James, Lee

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Lee James,
a prisoner at HMP Long Lartin,
on 16 December 2020
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist HMPPS in ensuring the standard of care received by those in
prison is appropriate then our recommendations should be focused, evidenced and viable.
This is especially the case if there is evidence of systemic failure.
Mr Lee James was found hanged in his cell in the segregation unit at HMP Long Lartin on
16 December 2020. He was 44 years old. I offer my condolences to Mr James’ family and
friends.
Mr James had been at HMP Long Lartin since July 2017 and in prison since 2008. During
his time in prison, Mr James had been subject to suicide and self-harm monitoring (ACCT)
procedures numerous times. He was subject to ACCT monitoring when he died.
My investigation found that, at the time of Mr James’ death, there were deficiencies in
ACCT management at Long Lartin. However, the Governor has undertaken work to
improve the delivery of prisoner safety at the prison and both HM Chief Inspector of
Prisons and the Independent Monitoring Board have found examples of good
multidisciplinary work to support complex prisoners at risk of suicide and self-harm.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman October 2023
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 14
Summary
Events
1. Mr Lee James was remanded in prison on 9 January 2008, charged with murder.
On 22 December 2008, he was sentenced to life imprisonment and received a tariff
of 27 years.
2. Mr James was transferred to HMP Long Lartin on 12 July 2017, having spent time
at HMP Belmarsh, Frankland and Full Sutton. Between July 2017 and April 2019,
he was subject to suicide and self-harm monitoring procedures (known as ACCT),
on six occasions after he said that he intended to harm himself.
3. On 26 November 2019, Mr James was transferred to HMP Belmarsh to facilitate
visits with his mother, who was unwell. During his time there, he was found in his
cell with a ligature around his neck. Staff started ACCT monitoring and placed him
on constant supervision until 11 December.
4. On 15 January 2020, Mr James was transferred back to Long Lartin. Staff held an
ACCT review, and he was supported under ACCT procedures until 22 January. Mr
James was subject to ACCT monitoring a further four times between June and
December 2020. On each occasion he told staff that he was concerned for his
mother’s health and was frustrated about his accumulated visits and possible
transfer to facilitate these.
5. On 14 December, Mr James made threats towards a member of staff. Officers
restrained him and moved him to the segregation unit. Prison staff started ACCT
monitoring after Mr James said that he was going to kill himself. Staff checked him
every hour.
6. On the morning of 16 December, an officer completed an ACCT check on Mr
James. He recorded that he was asleep, and that he had noted movement. At
7.45am, the officer completed a further observation check. Mr James was in bed.
7. At 8.30am, another officer made an entry in Mr James’ ACCT document and
recorded that he had checked on Mr James. He recorded that Mr James was
asleep on his left side and that he had noted movement. However, the officer later
admitted that he had not checked Mr James as he should have done and had
falsified the record. The officer resigned from his post while under investigation by
HMPPS.
8. At approximately 9.05am, an officer went to Mr James’ cell to give him his
medication. When he entered the cell, he found Mr James suspended by a ligature
around his neck. At 9.07am, the officer called a medical emergency code, staff
attended and begun cardiopulmonary resuscitation (CPR). Nursing staff attended
and noted signs that Mr James had been dead for some time. They decided to stop
CPR at 9.15am. A prison GP confirmed his death at 9.30am. Paramedics arrived at
around 9.45am.
Prisons and Probation Ombudsman 1
Findings
9. Mr James had been in prison for many years when he died. He was a complex man
who had been supported by ACCT procedures a number of times. He often
threatened suicide or self-harm, and this was particularly likely when he felt
frustrated by aspects of prison life. Generally, staff at Long Lartin tried to support
him and were actively pursuing the transfer he so keenly wanted.
10. Mr James had been back at Long Lartin for several months when he died. In that
time, he had been subject to ACCT procedures, including when he died, and staff
had tried to balance the need to keep him safe with his obvious dislike for the
additional monitoring required by the ACCT process.
