Dealey, Paul

[Page 1]
Independent investigation into
the death of Mr Paul Dealey,
a prisoner at HMP Swaleside,
on 1 August 2021
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

[Page 2]
© 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.

[Page 3]
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 in ensuring the
standard of care received by those within service remit is appropriate, then our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Paul Dealey died after he was found hanged in his cell at HMP Swaleside on 1 August
2021, five days before he was due to be released. He was 40 years old. I offer my
condolences to his family and friends.
I found evidence of effective risk management and support by staff, including appropriate
referrals to the mental health team, the flexible use of the inpatient unit when Mr Dealey
felt unsafe and efforts to transfer him to a prison closer to his home area. However, the
decision to end suicide and self-harm monitoring was premature and no post-closure
monitoring took place.
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 November 2023

[Page 4]
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 14

[Page 5]
Summary
Events
1. On 14 August 2019, Mr Dealey was recalled to prison, five days after he was
released on licence. He was transferred to HMP Swaleside on 16 September 2020.
Mr Dealey had a history of substance misuse and mental ill-health, including anxiety
and depression.
2. In May 2021, officers referred Mr Dealey to the mental health team because he was
not coming out of his cell very often or engaging with staff. The mental health team
monitored and assessed Mr Dealey’s mental health during the month of June.
3. On 5 July, a GP at Swaleside prescribed Mr Dealey anti-anxiety and antidepressant
medications. The GP did not find any evidence of severe depression or anxiety but
recorded that Mr Dealey would need support from the community mental health
team after his release, which was due on 6 August.
4. On 26 July, an officer referred Mr Dealey to the mental health team again after
becoming increasingly concerned about his paranoid behaviour. The next day, a
mental health nurse reviewed the referral and discussed it with the mental health
team. The team concluded that Mr Dealey’s paranoia and anxiety levels had
increased and that his care planning should be reviewed.
5. On the morning of 28 July, Mr Dealey smashed his cell door observation panel and
barricaded his cell door using broken furniture. He also made cuts to his arms.
Staff put additional monitoring in place under suicide and self-harm prevention
procedures (known as ACCT), to manage the risks. They noted that Mr Dealey’s
mental health had rapidly deteriorated, and that he was feeling very paranoid and
anxious about his upcoming release.
6. At around 12.30pm on 29 July, an ACCT review / Multi-Disciplinary Team (MDT)
meeting took place to discuss Mr Dealey’s mental health. The review decided that
Mr Dealey should be moved to the inpatient unit in the prison’s healthcare
department as soon as possible, to help him feel safer. The move took place at
1.00pm.
7. At 10.45am on 30 July, Mr Dealey’s next review meeting took place and staff
agreed that his ACCT should be closed because his engagement, behaviour and
presentation had improved, and he did not pose a risk to himself.
8. During the night of 31 July to 1 August, the Healthcare Assistant (HCA) on the
inpatient unit completed hourly checks on Mr Dealey and raised no concerns.
However, at around 6.30am, the HCA became concerned that Mr Dealey had been
in the same position for several hours. The HCA spoke to his supervisor, who
attended the cell and radioed a medical emergency ‘code blue’ (indicating a life-
threatening situation) at 6.44am. Officers and healthcare staff responded to the
code blue and found that Mr Dealey had a ligature around his neck. They cut the
ligature and began cardiopulmonary resuscitation (CPR) but were unable to revive
him. At 7.29am, paramedics confirmed that Mr Dealey had died.
Prisons and Probation Ombudsman 1

[Page 6]
Findings
Clinical care
9. The clinical reviewer concluded that overall, the clinical care provided to Mr Dealey
was equivalent to that which he could have expected to receive in the community.
However, she found issues with clinical assessment and discharge planning that
the Head of Healthcare will need to address.
Management of risk of suicide and self-harm
10. We consider that the decision to close Mr Dealey’s ACCT on 30 July was
premature. There was limited evidence that his risk of suicide and self-harm had
reduced and that he could be safety managed without additional monitoring. The
post-closure ACCT monitoring process would have enabled a review of the
decision, but this was not used by staff. The routine observations in place on the
inpatient unit should not have been relied upon as an alternative method of
monitoring Mr Dealey’s welfare.
11. Staff did not follow the self-isolation policy when Mr Dealey withdrew from the
regime.
12. We also consider that Mr Dealey’s cell on the inpatient unit was not appropriate in
the circumstances. Staff could not easily check him because of the unusual flap
system on the door.
Emergency response
13. Staff delayed calling the medical emergency ‘code blue’ and entering the cell when
Mr Dealey was discovered unresponsive. This does not appear to have impacted
on the outcome for Mr Dealey, but a delay might have critical consequences in
future emergencies.
Preparation for release from prison
14. Mr Dealey had no accommodation to move into on release. We note the steps
taken by his Offender Supervisor (OS) to secure housing and recognise the national
shortages that impact on this. The OS told us that accommodation support was
limited at Swaleside because it was not a resettlement prison and because Mr
Dealey’s release area was far away from the prison.
Substance misuse
15. Mr Dealey had a long and documented history of substance misuse, and evidence
suggests that he may have been in debt with other prisoners around the time he
died. We are concerned that he was not referred to the substance misuse team
until 11 July 2021, around 10 months after he arrived and shortly before his release.
We consider that this was a serious oversight during the initial screening process.
2 Prisons and Probation Ombudsman

[Page 7]
Meaningful contact
16. We identified a lack of meaningful contact with staff in the months before Mr
Dealey’s death, due to staffing shortages during the COVID-19 pandemic.
Recommendations
• The Head of Healthcare should develop and issue guidance to healthcare staff
which clarifies the process for inpatient unit referrals, to ensure that admissions are
clinically appropriate, and that clinical support is in place.
• The Head of Healthcare should ensure that individual care plans are created and
implemented for prisoners on the inpatient unit, to enable effective management of
health conditions and to prepare them for release (if applicable)
• The Governor and Head of Healthcare should ensure that ACCT reviews thoroughly
assess the risk presented by individuals and only approve closure where there is
robust evidence that risks have reduced.
• The Governor and Head of Healthcare should remind all disciplinary and healthcare
staff of the difference between standard inpatient healthcare observations and ACCT
monitoring procedures, to ensure they are not viewed as alternatives.
• The Governor and Head of Healthcare should remind disciplinary and healthcare
staff to complete the ACCT post-closure section, to ensure that any ongoing risks
are appropriately monitored, and the ACCT is reopened where needed.
• The Governor and Head of Healthcare should review the suitability of cell 5 in the
inpatient unit for prisoners who are vulnerable.
• The Head of healthcare should issue guidance to staff on the inpatient unit that
clearly explains the purpose of and expectations for hourly observations.
• The Governor and Head of Healthcare should ensure that prisoners with a history of
substance misuse are referred to the substance misuse team on arrival, to enable
them to access the appropriate support.
Prisons and Probation Ombudsman 3

[Page 8]
The Investigation Process
17. The investigator issued notices to staff and prisoners at HMP Swaleside informing
them of the investigation and asking anyone with relevant information to contact
him. One prisoner responded and agreed to be interviewed.
18. The investigator obtained copies of relevant extracts from Mr Dealey’s prison and
medical records.
19. NHS England commissioned a clinical reviewer to review Mr Dealey’s clinical care
at the prison.
20. The investigator, accompanied by the clinical reviewer, interviewed 13 members of
staff and one prisoner at Swaleside. The interviews were completed by video link
and telephone due to the restrictions imposed as a result of the COVID-19
pandemic.
21. We informed HM Coroner for Kent and Medway of the investigation who gave us
the results of the post-mortem examination. We have sent the coroner a copy of
this report.
22. The Ombudsman’s family liaison officer contacted Mr Dealey’s father, to explain the
investigation and to ask if he had any matters, he wanted the investigation to
consider. Mr Dealey’s father did not have any questions, but said he thought his
son may have taken “Spice” (also known as psychoactive substances or PS)
around the time of his death. He said he did not know why his son would have
taken his own life, when he had only five days until his release.
23. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not identify any factual inaccuracies.
24. Mr Dealey’s family received a copy of the draft report. They did not make any
comments.
4 Prisons and Probation Ombudsman

[Page 9]
Background Information
HMP Swaleside
25. HMP Swaleside, on the Isle of Sheppey, is part of the Long-Term and High Security
estate. It houses up to 1,112 men serving sentences of four years or more.
Integrated Care 24 Ltd provides primary healthcare. There is 24-hour nursing cover
and a 17-bed inpatient unit. GPs work in the prison Monday to Friday, and Medway
on Call Care provides an out of hours GP service. Oxleas NHS Foundation Trust
provides mental health services. The Forward Trust provides substance misuse
treatment.
HM Inspectorate of Prisons
26. The most recent published inspection of HMP Swaleside was in July 2022.
Inspectors reported that the shortage of officers was worse than at their previous
inspection in October 2021, leading to very limited time out of cells for most
prisoners. Good progress had been made in addressing inspectors’ concerns
about early days support and it was evident that a significant amount of effort had
been put into creating a well-thought-out service. However, inspectors reported that
staffing levels were now at ‘crisis point’ and this was having an impact on all
aspects of the regime.
27. Inspectors reported that the rate of self-harm had declined considerably, but there
had been five self-inflicted deaths: four since the last inspection and a fifth two
months after their visit.
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 its annual report, for the year to April 2021, the IMB found the prison
had had a difficult year coping with the COVID-19 pandemic – at one point 150 staff
were off work. Although they felt as a whole the prison had still managed to forge
ahead and make some improvements regarding physical repairs and collaborative
working, they remarked on the lack of meaningful activity or work available for
prisoners which had been necessary to keep staff and prisoners safe.
29. In its most recent annual report, for the year to April 2022, the IMB found that the
lack of key working, meaningful employment and activities was still a concern.
They stated that it increased the frustration felt by prisoners, which in turn increased
the levels of violence and self-harm. However, they noted that the provision of in-
cell education packs helped alleviate boredom for those prisoners who were
interested. The IMB stated that current staffing levels were very low. As a result,
the support available for prisoners was inadequate and, seemingly, reducing year
on year, which did not bode well for the future security of the establishment nor the
provision of adequate support for prisoners.
Prisons and Probation Ombudsman 5

