his cell to speak to him. The nurse noted that he
seemed to be tired but he was polite and appropriate.
76. On 18 September, Mr Degg was found to be under the influence again. He was
seen by healthcare staff and placed on basic regime. Staff did not submit an
intelligence report. He refused to attend an ACCT review that day.
77. On 19 September, Mr Degg told an officer that he was under threat on A Wing from
the friends of his victim and wanted to move to B Wing. The officer submitted an
intelligence report.
10 Prisons and Probation Ombudsman
78. Mr Degg was moved to E Wing on 20 September. The following day, a CM chaired
an ACCT review which was also attended by the prison chaplain and a nurse. Mr
Degg said he was happy on E Wing. The CM moved Mr Degg back to standard
regime and arranged for him to have a television. Staff agreed to reduce his
observations to one observation an hour but continued to assess his risk as raised.
79. On 25 September, a CM chaired another ACCT review with Mr Degg which was
also attended by a prison chaplain. A nurse was unable to attend the review and
had tried to phone the wing to provide input but could not get through to anyone.
The nurse made a note in Mr Degg’s medical record to this effect. At the review,
the CM assessed Mr Degg’s risk as low and reduced his observations to one
observation every two hours.
80. The CM told the investigator that he felt confident to do this without input from the
mental health team. He said he had a good prior knowledge of Mr Degg, he had
experience of undertaking ACCT reviews and he was supported by the chaplain in
making the decision in the absence of the mental health team. The CM said that Mr
Degg’s mood had improved, he was no longer on basic regime, and appeared
positive.
81. On 27 September, Mr Degg was moved to D Wing. No one recorded the reason for
the move and it has not been possible to establish the reason during this
investigation.
82. On 29 September at 5.15pm, an officer checked Mr Degg and saw him eating his
dinner and watching television. When the officer returned to carry out the next
ACCT check at around 6.45pm, he found Mr Degg had made a ligature from a
sheet and was hanging from his window. The officer radioed for staff assistance
and then immediately entered the cell. He cut down Mr Degg and started
cardiopulmonary resuscitation (CPR). Another officer and a CM responded promptly
and assisted the officer in trying to resuscitate Mr Degg. Two nurses arrived shortly
afterwards and took over CPR.
83. The control room log shows that the officer called for assistance at 6.48pm and an
ambulance was called at 6.49pm. Paramedics arrived at 6.58pm but were unable
to resuscitate Mr Degg and he was declared dead at 7.15pm.
Contact with Mr Degg’s family
84. Mr Degg’s daughter was listed as his next of kin. The governor and a prison
chaplain visited Mr Degg’s daughter at her home address at approximately 9.50pm
on 29 September to inform her of her father’s death. The prison contributed to the
cost of Mr Degg’s funeral, in line with Prison Service instructions.
Support for prisoners and staff
85. Some members of staff who were directly involved in the emergency response said
that they were offered support by the prison’s care team and felt supported by
managers and other colleagues. However, staff were not invited to a hot debrief
immediately after the incident. Some staff who had worked closely with Mr Degg
said they had been affected by his death and did not feel supported.
Prisons and Probation Ombudsman 11
86. The governor posted a notice for prisoners informing them of Mr Degg’s death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide and
self-harm, in case they had been adversely affected by Mr Degg’s death.
Post-mortem report
87. The post-mortem report concluded that Mr Degg’s death was due to hanging. PS
was found in his blood but it was not possible to establish what impact that may
have had on his decision to take his life.
12 Prisons and Probation Ombudsman
Findings
Identifying and managing Mr Degg’s risk of suicide and self-harm
88. Prison Service Instruction 64/2011, Management of prisoners at risk of harm from
self, from others and to others (Safer Custody), sets out a list of risk factors and
triggers that might increase the risk of suicide and self-harm. These include mental
health and substance misuse issues, which applied to Mr Degg. Reception staff at
Risley identified that Mr Degg was in the post-closure phase of an ACCT when he
transferred from Manchester and they took appropriate action to identify any risk
issues and offer him appropriate support.