11. Healthcare staff were not always as involved in the ACCT process or subsequent
decisions as they should have been and there were missed opportunities for
multidisciplinary working. Too many staff involved in Mr James’ ACCT plans were
not sufficiently trained. Since Mr James’ death, the Governor has made a number of
changes to the delivery of ACCT procedures and suicide and self-harm prevention
at Long Lartin.
12. The clinical reviewer concluded that the clinical care Mr James received at Long
Lartin was of a good standard and was equivalent to that which he could have
expected to receive in the community.
13. Two members of staff involved in Mr James’ care were subject to internal
disciplinary investigations and subsequent police investigations (which ultimately
did not result in criminal charges). One officer was given a final warning and the
other resigned from the Prison Service.
Recommendation
• The Governor should provide the PPO with an update on the improvements in
relation to safety and the management of the ACCT process that have taken place
at HMP Long Lartin since December 2020.
2 Prisons and Probation Ombudsman
The Investigation Process
14. HM Prisons and Probation Service (HMPPS) notified us of Mr James’ death on 16
December 2020.
15. The investigator issued notices to staff and prisoners at HMP Long Lartin informing
them of the investigation and asking anyone with relevant information to contact us.
No one responded.
16. Our investigation was suspended until 22 September 2022, to allow the police to
conduct an investigation into staff actions and to be considered by the Crown
Prosecution Service (CPS).
17. The investigator visited HMP Long Lartin on 12 October 2022. Copies of relevant
extracts from Mr James’ prison and medical records had already been obtained.
18. The investigator interviewed four members of staff at Long Lartin on 19 October.
19. NHS England commissioned a clinical reviewer to review Mr James’ clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews with
seven healthcare staff between 5 and 15 December 2022.
20. We informed HM Coroner for Worcestershire of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
21. The Ombudsman’s family liaison officer contacted Mr James’ family in January
2021, to explain the investigation and to ask if they had any matters, they wanted us
to consider. Ms Laing contacted the family again in September 2022, to inform them
that our investigation had resumed.
22. The family asked the following questions:
• Where was Mr James at the time of his death?
• How had he taken his life?
• What level of observations was he supposed to have been on; and
• When was Mr James last observed?
We have answered the family’s questions in this report.
23. The family received a copy of our initial report, but no feedback was received
regarding our findings or factual accuracy.
24. An inquest was concluded on 8 April 2024. The Coroner gave the cause of death as
hanging by ligature, and concluded that:
‘… On the morning of 16th December 2020 Lee James died at HMP Long Lartin
having been discovered suspended by a ligature attached to a window in his cell. It
is admitted that the first ACCT case review on 14th December 2020 was chaired by
Prisons and Probation Ombudsman 3
a prison officer who was not suitably trained to perform that role. It cannot be
concluded that this failing possibly caused or contributed to Lee James' death on
16th December 2020. It is admitted that no ACCT observation check was carried
out on Lee James between 0745hrs and 0905hrs on 16th December 2020, and that
a false entry was made in the ACCT 'on-going record' at 0830hrs which made it
appear as though an ACCT observation check had been carried out at that time. It
cannot be concluded that this failing possibly caused or contributed to Lee James'
death on 16th December 2020 ...’
4 Prisons and Probation Ombudsman
Background Information
HMP Long Lartin
25. HMP Long Lartin is a high security prison in the Vale of Evesham, Worcestershire.
It holds up to 609 male prisoners across five main wings and two support wings. All
prisoners are accommodated in single cells. Practice Plus Group provides
healthcare services at the prison, and mental healthcare is provided by Midlands
Partnership Foundation Trust.
HM Inspectorate of Prisons (HMIP)
26. The most recent inspection of HMP Long Lartin was December 2022. Inspectors
said that the standard of assessment, care in custody and teamwork (ACCT) case
management documentation for prisoners at risk of suicide or self-harm was
variable, but they found good examples of multidisciplinary work to support the
individual care of some prisoners with complex needs. There had been some useful
efforts to bring in families to support vulnerable prisoners.