[Page 10]
Previous deaths at HMP Swaleside
30. Mr Dealey was the 12th prisoner at Swaleside to die since August 2019. Eight of
the previous deaths were from natural causes, two were drug-related and one was
self-inflicted. We found some similarities in our investigation findings following Mr
Dealey’s death and the previous self-inflicted death in 2021. Staff did not call a
code blue straight away when they identified the emergency, and the substance
misuse team did not share information about the prisoner’s drug use with
healthcare.
31. Since Mr Dealey’s death, there have been seven further self-inflicted deaths. As a
result, Swaleside is receiving support and monitoring from His Majesty’s Prison and
Probation Service Headquarters.
Assessment, Care in Custody and Teamwork (ACCT)
32. 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
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.
33. As part of the process, a caremap (a plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011,
Management of prisons at risk of harm to self, to others and from others (Safer
Custody).
Key worker scheme
34. The key worker scheme aims to improve safer custody by engaging with prisoners,
building better relationships between staff and prisoners and helping prisoners
settle into life in prison. It provides that all adult male prisoners will be allocated a
key worker who will spend an average of 45 minutes a week on key worker
activities, including having meaningful conversations which each of their allocated
prisoners.
35. The key worker scheme was suspended across the estate on 24 March 2020 due to
the COVID-19 pandemic. To ensure that meaningful interaction continued for
priority prisoners, the Prison Service used an Exceptional Delivery Model until May
2022. This involved weekly conversations with prisoners identified as vulnerable.
6 Prisons and Probation Ombudsman

[Page 11]
Key Events
Background
32. Mr Paul Dealey had spent several periods in prison for a range of offences including
theft and public disorder. He had a long history of class A substance misuse in the
community and was found under the influence of psychoactive substances (PS) on
several occasions in prison. He also had a history of mental ill-health, including
anxiety and depression for which he had been prescribed medication, but this was
withdrawn after he was found to be tampering with it. In 2016, doctors diagnosed
Mr Dealey with attention deficit hyperactivity disorder (ADHD) and prescribed
medication for the symptoms. Healthcare professionals also suspected that he had
a personality disorder, however a formal diagnosis was never reached.
33. On 17 October 2018 at HMP Manchester, Mr Dealey threatened to take his life if
staff did not move him onto a different wing. Staff monitored Mr Dealey under
suicide and self-harm procedures known as ACCT, until 18 December 2018. Mr
Dealey told them he was in debt and wanted to move wings for his own safety.
Staff closed the ACCT once they were satisfied that the risk of suicide and self-
harm had reduced and could be managed without additional monitoring.
36. Mr Dealey was released and recalled to prison several times. As result of this and
his behaviours, he spent time in a variety of prisons. During a period at HMP
Manchester, from 11 July to 25 August 2020, Mr Dealey refused his food. Staff
monitored him under the ACCT process again. This was not the first time that Mr
Dealey had refused food in prison.
37. In his final months at Manchester, Mr Dealey resided on the segregation unit after
saying he wanted to self-isolate and exhibited disruptive behaviour. Mr Dealey’s
final transfer, from Manchester to HMP Swaleside, took place on 16 September
2020.
HMP Swaleside
38. At his initial health screening on 16 September, Mr Dealey said that he had a
history of substance misuse and self-harm. He said he had not self-harmed for 12
months, but said he had a long history of ADHD, anxiety, depression and insomnia
for which he had previously been prescribed medication until it was stopped. The
nurse noted that Mr Dealey was waiting to see a doctor to review his medication.
She referred him to the mental health team.
39. The next day, Mr Dealey was assessed by mental health nurse, in consultation with
two other members of healthcare staff. The team concluded that Mr Dealey should
be seen routinely for mental health assessments but did not think he needed any
urgent or specific support or treatment at the time.
40. On 21 September, Mr Dealey told a nurse that he had not eaten for six days. He
was speaking rapidly, appeared anxious and talked about his ADHD diagnosis.
The nurse referred him to the GP and for counselling.
41. On 22 September, the mental health team discussed Mr Dealey’s care at their team
meeting. They reviewed his previous medication and identified behavioural
Prisons and Probation Ombudsman 7

[Page 12]
changes when he felt his needs were not being met. They also noted that Mr
Dealey was requesting sealed meals because he thought his food was being
tampered with. In interview, Mr Dealey’s keyworker told us that Mr Dealey spent
most of his time in his cell and self-isolated during his time at Swaleside. He also
told us that although Mr Dealey told staff that he was on hunger strike, he was in
fact eating. Officers concluded that there was no benefit in logging the food refusal.
The mental health team agreed that no immediate action was required but that they
would continue to monitor Mr Dealey.
42. On 2 October, the mental health team completed one of their regular assessments
of Mr Dealey. They booked an appointment with the consultant psychiatrist at
Swaleside for a review of Mr Healey’s medication. Mr Dealey did not attend GP
appointments on 2 October and 23 October for unknown reasons, however the
mental health team continued to complete regular welfare checks. On 20
November, Mr Dealey decided not to attend a further GP appointment.
43. On 16 December, the consultant psychiatrist tried to complete a psychiatric
appointment with Mr Dealey in his cell, over the telephone (this was due to COVID-
19 restrictions). Mr Dealey did not answer the telephone. In interview, the
psychiatrist told us that the average time it took for him to see a patient during the
pandemic had increased from around three weeks to around two to three months.
He said this caused stress for him, patients and the wider service.
44. On 6 January 2021, Mr Dealey spoke to the consultant psychiatrist on his in-cell
telephone. The psychiatrist told us that he was confident that Mr Dealey had
ADHD, because he observed symptoms including hyperactivity and impulsiveness.
He was aware that Mr Dealey had not received any medication since July 2020 and
could see that he was struggling without it. He prescribed medications to help with
Mr Dealey’s sleeping issues and ADHD. He arranged to review Mr Dealey in four to
six weeks’ time.
45. On 6 April, Mr Dealey met the consultant psychiatrist in person for the first time.
Officers that knew Mr Dealey told the psychiatrist that Mr Dealey’s behaviour had
improved. They said he had been leaving his cell and interacting with other
prisoners, which was unusual for him as he often self-isolated. At the meeting, Mr
Dealey told the psychiatrist that he continued to have trouble sleeping and felt
anxious and low in mood. The psychiatrist concluded that Mr Dealey had a panic
disorder and prescribed an anti-anxiety medication for five days. They discussed
psychological therapies and relaxation techniques.
46. On 12 May, wing staff referred Mr Dealey to the mental health team because he
was not coming out of his cell very often or engaging with staff. On 28 May, the
consultant psychiatrist met with Mr Dealey again and noted that he was due to be
released from prison in around ten weeks’ time. Mr Dealey told him that he became
hyperactive if he was not engaged in purposeful activity and still had trouble
sleeping. The psychiatrist prescribed more medication for insomnia and increased
Mr Dealey’s ADHD medication.
47. The mental health team continued to monitor and assess Mr Dealey during June.
8 Prisons and Probation Ombudsman

[Page 13]
July 2021
48. On 5 July, the consultant psychiatrist assessed Mr Dealey at a face-to-face
meeting. He did not consider that Mr Dealey presented any evidence of severe
depression or anxiety that he could not cope with. He recorded the need for a
mental health review following release.
49. On 11 July, Mr Dealey’s Offender Supervisor met Mr Dealey and recorded that he
would have nowhere to live after his release from prison on 6 August. As a result,
she referred him to the Leicester Housing Authority, which is where Mr Dealey
intended to live upon his release.
50. On 20 July, Mr Dealey met his keyworker and another officer on the wing. They
asked him why he was self-isolating and found that this may have been due to an
outstanding debt, although Mr Dealey did not tell them this explicitly. Mr Dealey told
them that he wanted to self-isolate until his release.
51. On 26 July, a Supervising Officer (SO) on G Wing referred Mr Dealey to the mental
health team after becoming increasingly concerned about his behaviour and
presentation.
52. On 27 July, a mental health nurse reviewed the SO’s referral alongside Mr Dealey’s
healthcare notes and discussed it with the wider team. They concluded that Mr
Dealey’s paranoia and anxiety levels had increased and that he should be
reviewed.
53. At around 9.30am on 28 July, a Custodial Manager (CM) completed a welfare
check on Mr Dealey and found him in a paranoid, distressed state. He recorded
that Mr Dealey had damaged his cell and was anxious about his impending release
from prison. He also noted that Mr Dealey had made superficial cuts to his left
forearm, had clad himself in makeshift armour and was threatening to escalate his
behaviour by either self-harming or seriously assaulting staff or prisoners. The CM
immediately contacted the mental health team and opened an ACCT. Staff put
hourly observations in place to monitor Mr Dealey’s wellbeing and included a
requirement for one quality conversation in the morning and one in the afternoon.
54. At 10.00am, the mental health team tried to assess Mr Dealey but were unable to
due to his distressed state. At 11.50am, a mental health nurse attended his wing
and, with support from the CM, completed the mental health assessment. The
nurse did not record any observations about Mr Dealey’s physical or mental state
but noted that an ACCT/MDT meeting was due to take place at 2.00pm that day.
55. The CM told the Offender Supervisor nurse about the deterioration in his mental
health and anxiety surrounding release. The Offender Supervisor confirmed that
because Mr Dealey was on a recall and about to reach the end of his sentence, he
would not be subject to a licence or under probation supervision when released.
Leicester Housing Authority told her that if Mr Dealey was released with nowhere to
live (which appeared likely), he would have to contact them on the day he became
homeless in order for them to try and find him a bed space. At the time, they had
nowhere to house him. The Housing Authority could not give her any further help or
assurances regarding Mr Dealey’s housing situation. Mr Dealey was told this at the
later ACCT review.
Prisons and Probation Ombudsman 9