89. Mr Degg had complex needs which resulted in regular self-harm, including three
serious attempts to take his life. During his time at Risley, Mr Degg was monitored
under ACCT procedures six times. We found that, up to 25 September 2018, he
was supported well by prison and healthcare staff and that staff set observations at
a level appropriate to his risk.
90. Mr Degg had a high number of case reviews and we found that the vast majority
were multidisciplinary, involving healthcare professionals and other keyworkers who
were involved in his care. However, some case reviews were carried out without
input from healthcare staff, specifically the mental health team. This was the case
for five of the 23 ACCT reviews held between 18 December 2017 and 20 February
2018, five of the 27 reviews held between 4 March and 18 May 2018, and six of the
20 reviews held between 5 August and 25 September 2018.
91. We found that healthcare staff did not attend Mr Degg’s final ACCT review on 25
September and we are concerned that, given Mr Degg’s complex needs, a CM
reassessed his risk as low and reduced the frequency of observations without input
from the mental health team. We make the following recommendation:
The Governor and Head of Healthcare should ensure that prison staff manage
prisoners at risk of suicide and self-harm in line with PSI 64/2011, in particular
that there is a multidisciplinary approach for all case reviews with relevant
healthcare staff and other keyworkers providing detailed input if they are
unable to attend.
Mental health
92. The clinical reviewer concluded that Mr Degg’s mental health care was equivalent
to that which he could have expected to receive in the community. She considered
that Mr Degg received extensive mental health support, his medication was
administered in a consistent and timely manner, and he had regular reviews with a
psychiatrist where adjustments were made to his medication to improve his mental
health symptoms and reduce his risk.
93. The clinical reviewer said that Mr Degg’s use of PS had a detrimental effect on his
mental health but it was not possible to conclude how this contributed to his
decision to take his life, a fact also identified by the pathologist.
Prisons and Probation Ombudsman 13
Substance misuse
94. We found that Mr Degg was offered appropriate support to help him address his
substance misuse issues. The clinical reviewer noted that his opiate substitution
medication was continued when he arrived at Manchester and on transfer to Risley.
Mr Degg’s request to change his medication from buprenorphine to methadone was
actioned and he was correctly monitored.
95. However, Mr Degg’s use of PS meant that, at times, his methadone was withheld
for reasons of safety. The clinical reviewer concluded that this was the correct
decision. Mr Degg had a named keyworker who tried to engage him in
psychosocial work and she, along with other healthcare professionals, frequently
reminded Mr Degg of the dangers of using PS and, in particular, the effect it was
having on his mental health.
96. The prison’s psychoactive substance strategy policy, A Strategy to manage the
threat and risk of New Psychoactive Substances (PS), states:
“It [the policy] sets out clear actions that must take place in the event of every
incident of suspected use, possession or supply [with the aim to] ensure that
we are all confident in how to deal with prisoners who are suspected of using
PS or to be involved in the distribution or supply of PS and that we continue
to tackle the problem with a holistic approach.”
The policy goes on to list the required actions to be taken by staff when a prisoner
is suspected of being under the influence of PS. These actions include alerting
healthcare, making an entry in the prisoner’s record and submitting an intelligence
report.
97. We found six occasions where staff correctly submitted intelligence reports when Mr
Degg was found to be under the influence of PS. However, there were three
occasions when this did not happen, one of these being eleven days before Mr
Degg’s death. We therefore make the following recommendation:
The Governor should ensure that all staff adhere to the requirements of the
prison’s PS policy when prisoners are suspected of using PS.
Violence reduction
98. The prison’s Violence Reduction Policy, dated December 2017, states “Where staff
are suspicious that violence is occurring i.e. bullying, threats, these should be
reported to Security via Mercury Intelligence Reports.” The policy requires staff to
complete additional paperwork and provide additional support where they have
witnessed or seen evidence of violence towards a prisoner. However, this was not
relevant for Mr Degg as we found nothing to indicate that he had been subjected to
physical violence at any time.