27. The inspection also found that weekly Safety Intervention Meetings (SIM) were well
attended and again evidenced appropriate multidisciplinary care planning for the
most complex prisoners.
Independent Monitoring Board
28. 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 their most recent annual report, for the year to December 2022, the IMB
reported that the safety policy was dictated by a safety strategy document which
was issued in January 2022. Weekly safety intervention meetings (SIMs) to review
management of individual prisoners at risk, and monthly safer custody meetings to
manage performance, were chaired by the head of safety and equalities, and
helped to maintain staff focus on safety issues. These meetings were well minuted
and actions were pursued. In addition, safety staff attend weekly inclusion
multidisciplinary team (MDT) meetings to consider complex cases.
Previous deaths at HMP Long Lartin
29. Mr James was the sixth prisoner to die at Long Lartin since December 201. Of the
previous deaths, one was self-inflicted, two were from natural causes and two were
drug related. There have been a further ten deaths at Long Lartin since Mr James’
death, one of which was self-inflicted. There were no similarities between the
findings in this investigation and those in earlier investigations.
Assessment, Care in Custody and Teamwork
30. 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. After an
Prisons and Probation Ombudsman 5
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
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
6 Prisons and Probation Ombudsman
Key Events
31. On 9 January 2008, Mr Lee James was remanded to HMP Belmarsh charged with
murder. On 22 December, he was found guilty and sentenced to life imprisonment
with a tariff of 27 years. He was 32 years old.
32. During his time at Belmarsh, Mr James was placed on suicide and self-harm
prevention measures (known as ACCT) on two occasions, to provide additional
support during to his ongoing court case and subsequent sentencing.
33. From November 2009 to June 2017, Mr James was transferred between HMP
Frankland and Full Sutton. During this time, he was placed on ACCT monitoring
after he took an overdose of prescribed medication and self-harmed. He was also
placed in the segregation unit after he made threats to assault a member of staff
and described feeling under threat from other prisoners because he believed they
were aware of his offence. The victim of Mr James’ offence was of Muslim faith, and
Mr James believed that because of this, he was at risk from Muslim prisoners. Mr
James was concerned about this throughout his time in prison, although there were
no recorded incidents to substantiate his concerns.
HMP Long Lartin
34. On 12 July 2017, Mr James was transferred to HMP Long Lartin. His behaviour was
generally good, and he engaged with offending behaviour programmes and targets.
However, there were a number of times when he had disagreements with other
prisoners, and his behaviour became difficult for staff to manage. As a result, he
was placed on report for breaching the prison rules. (Prisoners who breach prison
rules are placed on report pending an adjudication before a senior manager to
determine whether they are guilty of the offence. If found guilty, they can receive a
range of punishments including cellular confinement in the segregation unit.)
Between July 2017 and April 2019, Mr James was subject to ACCT monitoring six
times, after he told staff that he intended to self-harm. However, on these occasions
he did not physically harm himself.
35. Mr James’ mother was unwell. Mr James spoke to staff about his concerns about
her poor health regularly, and he asked for accumulated visits so that he could see
her more often. (This is when prisoners save their visits and apply to take them at a
prison closer to their families. If granted, the prisoner is transferred to the requested
prison for a period of time to enable them to receive visits from family members.) Mr
James was transferred to HMP Belmarsh on 26 November 2019, for accumulated
visits to see his mother and family.
HMP Belmarsh
36. On 29 November, Mr James asked to speak to a Supervising Officer (SO). He told
the SO that prison staff had not been treating him with his expected level of respect
and that he had issues with other prisoners. Mr James said that he believed that
other prisoners knew why he was at Belmarsh and were out to get him. Mr James
said that he was not eating the food as he one of the hotplate workers had given
Prisons and Probation Ombudsman 7
him a smaller portion meal than expected and again said that he believed that this
was because prisoners knew why he was there and were out to get him.
37. The SO recorded that Mr James seemed very agitated. He had only been at
Belmarsh for three days, and the SO believed that he was experiencing paranoia.
(The investigation found no evidence that would support Mr James’ belief that he
was under threat or that he had been treated differently by staff.) The SO recorded
that Mr James had said that he felt things were getting to a point where he would
have to do something, but he did not specify what he meant by this. He reassured
Mr James and advised him to calm down until he had time to settle and get to know
people and for them to get to know him.
38. On the morning of 2 December, Mr James pressed his cell bell. When staff
attended, he was in a distressed state. He told them that he had attempted suicide
by using a ligature and that he believed his life was in danger. Prison staff started
ACCT procedures and moved him to the healthcare unit at Belmarsh under
constant supervision. He remained under constant supervision until 11 December
when observations were reduced to twice every hour.
39. Mr James was due to return to Long Lartin on 15 January 2020. Before leaving
Belmarsh, staff held a multidisciplinary ACCT review, but Mr James refused to
engage. Mr James said that he was not happy about his transfer and that he would
go to ‘extreme lengths’ to sort things out. Mr James said, ‘I might as well end it.’ He
said that this was because he was unable to see his mother and that he had been
promised ten visits but had only seen her four times. Prison and healthcare staff
tried to reassure Mr James and reminded him of the support that was available to
him. A nurse attended the ACCT review. She wrote in Mr James’ medical record
that she had concerns about the level of risk Mr James posed to himself because of
his worries.
HMP Long Lartin from 15 January 2020
40. On 15 January 2020, Mr James transferred back to Long Lartin. On his arrival,
prison staff held an ACCT review. Mr James said that he wanted ACCT monitoring
to stop and denied any intent to harm himself. Staff at the meeting decided to keep
ACCT monitoring in place and set hourly observations until he had settled back into
Long Lartin. Staff at the meeting talked to Mr James about the possibility of him
returning to Belmarsh for further accumulated visits at some stage, and also the
possibility of a transfer to HMP Manchester. Caremap actions included pursuing Mr
James’ possible transfer to another prison for accumulated visits. Mr James had
settled back into the regime on B wing and those present at a further review on 22
January agreed it was appropriate to close the ACCT.
41. An officer, Mr James’ key worker, held key work sessions with him between
January and March. Although Mr James had settled back into Long Lartin, he
continued to talk about his frustration with accumulated visits during his key work
sessions. The officer recorded that Mr James had said that he was not expecting to
return from accumulated visits at Belmarsh until March and felt angry about this. He
was also still concerned about his mother’s health. The officer recorded that Mr
James could not understand why he had not been returned to Belmarsh yet and
refused to accept that the COVID-19 pandemic had caused delays. Mr James said
8 Prisons and Probation Ombudsman
that if his mother died while he was awaiting a move back to Belmarsh, he would do
‘something'.
42. In the early hours of the morning on 3 June, Mr James made scratches to his torso.
He alerted staff, but when they went to his cell, he threatened to attack them if they
opened his door. and refused any medical treatment. Two members of staff stayed
outside his door for several hours and continued to talk with him and calm him
down. Mr James told the staff that he was frustrated about not having his X-box and
other issues within the prison. Staff started ACCT monitoring. They completed an
assessment and conducted an ACCT review later that morning.
43. Mr James was open and honest about why he had self-harmed. He said that he
was desperate to return to Belmarsh for accumulated visits and was unhappy on a
wing with sex offenders. He asked if he could move to a different wing. Mr James
told staff at the review meeting that a build-up of frustration had led him to cut
himself, but that he was feeling a lot calmer. A caremap action for Mr James was to
engage with the Inclusion Team (the mental health team at Long Lartin). Staff at the
review meeting planned a further review for 5 June, but Mr James refused to attend.
It was re-scheduled for 8 June.
44. The ACCT review took place as planned on 8 June. Mr James presented with a
positive outlook, and he said that he had allowed himself to get wound up with
current issues, but since harming himself, he had been concentrating on helping
and supporting a fellow prisoner who had been diagnosed with cancer. Staff at the
review meeting agreed to stop ACCT monitoring. His caremap actions were
ongoing.
45. Throughout June and August, Mr James received positive comments for his
behaviour and no concerns were raised about him or by him. However, at 11.15pm
on 17 August, staff started ACCT monitoring after he made multiple long cuts to his
arm with a razor. Nurses attended his cell and started to treat his wounds. After a
few minutes, Mr James told them to stop because he did not want further medical
attention. Mr James said that staff had lied to him and that he had had enough.
Staff recorded that earlier that day, Mr James had asked to visit his friend in the
healthcare unit, but healthcare staff said no because his friend had presented with
COVID-19 symptoms, and they were waiting for the test results. Mr James reacted
badly to this and felt that staff were lying to him.
46. At an ACCT review on 18 August, Mr James said that he was worried about his
mother and wanted to know what was happening with his transfer to Belmarsh. He
said that he had self-harmed out of frustration, but that he felt better now and did
not want to be on ACCT procedures. Despite this, staff at the review meeting
agreed that ACCT monitoring would remain in place until a further review.
47. The next ACCT review was held on 21 August. Mr James said that he was still
worried about his mother and was eager to return to Belmarsh, where he would be
closer to his family. Mr James said that he had self-harmed due to a build-up of
frustrations and his underlying paranoia, but that he had no current thoughts of self-
harm and was thinking clearly. Mr James said that he was aware of the support on
offer should he need it and that he had an appointment with the Inclusion Team the
following week. Mr James also told staff at the review, that he had had a
constructive conversation with a member of the chaplaincy team the previous day
Prisons and Probation Ombudsman 9
which was a great help. The review team discussed Mr James’ level of risk and
agreed to stop ACCT monitoring. Mr James remained under the care of a member
of the Inclusion Team during his time at Long Lartin.
48. On 25 November, staff started ACCT procedures after Mr James made comments
to staff about harming himself. The following day, he refused to attend the ACCT
assessment. He said that he was angry that he was subject to ACCT monitoring
and that he could not trust the staff on the wing. Staff at the ACCT review decided
to continue with ACCT monitoring to allow him time to calm down and engage with
a further review. The next day, he was placed on hourly observations.
49. On 30 November, staff held a multidisciplinary ACCT review. They discussed Mr
James’ various issues in depth and the reason ACCT monitoring was started. Mr
James said that he wanted ACCT monitoring to stop as it served no purpose for
him, and that if he decided to take his life, he would do so whether on an ACCT or
not. Staff at the review meeting agreed to stop ACCT monitoring and they set a
post-closure review for 6 December.
50. On 3 December, the member of the Inclusion Team went to see Mr James. Mr
James talked about how unhappy he was, that the prison was making things difficult
for him and that he had had enough. She tried to calm him down, but it had no
effect. Mr James said, ‘I am going to call my mum and tell her I have had enough,
then I am going to do what I need to do’. She asked Mr James if he intended to kill
himself and he replied ‘no’. She then asked him if that was a promise and he
replied, 'I can't make promises I can't keep'. She said that it was clear Mr James
was in distress, and she told him that because of what he had said, she would have
to start ACCT procedures. Mr James said, 'you do what you have to do'.
51. The member of the Inclusion Team spoke to the wing manager. They decided to put
Mr James on twice hourly observations, and she made an entry in Mr James’ ACCT
document, which was in post closure. She made a note for the wing staff to contact
her in the afternoon if they wanted her to attend a case review to identify how best
to support Mr James. ACCT monitoring was officially re-started.
52. That afternoon, a Custodial Manager (CM) and a SO spoke to Mr James because
he was unhappy about being placed on ACCT monitoring. When Mr James went
into the wing office, he was shouting and very irate. The SO asked him to explain
what he had said to the member of the Inclusion Team that led her to re-start ACCT
monitoring. Mr James said that everything was fine, that he was fine, but that she
approached him and wanted to talk to him about things he did not want to talk
about. A further review was held on 4 December, chaired by a CM and the decision
was taken to close the ACCT, and a post-closure review was planned for seven
days’ time.
53. On 9 December, a manager and a CM went to tell Mr James that they had refused
his transfer to Frankland (where Mr James had been before) and that he would not
be moving to another prison until after Christmas. Mr James was unhappy with the
news and told them that he ‘would not be here over Christmas’ and left the room.
The CM spoke to him again and asked him what he had meant by his statement
and whether he intended to harm himself. Mr James said that he had no thoughts of
harming himself, but that he was considering whether he would rather be located in
the segregation unit as he was struggling on B wing and felt that he was being
10 Prisons and Probation Ombudsman
constantly lied to. The CM said that, at that stage, he did not feel it was necessary
to re-start ACCT monitoring, which was coming to the end of the post-closure stage,
as he thought it could do more harm than good, given Mr James’ previous reaction
to ACCT monitoring. The CM recorded that staff would continue to monitor and
support Mr James.
54. Over the next few days, Mr James’ behaviour was recorded as being increasingly
irate; he was fed up and abusive towards staff. On the morning of 14 December,
staff restrained him after he became violent toward a member of staff and took him
to the segregation unit to await a disciplinary hearing. A CM went to the segregation
unit to speak to Mr James. He was concerned that being located in the segregation
unit could increase his self-harm risk. Mr James said, ‘I’ll cut myself down here’. As
a result, the CM started ACCT procedures.
55. The duty governor went to the segregation unit to approve Mr James’ being located
there. He spoke to Mr James at his cell door to check that he was all right. He
returned to the office and completed all the paperwork, including the exceptional
circumstances form, which is standard practice for anyone located on the unit while
subject to ACCT procedures. He recorded that Mr James was to be observed five
times per hour until the ACCT assessment and first case review had been
completed.
56. Two SOs went to speak to Mr James around 90 minutes after he had arrived in the
segregation unit, to complete the ACCT assessment and first case review. They
recorded that Mr James said that he was very angry about being restrained, and
although calmer, he remained unpredictable. Mr James told them that he had no
imminent plan to self-harm. He talked about his plans for the future and his goal to
transfer to another prison. They returned to the wing office to write up their
respective parts of the ACCT document. They did not ask other staff to attend the
ACCT review and they did not inform those involved in Mr James’ care of its
outcome. One of the SOs recorded that Mr James had asked for the ACCT
procedures to stop, but that they had decided that they should continue. They set
observations at hourly.
57. Mr James remained on the segregation unit, and over the next few days staff did
not raise any concerns, and Mr James did not make any references to harming
himself. Mr James remained on ACCT monitoring and continued to be observed
hourly.
Events of 16 December
58. On the morning of 16 December, a SO was on duty in the segregation unit. The
night staff gave him full handover at the start of his shift. They said that Mr James
had been awake during the night and that they had spent a lot of time talking to him
at his door. Mr James had been asking for e-cigarettes (vapes), so that was likely to
be an issue for the day staff. At 6.55am, the SO completed an ACCT check on Mr
James. He recorded that Mr James was asleep and that he had noted movement.
He completed another routine observation check at 7.45am. He looked in Mr
James’ cell and initially did not see any movement. He saw that Mr James was in
bed, and then he saw him pull the covers over himself.
Prisons and Probation Ombudsman 11
59. That morning, Officer A was assigned to work in the segregation unit and was
tasked with completing ACCT checks along with other general duties. The
segregation unit was not his usual place of work. A senior manager asked Officer A
to escort a prisoner from the unit to the reception area. On his return, he made an
entry in Mr James’ ACCT document at 8.30am. He recorded that Mr James was
asleep on his left side and that he had noted movement.
60. At approximately 9.05am, Officer B went to unlock Mr James’ cell so that he could
collect his medication. He saw Mr James sitting at the back of the cell and that he
was unresponsive. The officer called to other staff. They entered the cell and found
Mr James suspended from the window at the back of the cell with a ligature around
his neck. At 9.07am, a SO radioed a code blue (indicating a prisoner is unconscious
or is having breathing difficulties). The SO and the other staff released Mr James
from the ligature and started cardiopulmonary resuscitation (CPR).
61. Nursing staff attended at 9.07am and continued with CPR attempts. They attached
a defibrillator to Mr James’ chest which indicated that they must continue with CPR.
Nurses described Mr James’ appearance as very pale and waxy, his eyes were
fixed, and they decided that any further attempts to resuscitate him would be futile.
At 9.15am, nursing staff decided to stop CPR. They contacted a GP at Long Lartin,
who attended and, at 9.30am, confirmed that Mr James had died.
62. At around 9.45am, paramedics arrived and were told that Mr James had died.
Contact with Mr James’ family
63. A CM was appointed as the family liaison officer (FLO) for Long Lartin following Mr
James’ death. At 10.50am on 16 December, the CM asked HMP Maidstone, which
was geographically closer to Mr James’ next of kin, whether a FLO could visit Mr
James’ next of kin to inform them of his death. HMP Maidstone agreed to assist. At
1.00pm, the FLO from Maidstone informed Mr James’ family of his death. The CM
telephoned the family later that day and remained in regular contact with them over
the next few weeks.
64. Long Lartin contributed towards the cost of the funeral in line with HMPPS policy.
Support for prisoners and staff
65. After Mr James’ death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support.
66. The prison posted notices informing other prisoners of the death and offering
support. Staff reviewed all those prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr James’ death.
Post-mortem report
67. The post-mortem report gave Mr James’ cause of death as hanging by ligature.
12 Prisons and Probation Ombudsman
Events following Mr James’ death
68. Once the prison manager had finished the debrief, Officer A approached him and
told him that he had not actually checked Mr James at 8.30am as he should have
done, when he had made the entry in his ACCT document.
69. HMP Long Lartin conducted an internal investigation into Officer A’s actions. He
informed the investigation that he was not aware that he was supposed to be
checking ACCT documents on 16 December, but that he had received training in
the ACCT process and was aware of what was required of him. He also said that he
thought that the ACCT process was ‘just a paper exercise’. He resigned from the
Prison Service in 2021, before the internal investigation had concluded. We did not
interview him as part of this investigation.
70. HMP Long Lartin also carried out an internal disciplinary investigation into the
actions of a SO for the way he managed the initial case review on 14 December.
The Governor issued him with a final written warning.
71. Officer A and the SO’s actions and their management and involvement in the ACCT
process were referred to the police. West Mercia Police conducted an investigation
and referred their findings to the Crown Prosecution Service (CPS). The CPS
decided that there were insufficient grounds for criminal charges to be brought
against them.
Prisons and Probation Ombudsman 13
Findings
ACCT Management
72. Mr James presented as a complex and sometimes challenging man. Between 2017
and his death, he was monitored under ACCT procedures many times, including at
the time of his death. Mr James often talked of killing himself, had attempted suicide
at least once and had harmed himself several times. It seems his statements of
intent and acts of self-harm followed periods of frustration or when he was coping
less well with prison life.
73. Staff at Long Lartin were actively pursuing a transfer for Mr James and supported
his requests for accumulated visits. They were hampered by Mr James’ custodial
history and the COVID-19 pandemic.
74. Generally, we found that the ACCT plans were managed in line with Prison Service
Instruction 64/2011. Staff at Long Lartin were clearly trying to balance keeping Mr
James safe with his strong resistance to being supported on an ACCT. At times,
they believed that ACCT monitoring might increase the risk of him harming himself
rather than provide him with support, as is the intention.
75. Healthcare staff were not as well represented at ACCT reviews or in key decisions
about Mr James’ risk as they should have been. The member of the Inclusion
Team, who had worked with Mr James for some time, was not always invited to
ACCT reviews or asked for her input. While prison staff involved in the ACCT
management knew Mr James well, there are clear benefits to a multidisciplinary and
collaborative approach.
76. The lack of multidisciplinary working was particularly evident on 14 December when
two SOs completed the ACCT assessment and case review simultaneously at Mr
James’ cell door. At interview, one said that he was unable to say whether this was
normal practice as he had not been trained in the case manager role. Because they
completed Mr James’ review and assessment at his door, there was no opportunity
to involve those that knew Mr James, such as the member of the Inclusion Team or
other staff from the mental health team. This would have provided the opportunity to
fully assess his needs and risk.
77. Senior managers conducted an internal investigation into one of the SO’s actions
on 14 December 2020 and issued him with a final written warning.
78. The Head of Healthcare told us that the issues that existed with ACCT case reviews
had improved since Mr James’ death. He said that there was now ‘healthy
communication’ between prison and healthcare staff. Nursing staff also reported
that they felt confident in challenging prison officers on the issues around ACCT
monitoring, opening ACCT documents and issues raised at assessments.
ACCT Checks
79. On 16 December, Officer A was required to complete welfare checks on all
prisoners subject to ACCT monitoring. At 8.30am, he recorded in Mr James’ ACCT
document that he had looked in on Mr James, he was asleep on his left side and
14 Prisons and Probation Ombudsman
that he had noted movement. Following Mr James’ death, he told a prison manager
that the entry he had made at 8.30am was false and that he had not observed Mr
James at that time. The Governor suspended the officer from duty, and he later
resigned from the Prison Service. In light of this, we make no further comment on
his actions and make no recommendation.
ACCT training
80. At the time of Mr James’ death, prison staff at Long Lartin were not appropriately
trained in ACCT case management. Our investigation found that none of the staff
who were recorded as case managers in Mr James’ ACCT documents had
undergone the appropriate training.
81. A prison manager told us that since December 2020, ACCT reviews were only
completed by trained staff and that a database had been developed to show all staff
who were case manager trained. All prisoners subject to ACCT monitoring are
reviewed at the weekly safety meeting and those identified as needing a case
manager are referred to the custodial manager. When staff start ACCT procedures,
a case manager is allocated within 24 hours.
82. We acknowledge the improvements that a prison manager has put in place in
relation to safety and the delivery of ACCT at Long Lartin. The investigator saw first-
hand some of the changes that had taken place at Long Lartin and attended a
meeting with the manager and the Independent Monitoring Board where they
discussed the safety initiatives that had been implemented.
83. HMIP conducted an inspection of Long Lartin in December 2022, and the prison
received a ‘reasonably good’ marking for safety. We make the following
recommendation:
The Governor should provide the PPO with an update on the improvements in
relation to safety and the management of the ACCT process that have taken
place at HMP Long Lartin since December 2020.
Segregation
84. On 14 December, Mr James was physically restrained after he became violent
towards a member of staff and was subsequently relocated to the segregation unit.
A prison manager spoke with Mr James on the segregation unit before completing
the safety algorithm and appropriately completed the necessary documentation
(exceptional circumstances form) required when a prisoner on an open ACCT is
located on the unit.
85. We are satisfied that staff followed the correct procedures and that the decision to
segregate Mr James at that time was appropriate.
Clinical care
86. The clinical reviewer concluded that the clinical care Mr James received at Long
Lartin was of a good standard and equivalent to that which he could have expected
to receive in the community.
Prisons and Probation Ombudsman 15
87. She was also concerned about the management of the ACCT process and the lack
of involvement from healthcare staff. The clinical reviewer made a number of
recommendations about record keeping and clinical supervision, which we do not
repeat in this report, but which the Head of Healthcare will need to address.
.
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