[Page 14]
56. At around 2.30pm, Mr Dealey attended an ACCT review. Staff from healthcare,
psychology, safer custody, the offender management unit (OMU) and officers on Mr
Dealey’s wing also attended.
57. A SO and the ACCT case coordinator recorded that Mr Dealey said he was in debt,
concerned about his upcoming release from prison and struggling with his mental
health. Mr Dealey told staff that he did not feel suicidal and did not want to harm
himself. He repeatedly requested a move to the Care and Separation Unit (CSU),
also known as segregation, which he felt it was the only place that was safe for him.
The group decided to keep the ACCT open with two conversations a day (one in the
morning and one in the afternoon) and two observations during the night.
58. On 29 July in the morning, a SO made another referral to the mental health team
based on serious ongoing concerns about Mr Dealey’s emotional welfare. Mr
Dealey was already being monitored by the ACCT process, but the SO assessed
that he might need additional support.
59. The mental health in-reach team meeting discussed the referral later that day. The
team noted that Mr Dealey did not have a severe or enduring mental health
diagnosis. They assessed that there was no specific input needed from the mental
health team and that the referral was in effect a duplicate of that which had been
dealt with the previous day. They agreed the SO should be signposted to other
services including the Forward Trust, Chaplaincy, Offender Management and
Primary Care which might be able to support Mr Dealey.
60. At around 12.30pm, staff held another ACCT review / MDT meeting due to
continued concerns about Mr Dealey’s emotional welfare. The review decided that
Mr Dealey should be moved to the inpatient unit in the prison’s healthcare
department as soon as possible, rather than the CSU which they felt was unsuitable
for him. They also considered that transferring Mr Dealey to a prison in the
Leicester area would help him, so that he could reach support services and
probation more easily when released. The group decided to keep his ACCT
observations at the same level.
Move to the Inpatients Unit
61. At around 1.00pm on 29 July, officers escorted Mr Dealey to the inpatient unit and
conducted a full search on arrival. They found two improvised bladed weapons,
which were placed in evidence bags. Healthcare staff on the inpatient unit began
completing hourly observations (basic, routine visual checks) on Mr Dealey, in line
with standard procedures.
62. On 30 July at 9.10am, a nurse recorded in Mr Dealey’s ACCT document that after
damaging his cell overnight, he had been moved within the inpatient unit from cell
14 to cell 5 and placed on report for his actions. At 10.45am, a CM chaired an
ACCT review for Mr Dealey on the inpatient unit. Mr Dealey attended the meeting
alongside a nurse, his Offender Supervisor, a member of the substance misuse
team, a member of psychology and the Head of Residence, who was ACCT co-
chair. Mr Dealey spoke about his adverse childhood experiences, which he had not
talked about before. He presented as paranoid about his safety in prison and on
release. However, as the review progressed, he became more engaged, and his
anxiety appeared to reduce. He said he wanted to start afresh upon his release
and live in the countryside. Mr Dealey said he felt safer on the inpatient unit than
10 Prisons and Probation Ombudsman

[Page 15]
on a normal wing, and despite the stress of his release he said he would not self-
harm or consider suicide as he loved himself too much. Staff noted that he was
eating well.
63. The review agreed that Mr Dealey’s ACCT should be closed, because Mr Dealey
did not pose a risk to himself. The care plan was not updated, and a post closure
review was scheduled for 5 August. Mr Dealey said he would ask for the CM if he
needed further support. At interview, the CM told us that the hourly healthcare
observations in place in the inpatient unit were a factor in the decision to close Mr
Dealey’s ACCT.
64. The Head of Residence submitted an urgent transfer request to HMP Lowdham
Grange for Mr Dealey, which was near his hometown of Leicester and would help
with his transition into the community following release. However, Lowdham
Grange were unable to accept him as they did not have space. We understand that
staff then put in a transfer request to HMP Leicester, but this was also
unsuccessful.
65. Between 9.00am and 9.00pm on 31 July, a healthcare assistant on the inpatient
unit completed basic visual checks on Mr Dealey and raised no concerns.
66. From 9.00pm, a healthcare assistant (HCA) completed hourly observations on Mr
Dealey. At interview, he told us that observation times were staggered so that
prisoners did not know exactly when the check would take place. He was
supervised by the emergency response nurse. However, the nurse was not
involved in the checking process. The HCA told us that it was difficult to conduct
the visual checks on Mr Dealey because of a vertical flap system in the cell door
that obscured the view.
67. At around 11.00pm, the HCA recorded on the observation chart that Mr Dealey was
awake and talking to staff.
1 August
68. At midnight, the HCA noted that Mr Dealey was engaging with staff members. At
3.00am, he saw Mr Dealey pulling out the cupboards in his cell.
69. At around 4.00am, the HCA noted that Mr Dealey, “appeared to be dozing off” on
the cell floor. At interview, he told us that he could see the lower part of Mr
Dealey’s legs but could not see his body because he was at an angle behind the
door.
70. At around 5.00am, the HCA recorded that Mr Dealey was, “sitting on the floor and
appeared asleep”. As before, he could not see Mr Dealey’s upper body.
71. At some time between 6.05 and 6.40am (we are unable to corroborate the exact
timing as there was no CCTV in the area and the HCA said that he did not record
the exact times of his checks), the HCA checked Mr Dealey and saw that he was in
the same position. At interview, he said he became concerned at this point and
tried to speak to Mr Dealey but received no response. At around 6.30 – 6.40am, he
went to speak to the emergency response nurse, who was a few seconds away in
his office.
Prisons and Probation Ombudsman 11

[Page 16]
72. The HCA and emergency response nurse attended the cell and started banging on
the door and calling Mr Dealey’s name. At 6.44am, when they did not receive a
response, the nurse radioed a medical emergency ‘code blue’, indicating a life-
threatening situation. At interview, the nurse told us that healthcare staff did not
have keys to the cells on the inpatient unit, so could not enter until officers arrived to
unlock them.
Emergency response
73. A CM and officers responded quickly to the code blue call. They arrived at Mr
Dealey’s cell at 6.46am.
74. The CM tried to open the cell door but struggled because Mr Dealey’s body was
blocking it. He managed to squeeze into the cell and saw that Mr Dealey had a
ligature around his neck. An officer went into the cell and cut the ligature from
around Mr Dealey’s neck.
75. In his statement following Mr Dealey’s death, the CM noted that Mr Dealey showed
clear signs that he had been dead for some time. An officer began performing
cardiopulmonary resuscitation (CPR), with support from the emergency response
nurse and the HCA. Staff attached a defibrillator (a device that can give a high
energy shock to someone who is in cardiac arrest), and no shock was advised.
Staff continued with chest compressions until the ambulance crew arrived shortly
after 7.00am. At 7.29am, paramedics confirmed that Mr Dealey had died.
Contact with Mr Dealey’s Family
76. The prison’s family liaison officer (FLO) tried to contact Mr Dealey’s father on 1
August. The prison did not have a telephone number for Mr Dealey’s father and
searched Mr Dealey’s prison records for possible contact details. When they could
not find a correct telephone number, the FLO asked Leicestershire Police for help.
77. Leicestershire Police confirmed that Mr Dealey’s father still lived at the same
address, however the three further telephone numbers they supplied failed to
connect. The Coroner’s Office sent out a letter and an interim death certificate,
which Mr Dealey’s father received. Mr Dealey’s ex-partner contacted the prison
and gave the FLO the correct contact details for Mr Dealey’s father. The FLO was
able to make contact and let Mr Dealey’s father know about his death.
78. Swaleside contributed to the costs of Mr Dealey’s funeral, in line with Prison Service
instructions.
Support for prisoners and staff
79. A senior manager held a debrief with prison staff involved in the emergency
response. All staff were offered the support of the prison’s care team.
80. The senior manager posted notices informing other prisoners of Mr Dealey’s death
and offering support in case they had been adversely affected.
12 Prisons and Probation Ombudsman

[Page 17]
Post-mortem report
81. The post-mortem report concluded that the cause of Mr Dealey’s death was
hanging.
82. Toxicology tests found that amphetamine was present in Mr Dealey’s system,
however this was at a therapeutic level and did not contribute to his death. The
presence of amphetamine may be accounted for by the prescription of
lisdexamfetamine (for treatment of ADHD) which Mr Dealey was receiving.
Prisons and Probation Ombudsman 13

[Page 18]
Findings
83. Mr Dealey presented with complex issues including mental health concerns,
challenging behaviour, anxiety about his upcoming release and a history of self-
harm. He had been at Swaleside for ten months when he died. The investigation
found that both prison and mental health staff worked hard to understand and
support Mr Dealey. They were alerted to changes in his presentation, particularly
when he became increasingly paranoid or introverted and there was evidence of
swift referrals and personalised care and consideration.
Clinical care
84. The clinical reviewer concluded that overall, the clinical care provided to Mr Dealey
at Swaleside was equivalent to that which he could have expected to receive in the
community. However, she commented that Mr Dealey’s regular prison transfers
and long periods of seclusion meant that it was virtually impossible for staff to
provide good continuity of care between prisons. There are a range of factors that
result in prison transfers and that some of these cannot be avoided, however Mr
Dealey had complex needs that would have benefitted from more consistent care.
85. The clinical reviewer also found some specific areas of learning on the clinical care
provided to Mr Dealey at Swaleside.
86. Mr Dealey’s move to the inpatient unit was driven by the need to find somewhere
secure and appropriate for him to reside prior to his imminent release. However,
the clinical reviewer found that there was no clear care plan for Mr Dealey during
his time in the inpatient unit, with no clinical assessment or discharge planning to
ensure that he would be connected to local clinical services following release. We
make the following recommendations:
• The Head of Healthcare should develop and issue guidance to healthcare
staff which clarifies the process for inpatient unit referrals, to ensure that
admissions are clinically appropriate, and that clinical support is in place.
• The Head of Healthcare should ensure that individual care plans are created
and implemented for prisoners on the inpatient unit, to enable effective
management of health conditions and to prepare them for release (if
applicable).
Management of risk of suicide and self-harm
87. Prison Service Instruction (PSI) 64/2011 Safer Custody contains national
requirements on ACCT suicide and self-harm prevention procedures. It requires
that all staff who have contact with prisoners are aware of the risk factors and
triggers that might increase the risk of suicide and self-harm and take appropriate
action.
88. We have considered whether staff acted appropriately when they closed Mr
Dealey’s ACCT on 30 July, two days before his death. Decisions on whether to
close an ACCT are finely balanced, and we understand the challenges staff
14 Prisons and Probation Ombudsman

[Page 19]
encounter in assessing risks, particularly those presented by individuals with
complex needs and behaviours.
89. At interview, staff told us that during Mr Dealey’s final ACCT review on 30 July, he
said that he did not want to die. He said he wanted to be released from prison
(which was due to happen seven days later) and was making plans for his future.
Staff also told us that Mr Dealey’s presentation had improved since the ACCT was
first opened.
90. Two days earlier, on 28 July, Mr Dealey was presenting as extremely distressed.
He barricaded himself in his cell, attached makeshift armour to his torso and made
cuts to his arms. A CM recorded that “…it was evident Mr Dealey was suffering a
rapid deterioration in his mental health or he was experiencing drug psychosis. Mr
Dealey is massively paranoid about everyone and very anxious about his
impending release”. We consider that there were ongoing risk factors that had not
been reduced to the extent that justified ACCT closure, including self-harm, anxiety
about release and uncertainty around his accommodation on release. Before this
move onto the inpatient unit, Mr Dealey had withdrawn from the regime and self-
isolated for nearly two weeks and had a pattern of doing so.
91. Staff said that the fact that Mr Dealey would receive standard hourly welfare
observations in the inpatient unit was a factor in the decision to close his ACCT.
The observations in place on the inpatient unit and ACCT monitoring are not
comparable and the hourly checks should not have been relied upon as an
alternative method of monitoring Mr Dealey’s welfare.
92. Mr Dealey’s ongoing risks might have been managed by ACCT post-closure
monitoring, which is required by policy but was not utilised for Mr Dealey. This was
a missed opportunity to ensure that ending ACCT monitoring was appropriate.
We make the following recommendations:
• The Governor and Head of Healthcare should ensure that ACCT reviews
thoroughly assess the risk presented by individuals and only approve
closure where there is robust evidence that risks have reduced.
• The Governor and Head of Healthcare should remind all disciplinary and
healthcare staff of the difference between standard inpatient healthcare
observations and ACCT monitoring procedures, to ensure they are not
viewed as alternatives.
• The Governor and Head of Healthcare should remind disciplinary and
healthcare staff to complete the ACCT post-closure section, to ensure that
any ongoing risks are appropriately monitored, and the ACCT is reopened
where needed.
93. Mr Dealey self-isolated from 20 July 2021 until his death and told staff he intended
to do so until his release. He was highly anxious and paranoid about his safety
during this time. We requested a copy of Mr Dealey’s self-isolation record but did
not receive it. We accept that there was not much more they could reasonably
have done to assist him in the circumstances, and that Mr Dealey was being
supported by the ACCT process for a period, which will have helped to explore the
Prisons and Probation Ombudsman 15