99. On 27 November 2017, after his daughter contacted the prison with concerns about
her father’s safety, Mr Degg told staff that he was being intimidated by other
prisoners on D Wing although he did not give any further details. We found that
staff acted in accordance with the prison’s policy by submitting an intelligence
report. Mr Degg remained on D Wing until 29 March 2018 and we found no
evidence that he made any further allegations of intimidation, threats or bullying
14 Prisons and Probation Ombudsman
during that time. The prison told us that they did not receive any further concerns
from Mr Degg’s daughter.
100. Similarly, on 19 September 2018, Mr Degg said that he was being threatened on A
Wing but he did not give any further details. Again, we found that staff acted in
accordance with the prison’s policy by submitting an intelligence report.
Furthermore, staff quickly met Mr Degg’s request for a move from A Wing, moving
him to E Wing the following day.
101. Staff did not record the reason why Mr Degg moved from E Wing to D Wing on 27
September 2018. The Head of Safer Custody told the investigator that wing staff
thought Mr Degg may have requested the move because he was in debt but it has
not been possible to establish whether this was the case.
102. Mr Degg admitted to using PS and we found evidence of this in intelligence reports,
medical records, ACCT documents and prison records. It is possible that Mr Degg
was being threatened because of drug debts, but he did not tell anyone that this
was the case and he did not provide details of any threats towards him. We
consider that staff appropriately responded to Mr Degg’s requests to be moved to
different parts of the prison and offered him appropriate support when he asked for
it. We are satisfied that staff followed the correct procedure on the two occasions
when Mr Degg said he was being threatened.
Emergency response
103. PSI 03/2013, ‘Medical Emergency Response Codes’, says that all staff must be
made aware of and understand their responsibilities during medical emergencies.
The PSI requires staff to radio a medical emergency code to communicate the
nature of a medical emergency efficiently. The code triggers healthcare staff to
take the relevant equipment to the scene, and control room staff to call an
ambulance without delay.
104. When the officer found Mr Degg hanging in his cell, he should have used a medical
emergency code blue, which indicates that a prisoner is unconscious or having
breathing difficulties. He did not do so and instead called for urgent assistance.
Although we found there was no delay in the emergency response and it did not
affect the eventual outcome for Mr Degg, we are concerned that failure to use the
correct emergency code could be significant in future incidents. We therefore make
the following recommendation:
The Governor and Head of Healthcare should ensure that all staff are aware of
the correct medical emergency codes and have appropriate training in the
use of emergency call signs.
Staff support
105. PSI 64/2011 on Safer Custody says, “In line with PSI 08/2010 Post Incident Care, a
‘Hot Debrief’ must be held immediately after all deaths in custody. A senior
member of staff must act as the debriefer and a member of the care team must
attend. All staff directly involved in the incident, including healthcare staff, should
be invited. It may be useful to keep a record of those who attend.” While staff said
they felt supported by colleagues, managers and the prison’s care team following
Prisons and Probation Ombudsman 15
the death of Mr Degg, we found no evidence that a hot debrief was held
immediately after the incident.
106. Due to Mr Degg’s complex needs, many staff were directly involved in his care and
had a close working relationship with him. We found that some members of staff
had been significantly affected by Mr Degg’s death, but they did not feel adequately
supported. We therefore make the following recommendation:
The Governor should:
• ensure that, in accordance with PSI 64/2011, a manager holds a hot debrief
promptly after a death in custody, that all those involved in the incident
are invited to attend, and that an accurate written record of attendees is
kept; and
• undertake a review of post-incident processes to ensure that all staff
involved in an individual’s care are offered support following an
unexpected death.
Inquest
107. The inquest, held from 2 to 9 April 2024, concluded that: “Mr Paul Degg died as a
result of a self-applied ligature. His intention at the time of the act cannot be
determined.”
16 Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk