Weighman, Daniel

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Daniel
Weighman, a prisoner at HMP
Chelmsford, on 6 January 2023
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 Daniel Weighman was found hanged in his cell at HMP Chelmsford on 3 January 2023,
and died in hospital on 6 January. He was 38 years old. I offer my condolences to his
family and friends.
Mr Weighman told staff on the night of 1 January that he would harm himself. Prison staff
considered starting suicide and self-harm prevention procedures (known as ACCT) but did
not do so, as they should have done. Two days later, when Mr Weighman harmed himself
by making superficial cuts to his neck, staff started ACCT procedures. However, Mr
Weighman was found hanged in his cell two hours later.
The clinical reviewer concluded that the healthcare Mr Weighman received at Chelmsford
was partially equivalent to that which he could have expected to receive in the community
but reported that there were missed opportunities to identify his history of mental health
issues. Despite subsequent referrals to the mental health team, he was not assessed at
Chelmsford. We also identified the need for healthcare staff to have adequate ACCT
training.
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 February 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
Summary
Events
1. On 15 October 2022, Mr Daniel Weighman was recalled to HMP Chelmsford for
breaching his licence conditions. He had a history of mental health issues and self-
harm. Mr Weighman told the reception nurse that he had no thoughts of suicide or
self-harm or any mental health issues. It was noted that he appeared to be in good
spirits.
2. During his first months at Chelmsford, Mr Weighman appeared settled and prison
staff allowed him to see his brother, who was also at the prison.
3. Mr Weighman was a heavy vape user and would ask his family to transfer money
for vapes. Mr Weighman shared a cell and appeared to get on well with other
prisoners but preferred to socialise in or near his cell.
4. On 1 January 2023, Mr Weighman threatened to harm himself if he was not given
sleeping tablets or moved to a single cell.
5. On 2 January, Mr Weighman’s cellmate asked to be moved to another cell as he
said Mr Weighman was taking his property and kept him up all night, watching
television. Staff moved Mr Weighman’s cellmate to another cell the following day to
prevent them fighting.
6. On the morning of 3 January, Mr Weighman told staff that he was hearing voices,
did not want to leave his cell and wanted to move to the healthcare unit. Staff tried
to contact the mental health team to find out if Mr Weighman was under their care
but were unable to get through. Later that afternoon, prison staff found Mr
Weighman with superficial cuts to his neck and started suicide and self-harm
monitoring procedures, known as ACCT.
7. At around 6.24pm, officers found Mr Weighman unresponsive in his cell. When staff
went into the cell, they found that he had tied a ligature around his neck. Officers
and emergency response staff started resuscitation procedures. Ambulance
paramedics arrived and Mr Weighman was taken to Broomfield Hospital for further
treatment. However, he died on 6 January.
Findings
8. On 1 January, Mr Weighman told staff that he would harm himself if he was not
given sleep medication. Although staff considered starting ACCT monitoring
procedures, they did not do so and missed an opportunity to assess his risk. Staff
did not record why they decided not to start ACCT procedures.
9. Healthcare staff had not received adequate ACCT training.
10. Staff at Chelmsford had no meaningful contact with Mr Weighman. The keyworker
scheme was not operating fully at the time due to staffing pressures. We cannot not
know if Mr Weighman would have shared his anxieties with staff if they had had
more contact with him.
Prisons and Probation Ombudsman 1
11. Although Mr Weighman had a history of mental health issues and self-harm, the
reception nurse was unaware of this as Mr Weighman did not tell her about it and
she had no access to his medical history during his initial health screen. She said
that if she had seen his medical records, she would have referred him immediately
to the mental health team.
12. There was a missed opportunity for the mental health team to assess Mr Weighman
after a referral on 4 November. This did not happen because of staffing pressures.
A referral made on 3 January was missed due to deficiencies in the way that mental
health referrals were made.
Recommendations
• The Governor and Head of Healthcare should ensure that:
• staff know when and how to start ACCT monitoring procedures, including
when a prisoner threatens self-harm;
• staff record why they did not start ACCT procedures if they are not
considered necessary; and
• healthcare staff receive ACCT training.
• The Head of Healthcare must ensure that staff access prisoners’ SystmOne medical
record before undertaking their initial health screen.
• The Head of Healthcare should write to the Ombudsman to set out how she has
assured herself that the new referral system to the mental health team is robust and
responsive and that there are timely mental health assessments following referrals
to the mental health team.
2 Prisons and Probation Ombudsman
The Investigation Process
13. The Prisons and Probation Ombudsman (PPO) was notified of Mr Weighman’s
death on 6 January 2023.
14. The investigator issued notices to staff and prisoners at HMP Chelmsford informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
15. The investigator obtained copies of relevant extracts form Mr Weighman’s prison
and medical records.
16. NHS England commissioned a clinical reviewer to review Mr Weighman’s clinical
care at the prison.
17. The investigator interviewed sixteen members staff and two prisoners at HMP
Chelmsford, some jointly with Mr McMorrow.
18. We informed HM Coroner for Essex of the investigation. He provided us with a copy
of the post-mortem and toxicology reports. We have sent him a copy of this report.
19. We contacted Mr Weighman’s next of kin to explain the investigation and to ask if
they had any matters they wanted us to consider. Mr Weighman’s next of kin raised
no issues.
20. Mr Weighman’s next of kin received a copy of the initial report. They did not make
any comments.
21. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS and Castle Rock Group Medical Services pointed out some factual
inaccuracies and the PPO report has been amended accordingly.
22. Castle Rock Group Medical Services also pointed out some factual inaccuracies
with the clinical review. The investigator passed these onto the clinical reviewer,
who amended their report.
Prisons and Probation Ombudsman 3
Background Information
HMP Chelmsford
23. HMP Chelmsford is a category B local prison that takes adult and young adult men
directly from the courts. It can hold around 713 men. Castle Rock Group Medical
Services provide 24-hour healthcare services. The prison has a 12-bed inpatient
unit.
HM Inspectorate of Prisons
24. Inspectors carried out a full unannounced inspection in August 2021. Following the
inspection, the Chief Inspector of Prisons invoked the Urgent Notification process
because he was so concerned about the conditions at Chelmsford. He reported that
the programme of special measures and other initiatives HMPPS introduced to
drive improvement since the previous inspection in 2018 had not worked.
25. Inspectors noted an inadequate response to high levels of suicide and self-harm at
the prison. They reported that self-harm incidents had increased significantly, the
safer custody team was not properly resourced, and staff lacked confidence in
using ACCT monitoring procedures. Despite flaws identified during their previous
inspection and subsequent failings identified by the PPO, outcomes had
deteriorated, recommendations had not been achieved and prison leaders had
repeatedly failed to address deficiencies with ACCT procedures.
26. Inspectors recommended that work to prevent suicide or self-harm should be
improved significantly and ACCT procedures should be delivered proactively and
robustly.
27. Inspectors reported a negative culture among some prison staff, including a lack of
respect, compounded by lack of management oversight, which went unchallenged.
28. Inspectors noted that plans to relaunch the key worker scheme had been
unambitious and would not provide consistent one-to-one support for prisoners.
29. Inspectors reported on the significant shortage of healthcare staff and in the mental
health and pharmacy teams which had impacted on the delivery of services. They
noted an over-reliance on agency staff, particularly in the mental health team, which
meant that service continuity could not be guaranteed.
30. Inspectors carried out an independent review of progress in August 2022. They
found that there had been reasonable progress in the work to prevent suicide and
self-harm and PPO recommendations were regularly reviewed to ensure that
processes were embedded.
31. Inspectors reported that staff were much more confident in using ACCT procedures
and the quality of reviews and care planning had improved. Most prisoners to whom
inspectors spoke said they felt supported by staff while on an ACCT. Inspectors
noted that quality assurance took place regularly and learning was shared with
managers.
4 Prisons and Probation Ombudsman
32. Inspectors reported that despite attempts to increase the number of keyworker
sessions with prisoners, they remained very limited.
Independent Monitoring Board
33. 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 annual report for the year to August 2022, the IMB reported that
there was good interaction between staff and prisoners and good care was provided
to those who needed support. The IMB reported that although there had been no
self-inflicted deaths since their last report, incidents of self-harm remained high,
65% of which was through superficial scratching and cutting.
Previous deaths at HMP Chelmsford
34. Mr Weighman was the fifth prisoner to take his life at Chelmsford since January
2020. Our investigation report into one of those deaths identified the failure of
prison staff to record their rationale when a decision was made not to monitor a
prisoner under ACCT procedures and of the need for prisoners to be assessed by
the prison’s mental health team within 72 hours.
35. There have also been two further apparently self-inflicted deaths since Mr
Weighman’s death. Our investigation report into one of these deaths identified
failures in the ACCT process. Following our recommendation to address these
deficiencies in November 2023, the Prison Group Director for Hertfordshire, Essex
and Suffolk wrote to the PPO, setting out the outcome of his review into the
measures introduced to improve ACCT management at HMP Chelmsford. We also
recommended that healthcare staff should act on mental health referrals
appropriately.
36. There has been one death from natural causes and one drug-related death since
January 2020. Since Mr Weighman’s death, there have been two further deaths
from natural causes. There are no similarities between our investigation findings in
this report and those of the previous deaths.
Assessment, Care in Custody and Teamwork
37. 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 prisoners. As part of
the process, a care plan which includes support and intervention, should be in
place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. Guidance on ACCT procedures is set out in Prison Service
Instruction (PSI) 64/2011 on safer custody.
Prisons and Probation Ombudsman 5
Key Events
Background
38. On 14 June 2019, Mr Daniel Weighman was sentenced to 28 days in prison for
theft, assault and possession of drugs. He was sent to HMP Chelmsford. On 26
July, he was sentenced to a further two years and four months for burglary. He had
been monitored under suicide and self-harm prevention procedures, known as
ACCT, during previous sentences.
39. In September and October 2019, Mr Weighman tried to hang himself and told staff
that he had heard voices. He was monitored under ACCT procedures and was
under the care of the mental health team.
40. On 11 May 2020, Mr Weighman was released from Chelmsford on licence.
HMP Chelmsford
41. On 15 October 2022, Mr Weighman was recalled to prison for breaching his licence
conditions. (The sentence for which he was recalled ended on 11 November, but he
remained in custody on remand, charged with two further offences, including actual
bodily harm.)
42. A mental health nurse completed his initial health screen. She did not have access
to Mr Weighman’s previous medical records. The Head of Healthcare told us that
medical records could only be accessed once the initial health screen had been
completed. The nurse noted that he had denied current or previous thoughts of
suicide or self-harm. She noted that Mr Weighman appeared agitated, restless and
was rude when answering questions. The next day, it was confirmed that that Mr
Weighman was not prescribed any medication.
43. During his first night interview, an officer noted that Mr Weighman was in good
spirits. When asked about his previous self-harm, Mr Weighman said he had been
in a “bad place”.
44. On 18 October, Mr Weighman was moved to E wing after his brother, who was also
at Chelmsford, asked for them to be near to each other. (His brother told the
investigator that his brother had been “upbeat” about the move. Although they lived
on different spurs of the wing, staff allowed them to meet almost every day.)
45. On 21 October, a healthcare administrator noted that Mr Weighman’s medical
record had been merged with his previous prison medical record.
46. On 4 November, a healthcare administrator completed Mr Weighman’s second
health screen. She reviewed his mental health self-assessment which he had
completed during his early days in custody. She did not see him in person. In the
assessment, Mr Weighman indicated that he had felt depressed daily for two weeks
and had been troubled by repeated thoughts. She referred him to the mental health
team. (She was not medically qualified but had some training to complete the task,
had been asked to review the assessment as no healthcare assistant was available
due to staff shortages.)
6 Prisons and Probation Ombudsman
47. The healthcare administrator emailed the mental health team leader to tell her that
Mr Weighman needed to see the mental health team. (Although the mental health
team leader confirmed receipt of the email, Mr Weighman was not subsequently
assessed by the mental health team.)
48. Mr Weighman’s brother described him as “a bit of a recluse” who “never had any
trouble”. He said his brother stayed in his cell most of the time but did not believe he
was being bullied, in debt or involved in drugs.
49. In December, Mr Weighman spoke to his sister by telephone on several occasions.
(Prisoners’ telephone calls are recorded but are not routinely monitored by HMPPS.
Prison staff were therefore not aware of the content of Mr Weighman’s calls. The
investigator listened to the recordings as part of the investigation.) He asked her to
transfer money into the accounts of other prisoners and hoped that he would be
tagged when released which he said would be better than being in prison. Mr
Weighman’s brother said he brought his brother coffee and vapes when he visited
him. He said that Mr Weighman helped him, and arranged money transfers so he
could buy vapes for him.
50. In a telephone call to his sister on 22 December, Mr Weighman again talked about
his release and his hope of being given a suspended sentence. Mr Weighman
asked his sister again to transfer money to other prisoners as he owed “double
back” and had “bought three boxes”. (Mr Weighman was likely talking about vapes
borrowed or bought from other prisoners.) In a call to his sister the following day, Mr
Weighman again talked about buying vapes. (Mr Weighman did not sound stressed
or upset during the call but his conversations indicated his frustration about being in
prison.) In telephone calls to his sister in December, Mr Weighman talked about the
transfer of money to buy vapes and his court case. He said he hoped to get a
community order as being in prison was “doing his head in”.
51. On 31 December, Mr Weighman spoke to his sister, told her he was “good” and
discussed money transfers. When his sister asked again how he was, he replied,
“Same old shit.” He sent her his love. (Mr Weighman appeared quieter than in
previous telephone calls with his sister.)
52. An officer who worked on E Wing, said that Mr Weighman spent a lot of time in his
cell as the wing was busy, he socialised with prisoners with whom he got on well
and he was a heavy vape user. The officer said that had never seen Mr Weighman
under the influence of drugs and he had never talked about self-harm.
53. A Supervising Officer (SO), the manager on E Wing, said that Mr Weighman never
talked about self-harm and there was no indication that he was being bullied, that
he was isolating himself or was involved in the prison drug culture.
54. Mr Weighman’s cellmate for around three weeks before his death said that when Mr
Weighman first moved in with him, he appeared “all right” but then started to
deteriorate. He said he had tried to help Mr Weighman, but it got to a point where
Mr Weighman talked to himself so much that it “rubbed him up the wrong way”. He
said he told officers, including the SO, that something was wrong with Mr
Weighman around New Year.
Prisons and Probation Ombudsman 7
55. At around 5.30pm on 1 January 2023, Mr Weighman rang his cell bell. Officer A,
who had been an officer for around seven months, responded and Mr Weighman
told her that he only wanted to speak to an SO or Governor. When she told him no
one was available, he asked to speak to the healthcare team.
56. Officer A asked a prison paramedic to speak to Mr Weighman. He told her that it
would not be appropriate for him to do so if there was no medical need. The officer
told him that Mr Weighman seemed stressed and angry. He said she told him that
Mr Weighman “had sort of threatened to self-harm if he was not seen”. He said he
told her that he would telephone Mr Weighman in his cell.
57. When the prison paramedic did so, Mr Weighman asked for sleeping tablets. He
told him this was not possible as a GP needed to prescribe them. He said Mr
Weighman said he felt as though he was going to harm himself. He told him that he
would ask the prison GP to consider his request for sleeping tablets. He said Mr
Weighman was “frustrated and argumentative” and had asked for his name so he
“knew who to blame” if the prescription was not made.
58. Officer A said that the prison paramedic called her back and said that Mr Weighman
had threatened to harm himself if he was not given sleeping tablets and discussed
with her whether he or she should start ACCT monitoring. She told him she would
open the ACCT.
59. Officer A said that as she started to open the ACCT, Officer B asked her if she had
heard Mr Weighman say that he would harm himself. She said she had not. She
said that Officer B told her that ideally, the prison paramedic should start ACCT
monitoring as Mr Weighman had told him that he would harm himself. She said she
could not recall Mr Weighman telling her that he would harm himself.
60. The prison paramedic said that Officer A told him that Officer B would speak to Mr
Weighman because ACCT monitoring might not be needed as Mr Weighman had
“not physically self-harmed”.
61. Officer B said that Officer A told him that Mr Weighman had asked to move to a
single cell. He spoke to Mr Weighman and told him that as a standard risk prisoner,
he would not be moved to one. He said Mr Weighman was angry and hit the cell
door. He said that Officer A asked whether she should start ACCT procedures. He
told her that if she thought there was a risk, she should do so. He also said that Mr
Weighman’s request to move cells may be goal-orientated.
62. Officer A said that she called the prison paramedic back and told him that he should
start ACCT procedures as Mr Weighman had told him that he would harm himself.
She said that she told him that Mr Weighman’s threat to harm himself appeared
goal-orientated as he had made the threat after being told he would not get sleeping
tablets. She said she told him that he should decide whether to start ACCT
monitoring. She said she did not hear from him again.
63. The prison paramedic said he told Officer A that as Mr Weighman had told them
both that he would harm himself, ACCT monitoring should be started. He said that
she agreed and said she would open the ACCT document. He said that a little later,
she told him that Officer B had told her he would need to open the ACCT as Mr
Weighman had told him that he would harm himself.
8 Prisons and Probation Ombudsman
64. Officer B said that if he had known that the prison paramedic was not going to open
an ACCT, he would have opened one with Officer A.
65. The prison paramedic said that Officer A told him that ACCT monitoring was not
needed as Mr Weighman appeared to be “manipulating”, but that he would be
monitored over the course of the evening. He contacted the prison GP about Mr
Weighman’s request for sleep medication.
66. Officer A said she checked on Mr Weighman twice before she left the prison at
8.30pm. She said that on both occasions, Mr Weighman was sitting on his bed,
watching television, and she had no concerns about him.
67. On 2 January, the cellmate told the SO that he needed to move out of Mr
Weighman’s cell, as Mr Weighman was taking items he had bought from the prison
shop and had kept him up for the previous three nights, watching television and
pacing up and down their cell. She told him that she would try and move him to
another cell the next day.
68. At around 11.00am, a mental health nurse and locum advance nurse medical
practitioner and prescriber remotely reviewed the prison paramedic’s request for the
GP to prescribe Mr Weighman sleep medication. He noted that a face-to-face
consultation was not needed, and he prescribed a short course of promethazine (an
antihistamine sometimes used to aid sleep).
Events of 3 January 2023
69. At 9.15am on 3 January, Mr Weighman spoke to his sister. They briefly talked about
a money transfer that had not gone through. Mr Weighman told his sister he would
call her back with further details and that he loved her. (Mr Weighman sounded
okay during the telephone call.)
70. That morning, Mr Wilson was moved to another cell.
71. At around 10.15am, Officer C unlocked Mr Weighman for the morning regime. He
said Mr Weighman told him that he was hearing voices, did not want to leave his
cell but wanted to move to the healthcare unit. The officer told a colleague to tell the
SO and to contact the mental health team. The officer, who had not seen Mr
Weighman for a couple of weeks, said that his behaviour had changed dramatically,
and he planned to check on Mr Weighman throughout the day.
72. Mr Weighman’s brother said that he visited Mr Weighman in his cell that morning
and gave him vapes and clothing. He said Mr Weighman appeared okay.
73. Officer C said that Mr Weighman kept saying that he needed to go to the healthcare
unit. The officer said he initially thought that as Mr Weighman vaped a lot, he might
have wanted to move because he was in debt, but Mr Weighman told him that this
was not the case.
74. At around 11.00am, the SO tried to phone the mental health team several times but
no one answered. There was no voicemail facility to leave a message.
Prisons and Probation Ombudsman 9
75. At 12.02pm, the SO emailed the Head of mental health. She wrote that Mr
Weighman had said he was hearing voices and she asked if he was under the care
of the mental health team. She said that this was the first time that she had been
told that Mr Weighman was hearing voices. The email was sent to the Head’s
personal work email address, rather than the generic mental health team email
address, and she did not pick the email up until after Mr Weighman’s death.
76. Officer C said Mr Weighman rang his cell bell several times that afternoon to ask
when he would be moved to the healthcare unit as he was hearing voices.
77. At around 3.15pm, Mr Weighman’s brother visited him again and spoke to him at
his cell door. He said he told his brother that he would bring more vapes when he
was unlocked to collect his evening meal. He Weighman said that his brother
appeared okay and described him as being “as sweet as a nut”. He said that as it
was some time before Mr Weighman would be unlocked, he went back to his own
spur.
78. At around 4.10pm, the SO unlocked Mr Weighman for his evening meal and noticed
that he had made several superficial cuts to his neck. She said that Mr Weighman
told her that he had harmed himself and did not want to leave his cell in case
people saw him. She radioed for healthcare to attend and asked Officer C to speak
to Mr Weighman to find out why he had cut himself. She returned to the wing office
to start ACCT monitoring procedures. The officer visited Mr Weighman, who said he
was hearing voices, he wanted to go to the healthcare unit and denied being in debt
or bullied. The SO said Mr Weighman did not want to talk to her or the officer, and
that this was not unusual as he had never interacted much with staff.
79. The prison paramedic went to Mr Weighman’s cell to treat him. He said that
although Mr Weighman refused to engage with him, he let him dress his wounds
and told him that he had used a razor to cut himself which another prisoner had
given him.
80. The SO said that Officer C told her that Mr Weighman did not want to talk but had
said that he was not being bullied and was not in debt. She asked him to ask Mr
Weighman’s brother to talk to him.
81. Mr Weighman’s brother said that when he arrived at the cell, he tried to find out
what was wrong, but Mr Weighman told him to leave three times. Despite this, he
remained, helped clean his brother’s wound, comforted him and told him that he
could visit his spur the following day.
82. Officer C said he left Mr Weighman’s brother with him, hoping that Mr Weighman
might say more without an officer present. He noted that Mr Weighman was keen to
move to his brother’s spur the next day for extra support and had said he had
enough vapes for the night.
83. The SO completed the ACCT immediate action plan. She noted that Mr Weighman
was in a cell on his own after an argument with his cellmate. Mr Weighman was put
on hourly observations until his assessment the following day.
84. Mr Weighman’s brother said the SO asked him if Mr Weighman was in debt. He
said he told her that his brother “was not cutting up to get a smokers pack” and had
10 Prisons and Probation Ombudsman
plenty of vapes. She said Mr Weighman’s brother told her that Mr Weighman was
“doing me out of pocket at the moment with vapes”. He said he thought that the SO
would monitor Mr Weighman every fifteen minutes.
85. The SO checked on Mr Weighman again at 4.45pm and allowed his brother to
return to talk to him and give him his evening meal (which Mr Weighman did not
eat). Mr Weighman’s brother said that before he left his brother, he embraced him
and told him to promise that he would not do anything stupid.
86. At around 5.10pm, Mr Weighman’s brother returned to his cell for the routine
evening roll check. The SO reminded Mr Weighman that he could move to his
brother’s spur the following morning which she said he was happy about. She said
that he had given his brother more vapes, that Mr Weighman had seemed settled
and hugged his brother before he left.
87. The SO said that Mr Weighman’s brother told her that he did not want to share a
cell with his brother as they would end up fighting. She said that she had planned to
move Mr Weighman the following day because of the time and logistics involved in
facilitating the move.
88. The SO said that Mr Weighman’s brother told her that Mr Weighman was not
hearing voices but had been told he was looking at 16 months imprisonment. She
said that he told her that he understood that his brother could not be taken
immediately to the healthcare unit.
89. At 5.14pm, Mr Weighman was checked during the roll count. At 5.58pm, Officer D
checked on him. She said that he was sitting on his bed, watching television, did not
speak but acknowledged her.
90. At 6.24pm, Officer D completed another ACCT check. She said that Mr Weighman
was lying on the floor of the cell on his front. The officer said she could not see him
properly, as he was lying behind the privacy screen of the toilet, which obscured the
top part of his body. She said his face was not in view. She called Mr Weighman’s
name, but he did not respond.
91. At 6.25pm, concerned about Mr Weighman and unsure what was happening,
Officer D radioed for staff assistance and switched on her body-worn camera. A
Prison Education Instructor (PEI) and another officer responded immediately and
when she saw them arrive on the wing, she went into the cell.
92. Officer D said she tapped Mr Weighman on the shoulder and called his name, but
he did not respond. The PEI removed a covering from the cell light so that the
officers could see better. He noticed that Mr Weighman had a ligature around his
neck and had tried to hang himself. (Mr Weighman had tied the ligature, made of a
bed sheet, to the top bunk of his bed, and it appeared that the ligature had
snapped, and Mr Weighman had fallen to the floor, with the top of his body
obscured by the toilet privacy screen.)
93. The other officer passed the PEI a cut-down tool as he was not carrying one. The
PEI cut the ligature from Mr Weighman’s neck and at 6.27pm, he radioed the
control room to tell them that it was a medical emergency code blue (used when a
prisoner is unresponsive or has breathing difficulties).
Prisons and Probation Ombudsman 11
94. The officers laid Mr Weighman on his back, and the officer and PEI started
cardiopulmonary resuscitation (CPR).
95. The prison paramedic was in the healthcare unit when he heard the initial call for
staff assistance, and he made his way directly to the wing. He arrived at the cell at
6.27pm, immediately assessed Mr Weighman, established that he was in cardiac
arrest and took over CPR. An officer collected the emergency response bag from
the wing office. A nurse and other healthcare staff arrived soon afterwards and
assisted the paramedic. Ambulance paramedics arrived at 6.42pm and Mr
Weighman was moved to the landing at 6.45pm. At 7.44pm, Mr Weighman was
taken to Broomfield Hospital for further treatment. Mr Weighman’s family were told
about the incident and visited him in hospital. Due to the severity of Mr Weighman’s
condition, the prison arranged for Mr Weighman’s brother to visit his brother in
hospital on 4 January.
96. At 4.00pm on 6 January, life support was removed from Mr Weighman, and he was
pronounced dead at 5.08pm. Members of his family were with him when he died.
Contact with Mr Weighman’s family
97. At 8.20pm on 3 January, a prison chaplain broke the news to Mr Weighman’s family
that Mr Weighman had been found hanging in his cell and had been taken to
Broomfield Hospital for treatment. Mr Weighman’s family subsequently visited him
in hospital and were with him when he died. On 4 January, staff at Chelmsford
made arrangements for Mr Weighman’s brother to visit his brother in hospital.
Chelmsford contributed to Mr Weighman’s funeral expenses in line with national
instructions.
Support for prisoners and staff
98. On 4 January, the Head of Residential Services debriefed staff following the
incident and staff and prisoners, including Mr Weighman’s brother, were offered
support. A postvention response, used to support staff and prisoners after a death
in prison, was not initiated after Mr Weighman’s death.
Post-mortem report
99. A post-mortem examination found that Mr Weighman died from suspension by
ligature. Toxicology results found traces of ketamine, a drug used in emergency
medical care, but it was noted that the toxicology results had no bearing on Mr
Weighman’s death.
100. The toxicology report also identified that tablets were found in a Vitamin D bottle in
Mr Weighman’s cell. It noted that the toxicology laboratory should be told if the
identity of the tablets became known or further testing was needed. We have no
further information about this.
12 Prisons and Probation Ombudsman
Information received after Mr Weighman’s death
101. Mr Weighman’s brother told the investigator that something was not right about Mr
Weighman while at Chelmsford. He said that his brother talked about other
prisoners, but he had reassured him that they were his friends.
102. Mr Weighman’s brother said that Mr Weighman had told him and some officers,
including Officer D, that he was hearing voices. He said that his brother was not in a
good place and needed to be seen by the mental health team. He said he had
asked staff to “keep an eye” on him. He said that staff told him that his brother was
alright but had become withdrawn.
103. Mr Weighman’s brother said that his brother’s cellmate had told him that he had
wanted to stop sharing a cell with Mr Weighman because he was talking to himself
and hearing voices.
104. The cellmate told the investigator that Mr Weighman did not take drugs. He said
that Mr Weighman had talked about swallowing a razor blade days before the
incident and as a result, he had thrown a razor blade away. He said he had told an
officer, whose name he did not recall, that Mr Weighman was “not doing well” and
“might do something”.
105. Chelmsford carried out an immediate investigation after Mr Weighman’s death.
During an interview with the cellmate, he told staff that he was being bullied by Mr
Weighman, that Mr Weighman was stealing his property and that his own mental
health was deteriorating. He said he believed that Mr Weighman had not meant to
kill himself but was seeking attention. He said he did not tell Mr Weighman that he
was moving cells as he did not want to upset him. Contrary to what he told the PPO
investigator, he told prison staff that Mr Weighman might have been holding or
using illicit drugs.
Prisons and Probation Ombudsman 13
Findings
Assessment of Mr Weighman’s risk
106. PSI 64/2011 on safer custody requires all staff who have contact with prisoners to
be aware of the risk factors and triggers that might increase the risk of suicide and
self-harm and take appropriate action. Any prisoner identified as at risk of suicide or
self-harm must be managed under ACCT procedures. Staff should assess a
prisoner’s risk of suicide and self-harm based on all known risk factors rather than
on the prisoner’s presentation and what the prisoner tells them.
107. Mr Weighman was a quiet prisoner who kept to himself much of the time, mixing
only with a few prisoners. Mr Weighman’s brother and cellmate told us that
concerns about Mr Weighman had been raised with prison staff before he harmed
himself on 3 January 2023. However, we found no evidence of this or that he was
threatened or bullied at Chelmsford.
108. When Mr Weighman threatened to harm himself on 1 January, an ACCT was not
opened as it should have been. Staff accounts differ about why not, and no one
took responsibility for starting ACCT procedures, instead passing the accountability
to someone other than themselves. There is no record of a defensible decision to
explain why ACCT procedures were not started and the decision-making was poor
and confused. Staff missed an opportunity to identify through the ACCT
assessment and multidisciplinary review whether Mr Weighman’s risk had
increased.
109. During the investigation, it became apparent that healthcare staff were not
adequately trained in ACCT procedures. The Head of Healthcare said that she
struggled to get ACCT training for healthcare staff and healthcare staff had been
pulled from ACCT training to allow officers to attend.
110. The Prison Group Director for Hertfordshire, Essex and Suffolk wrote to the
Ombudsman in November 2023 in response to our recommendation in a previous
investigation report in which we asked him to assure us that the measures
introduced at Chelmsford to improve ACCT management were leading to sustained
improvement. He told us that he and the Governor of Chelmsford had reviewed the
senior management team to ensure safety and other key areas had consistent
leadership. He set out the detail of significant changes that had been made to
manage ACCT procedures. While we welcome these numerous changes and are
pleased that safety is being prioritised at Chelmsford, we want to ensure that the
particular deficiencies we identified in this investigation report, which were not
specifically addressed in the Prison Group Director’s letter, are addressed. We
therefore make the following recommendation:
The Governor and Head of Healthcare should ensure that:
• staff know when and how to start ACCT monitoring procedures,
including when a prisoner threatens self-harm;
• staff record why they did not start ACCT procedures if they are not
considered necessary; and
14 Prisons and Probation Ombudsman
• healthcare staff receive ACCT training.
Keyworker scheme
111. We found no evidence that Mr Weighman shared his concerns with staff until 1
January or that he gave them any reason to consider that he was at imminent risk
of suicide before then.
112. However, there is no evidence that staff had any meaningful contact with Mr
Weighman at Chelmsford before 1 January. There are no meaningful conversations
recorded in his prison record and the keyworker scheme at the prison was not
operating fully at the time due to staffing pressures. Had wing staff had more
regular and significant contact with Mr Weighman, it is possible they might have
become aware of Mr Weighman’s increasing risk. However, Mr Weighman
appeared to have been a private man and we cannot know whether he would have
shared this anxieties with staff.
113. During the investigation, we were told that 85% of prisoners at Chelmsford now
have a key worker. Given this, we make no recommendation, but the Governor will
wish to monitor key work delivery.
Clinical issues
114. The clinical reviewer concluded that the physical healthcare that Mr Weighman
received at Chelmsford was of a reasonable standard and equivalent to that which
he could have expected to receive in the community. However, the clinical reviewer
considered that the mental healthcare that Mr Weighman received was not of the
required standard and was not equivalent to that which he could have expected in
the community.
Reception screen and mental health referrals
115. The clinical reviewer concluded that Mr Weighman’s initial health screen on 15
October was not carried out to an appropriate standard. The clinical reviewer
reported that the reception nurse did not have access to Mr Weighman’s medical
records when she carried it out. We found that the nurse could only access medical
records once she had completed the initial health screen, therefore the nurse was
unable to refer to the record prior to completing the reception screen. We were told
that once the reception screen record is completed, full access to the records is
possible, and could have been accessed by the nurse during reception. However,
the records are merged by an administrator some days after the reception screen.
116. Had the nurse been able to access Mr Weighman’s previous medical records, she
would have seen his history of mental health issues and two previous suicide
attempts when Mr Weighman had tried to hang himself. The reception nurse said
that had she seen these records, she would have referred Mr Weighman to the
mental health team. However, this did not happen, and we make the following
recommendation:
The Head of Healthcare must ensure that staff access prisoners’ SystmOne
medical record before undertaking their initial health screen.
Prisons and Probation Ombudsman 15
117. The clinical reviewer reported that the secondary health screen, which was not
completed within the required seven days, was completed by a healthcare
administrator and not a clinician due to staff shortages. At the secondary health
screen, Mr Weighman was referred to the mental health team. Despite a referral
being made to the mental health lead, Mr Weighman was not assessed as he
should have been. The mental health lead said that due to overwhelming work
pressures at the time, she did not process the referral and subsequently Mr
Weighman was not seen by the mental health team.
118. After Mr Weighman harmed himself on 3 January, the wing SO emailed the mental
health lead’s personal work email account to say that Mr Weighman was hearing
voices and asked if he was under the care of the mental health team. The email
was not picked up until after Mr Weighman’s death. The clinical reviewer reported
that this again highlighted the lack of a formal mental health referral process and a
lack of awareness by officers about how to make mental health referrals.
119. It is not the first time that we have identified issues with the mental health referral
system in place, and we most recently made a recommendation to address this
concern in November 2023. The Head of Healthcare and the mental health lead
confirmed that there is now a more robust referral system to the mental health team
in place. We therefore make the following recommendation:
The Head of Healthcare should write to the Ombudsman to set out how she
has assured herself that the new referral system to the mental health team is
robust and responsive and that there are timely mental health assessments
following referrals to the mental health team.
120. The clinical reviewer was concerned about the missed opportunities for Mr
Weighman to access the mental health team at Chelmsford. However, the clinical
reviewer concluded that this might not have prevented Mr Weighman’s death.
Head of Healthcare to note
121. On 4 November, a healthcare administrator, who was not medically qualified,
completed Mr Weighman’s secondary healthcare screen. This should have been
completed by a qualified clinician.
Governor to note
Postvention
122. Postvention procedures, used to support staff and prisoners following a sudden
death, which should be implemented after all self-inflicted deaths or serious
incidents of self-harm, did not take place following the incident.
Good practice
123. We identified three areas of good and compassionate practice:
16 Prisons and Probation Ombudsman
• Prison staff allowed Mr Weighman and his brother to meet frequently, despite
living on different spurs. This was a particularly important protective factor
when Mr Weighman was being monitored under ACCT procedures;
• they planned for Mr Weighman to move to his brother’s wing after he harmed
himself; and
• they allowed his brother to visit him in hospital before he died.
Inquest Verdict
124. The inquest hearing into the death of Mr Weighman was held on 17 April 2024. It
confirmed that the medical cause of Mr Weighman’s death was suspension by
ligature. It concluded in a narrative verdict, that Mr Weighman deliberately deployed
a ligature in his cell on 3 January 2023, but that the evidence did not fully explain
whether or not he intended that the outcome would be fatal and reported on a
number of probabilities that might have contributed to Mr Weighman’s death.
Prisons and Probation Ombudsman 17
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