[Page 20]
deterioration in his mental health. However, it is important that isolating prisoners
are monitored, to ensure support can be provided and risks can be managed.
94. We note the transfer requests made by Swaleside, in order to reduce the impact of
the transition for Mr Dealey, following his release. We commend the decision taken
by staff to move Mr Dealey to the inpatient unit rather than the Care and Separation
Unit (CSU). We consider that the CSU was not appropriate for Mr Dealey, who was
experiencing a mental health crisis. However, we also consider that the cell he was
moved to in the inpatient unit (cell number 5) was not appropriate either. The HCA
told us that he had reported his concerns about cell 5 in the inpatient unit. He was
concerned about the limitations on visual observations caused by the flap system
on the door, which was different to the standard hatch structure and provided little
view into the cell. We make the following recommendations:
• The Governor and Head of Healthcare should review the suitability of cell
5 in the inpatient unit for prisoners who are vulnerable.
Emergency response
95. Mr Dealey had been in the same position on the floor of his cell for several hours
before the HCA realised something was wrong. We understand from interviewing
him that he did not raise the alarm sooner because Mr Dealey was not on suicide
monitoring, and he thought he was just sleeping. In interview, he told us that
prisoners sleep in many different positions, including on the floor, and he did not
think it was unusual for Mr Dealey to be lying in this way, especially considering his
recent erratic behaviour.
96. The hourly checks undertaken by healthcare staff on the inpatient unit are basic
visual checks and are not comparable to the welfare checks completed under the
ACCT process. In contrast to the ACCT welfare checks, there is no guidance about
how these checks should be completed. We consider that some form of guidance
would be helpful to ensure that healthcare staff are clear of the purpose of the
check, able to spot potential issues and act appropriately if required.
97. We therefore recommend:
• The Head of healthcare should issue guidance to staff on the inpatient unit
that clearly explains the purpose of and expectations for hourly
observations.
Preparation for release from prison
98. Mr Dealey’s behaviour seemed to deteriorate in the weeks leading up to his
release, which he said he was anxious about. Mr Dealey’s offender supervisor had
not yet been able to secure him accommodation on release. In interview, staff told
us that because Swaleside is not a resettlement prison, and because Mr Dealey
was not local to the area, there were additional challenges with finding housing.
99. On 30 July, Swaleside sent urgent transfer requests to HMP Lowdham Grange and
HMP Leicester, which were the closest prisons to Mr Dealey’s home area that he
was due to be released to. They were keen to reduce the length of his journey
16 Prisons and Probation Ombudsman

[Page 21]
home, which they felt would help reduce his anxiety, the risks for his safety and
potentially his offending. They were not able to secure a transfer for him.
Substance misuse
100. Despite Mr Dealey’s documented substance misuse history and evidence that he
may have been in debt to other prisoners, he was not referred to the substance
misuse team until 11 July 2021. This was around 10 months after he had arrived
and weeks before his release. We interviewed a drug and alcohol practitioner at
the Forward Trust, and she told us that Mr Dealey was completely unknown to the
team until 30 July when she attended his ACCT case review. She told us she had
no idea why Mr Dealey was not referred to the Forward Trust.
101. This was a serious oversight during Mr Dealey’s initial screening. We found no
evidence that Mr Dealey’s presentation was linked to drug use, but this was a key
area of need that should have been supported during his time in prison.
• The Governor and Head of Healthcare should ensure that prisoners with a
history of substance misuse are referred to the substance misuse team on
arrival, to enable them to access the appropriate support.
Meaningful contact
102. One of the main aims of the Key Worker Scheme was to improve prisoner safety
through meaningful contact with a consistent member of staff. The scheme usually
requires 45 minutes of key work per prisoner per week, delivered by a named
officer. However, during the time that Mr Dealey was at Swaleside, COVID-19 was
having a significant impact on staffing and an Exceptional Delivery Model (EDM)
was in place. This EDM required governors to prioritise the most vulnerable
prisoners for key work.
103. Prison records show that no key worker sessions were offered to Mr Dealey for over
five months, between 28 September 2020 and 3 March 2021, due to the EDM. Mr
Dealey’s allocated key worker between March and July 2021 told us that instead of
structured and diarised sessions with Mr Dealey, he had to try to find extra time to
spend with him as and when he could. Mr Dealey was not assessed as vulnerable
in the context of the EDM on key work and so was not prioritised.
104. In interview, staff commented on how low staffing levels meant that they did not
always have the time to properly engage with Mr Dealey’s complex needs. A CM
told us that G wing staff were ‘run ragged’ and that this might have meant Mr
Dealey did not receive the level of support he needed or the one-to-one staff
attention that might have helped them to better understand his needs.
105. We do not consider that there was anything more the Governor could have done in
the circumstances. We note that the EDM was stood down in April 2022 and hope
that staffing numbers are increasing at Swaleside following the pandemic, which will
in turn improve safety.
Prisons and Probation Ombudsman 17

[Page 22]
Other learning
106. The attempt to resuscitate Mr Dealey, who was displaying clear signs of death, was
not in line with National Resuscitation Council guidelines. We recognise how
difficult it must be for officers and healthcare staff to respond in these
circumstances, but it is important that they are aware of the actions they should and
should not take.
Inquest
107. The inquest, held on 6 November 2023, concluded that Mr Dealey died by suicide.
18 Prisons and Probation Ombudsman

[Page 23]
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk