Pearce, Luke

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Luke Pearce, a
prisoner at HMP/YOI Swinfen Hall,
on 6 April 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
© Crown copyright, 2024
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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 Luke Pearce was found hanging in his cell on 6 April 2023, at HMP/YOI Swinfen Hall.
Staff tried to resuscitate him but were unsuccessful. Mr Pearce was 21 years old. I offer
my condolences to his family and friends. Mr Pearce was the first prisoner to take his life
at Swinfen Hall in almost six years.
Mr Pearce gave no indication to staff that he was at risk of suicide or self-harm in the
months leading up to his death. I am satisfied that staff could not have foreseen his
actions.
When staff saw Mr Pearce hanging, there was a delay in them removing the ligature and
starting CPR. We cannot say whether the delay made a difference to the outcome for Mr
Pearce, but we know that in a medical emergency, any delay could be critical. The
Governor has told us that staff have been reminded of their responsibilities during medical
emergencies.
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 January 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
Summary
Events
1. In January 2019, Mr Luke Pearce, then aged 17, was sentenced to life
imprisonment for murder. He was moved to HMP/YOI Swinfen Hall on 30 April.
2. Staff started suicide and self-harm prevention procedures (known as ACCT) for Mr
Pearce on two occasions. The first was when he arrived at Swinfen Hall as staff
were concerned about Mr Pearce’s young age and long sentence. The second was
in July 2020, when Mr Pearce told staff that he was going to hang himself. Later
that day, he told staff that he had only said that to annoy them as he was frustrated
with the COVID-19 restrictions. There were subsequently no concerns that Mr
Pearce was at risk of suicide or self-harm.
3. On 22 April 2022, a prison chaplain saw Mr Pearce following the news that his
grandmother had died. Mr Pearce was close to his grandmother and was upset.
The chaplain offered support and arranged for Mr Pearce to watch a recording of
his grandmother’s funeral.
4. Shortly after 5.30am on 6 April 2023, during a routine check, an officer found that
Mr Pearce had covered the observation panel in his cell door. The officer called to
Mr Pearce but got no response. He looked through the crack of the door and saw
Mr Pearce with a ligature around his neck. The officer radioed for assistance. An
Operational Support Grade (OSG) attended and briefly entered Mr Pearce’s cell
before coming out again.
5. When another officer attended, the first officer and OSG told her that she should not
enter the cell as it was a crime scene. She contacted a custodial manager for
permission to go in and then cut the ligature and lowered Mr Pearce to the floor.
The officer and OSG waited outside and did not assist. At 5.40am, more staff
arrived and the control room staff called an ambulance. Staff started CPR at
5.42am. Ambulance paramedics arrived at 5.59am and took over CPR. At 6.30am,
they pronounced that Mr Pearce had died.
6. Mr Pearce left a note addressed to his mother, in which he apologised and said he
was not coping with the pain he was feeling. He said that ever since his
grandmother died, he had not felt the same. He said he was so far from home and
did not get to see anyone.
Findings
7. Mr Pearce gave no indication to staff that he was at risk of suicide or self-harm in
the months leading up to his death. We are satisfied that staff could not have
foreseen his actions.
8. There was a delay in staff entering the cell, removing the ligature and starting CPR.
We cannot say whether the delay affected the outcome. The Governor told us that
he had issued a notice to staff setting out the correct process to follow during a
medical emergency. However, the officer who found Mr Pearce was clearly still
unaware of the correct process when interviewed which indicates that the notice to
Prisons and Probation Ombudsman 1
staff was ineffective. Staff wrongly believing that they are unable to enter a cell
alone during a medical emergency is an issue we see time and again in our
investigations. HMPPS should consider reviewing their routine training of staff to
ensure that this is adequately covered.
Recommendations
 The Executive Director for Transforming Delivery and the Operational Security
Group Director should ensure that relevant training and guidance equips staff to
understand when and how to enter a cell in a medical emergency, including the
priority that must be given to acting quickly to preserve life, whilst maintaining their
own safety.
2 Prisons and Probation Ombudsman
The Investigation Process
9. HMPPS notified us of Mr Pearce’s death on 6 April 2023.
10. The investigator issued notices to staff and prisoners at HMP/YOI Swinfen Hall
informing them of the investigation and asking anyone with relevant information to
contact him. Three prisoners contacted the investigator.
11. The investigator visited Swinfen Hall on 9 June 2023. He obtained copies of
relevant extracts from Mr Pearce’s prison and medical records.
12. The investigator interviewed three members of staff and three prisoners at Swinfen
Hall on 9 June. The remaining two interviews took place over telephone on 24 and
25 August 2023.
13. NHS England commissioned an independent clinical reviewer to review Mr Pearce’s
clinical care at the prison.
14. We informed HM Coroner for South Yorkshire East of the investigation. He gave us
Mr Pearce’s cause of death. We have sent the Coroner a copy of this report.
15. The Ombudsman’s family liaison officer contacted Mr Pearce’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond.
Prisons and Probation Ombudsman 3
Background Information
HMP/YOI Swinfen Hall
16. HMP/YOI Swinfen Hall holds around 600 remanded and sentenced young adult
men aged 18 to 28 across nine wings. Healthcare services are provided by Practice
Plus Group (PPG) and the mental health services are provided by Midlands
Partnership NHS Foundation Trust (MPFT). Healthcare services are available from
7.30am to 7.30pm Monday to Thursday, and 7.30am to 5.30pm Friday to Sunday.
HM Inspectorate of Prisons
17. HM Inspectorate of Prisons carried out an inspection of Swinfen Hall in June and
July 2021. Although levels of self-harm had reduced, they were still higher than
similar prisons, and self-harm rates among the young adult population remained
higher than their older peers. Inspectors found the Safer Prisons Team provided
good support for prisoners being supported through the ACCT process. Progress in
developing positive staff-prisoner relationships had stalled in the last year and the
delivery of quality key work was too limited. Security was well managed and had a
good flow of intelligence, which was analysed swiftly by the newly developed
regional intelligence team. The prison had worked hard to reduce the availability of
illicit substances.
Independent Monitoring Board
18. 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 the most recent published report for the year to 30 April 2022, the
Board noted that a disproportionate number of self-harm incidents arose from a
small number of individuals experiencing crisis. Key worker sessions had been ad
hoc with high numbers being provided in January and February, then trailing off
slightly in the following months. The Board also noted that intelligence-led searches
had resulted in an increase in drug-related finds.
Previous deaths at HMP/YOI Swinfen Hall
19. Mr Pearce was the first prisoner at Swinfen Hall to die since May 2017.
Key worker scheme
20. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners and helping people
settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
 All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
4 Prisons and Probation Ombudsman
 Key workers must have completed the required training.
 Governors in the male closed estate must ensure that time is made available
for an average of 45 minutes per prisoner per week for delivery of the key
worker role, which includes individual time with each prisoner.
21. Within this allocated time, key workers can vary individual sessions in order to
provide a responsive service, reflecting individual need and stage in the sentence.
A key worker session can consist of a structured interview or a range of activities
such as attending an ACCT review, meeting family during a visit or engaging in
conversation during an activity to build relationships.
22. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
Prisons and Probation Ombudsman 5
Key Events
23. On 27 August 2018, Mr Luke Pearce, then aged 17, was remanded in prison,
charged with murder, and sent to HMP/YOI Feltham. It was his first time in prison.
In January 2019, he was sentenced to life imprisonment with a minimum term of 17
years.
24. On 30 April, Mr Pearce was moved to HMP/YOI Swinfen Hall. Staff started suicide
and self-harm prevention procedures (known as ACCT) because they were
concerned about Mr Pearce’s young age (he had recently turned 18), the length of
his sentence and that he said he punched walls when he got angry. The next day, a
mental health assessment found no issues and Mr Pearce said he had family
support and no concerns, so staff stopped ACCT procedures.
25. On 29 May, Mr Pearce was caught in possession of fermenting liquid (which as well
as being drunk as alcohol, can also be used to extract psychoactive substances
(PS) that have been impregnated into paper or clothing). He told staff that he was
being bullied but refused to give names.
26. On 2 April 2020, a letter addressed to Mr Pearce tested positive for PS.
27. On 10 July, Mr Pearce told prison staff that he was “going to string up”. Staff started
ACCT procedures. At the ACCT case review later that day, Mr Pearce told staff that
he said he was going to hang himself to annoy staff as he felt frustrated about the
COVID-19 regime and lack of visits. He also said he had felt disrespected by staff
as when he rang his emergency cell bell to ask for paper so he could write to his
parents, they told him it was not an emergency. Staff discussed with Mr Pearce how
he could manage his anger and frustration and stopped ACCT procedures.
28. On 1 January 2022, Mr Pearce assaulted another prisoner. Three days later he
assaulted an officer. He was managed using a Challenge, Support and Intervention
Plan (CSIP – a process to manage prisoners who are violent) and spent a period of
time in the Care and Separation Unit (CSU, the segregation unit).
29. On 17 January, Mr Pearce was moved from the CSU to G Wing.
30. On 30 January, an officer noted that he discussed Mr Pearce’s recent poor
behaviour with him during a key worker session. This was his last recorded key
worker session.
31. On 22 April, a prison chaplain saw Mr Pearce following his grandmother’s death (his
family had broken the news to him). Mr Pearce was close to his grandmother and
was upset. The chaplain offered support.
32. On 18 May, Mr Pearce attended the chaplaincy to view a recording of his
grandmother's funeral (which took place in Finland).
33. In May and July, Mr Pearce assaulted the same prisoner twice. This prisoner had
previously been on Mr Pearce’s wing but had moved to F Wing. Intelligence
indicated that the prisoner had a history of being assaulted for being in debt.
34. On 22 March 2023, staff smelled cannabis smoke coming from Mr Pearce’s cell.
6 Prisons and Probation Ombudsman
35. All prisoners’ telephone calls, except those that are legally privileged, are recorded,
and prison staff listen to a random sample. The investigator listened to the calls Mr
Pearce made from his in-cell telephone in the two weeks before his death.
36. Between 25 March and 4 April, Mr Pearce made several calls to friends during
which they talked about the receipt and movement of money. He made no calls to
his family. During one call, Mr Pearce said that he owed somebody £350 and that
he would give them goods amounting to £250 so he would owe £100. He did not
appear to be concerned about this.
37. At around 8.00pm on 5 April, Mr Pearce made his last telephone call to a friend.
They spoke for almost an hour about times they spent together, people they knew,
prison life and some frustrations. Mr Pearce said his 22nd birthday was coming up.
Mr Pearce complained about losing contact with some of his friends, when they had
changed their telephone numbers and not told him. They discussed selling vape
capsules for ‘food’ (a slang term for drugs) but did not discuss any money issues.
Nothing was said during the calls that indicated that Mr Pearce was distressed or
contemplating suicide.
Events of 6 April 2023
38. At 5.34am on 6 April, during a routine check, Officer A found that Mr Pearce had
covered his observation panel with a cloth. In his statement, Officer A said that he
knocked on the door several times and then switched the cell light on and off while
calling out to Mr Pearce but got no response.
39. Officer A looked through the crack of the door and saw Mr Pearce with a ligature
around his neck with his body hanging above his bed. The ligature was made from
a dressing gown cord and shoelaces. Mr Pearce had attached the ligature to a vent
and his notice board.
40. Officer A radioed, “Urgent message. Immediate threat to life.” The control room said
that staff were on their way and asked for more information. Officer A told them that
there appeared to be a ligature around the cell occupant’s neck.
41. At 5.36am, an Operational Support Grade (OSG) attended. He looked through the
crack of the door and could see what he thought was Mr Pearce’s torso, with
mottled flesh. The OSG told the investigator that he immediately turned to Officer A
and said that they needed to go into Mr Pearce’s cell. CCTV footage shows that at
5.37am, the OSG entered the cell briefly and then came out again. Officer A
remained in the doorway of the cell.
42. At 5.38am, Officer B attended. She told the investigator that Officer A and OSG told
her that she should not enter the cell as it was a crime scene. She thought this was
incorrect and radioed the custodial manager (CM) to check and get authorisation to
cut Mr Pearce down. The CM gave authorisation.
43. Officer B went into Mr Pearce’s cell. Officer B said she could not find a pulse for Mr
Pearce, and he had mottled legs and arms, but was still warm.
44. Officer B cut the ligature around Mr Pearce’s neck and lowered him to the floor. She
told the investigator that she struggled to lift him down by herself. Officer A and the
Prisons and Probation Ombudsman 7
OSG did not assist her. She said that by the time she got Mr Pearce to the floor,
she heard the CM arrive. CCTV footage shows that he arrived at 5.40am, along
with Officer C. At 5.40am, control room staff called an ambulance.
45. The CM found that Mr Pearce’s skin was still soft and warm. Body Worn Video
Camera (BWVC) footage shows that he started CPR at 5.42am. Officer C collected
a defibrillator. Officer B took over chest compressions while the CM set up the
defibrillator.
46. At 5.44am, the defibrillator indicated no shockable heart rhythm. The CM delivered
chest compressions, and Officer B delivered rescue breaths. This continued until
the ambulance staff arrived at the cell at 5.59am. Paramedics then took over CPR.
47. At 6.30am, paramedics stopped CPR and confirmed that Mr Pearce had died.
48. Mr Pearce left a note in his cell addressed to his mother, in which he apologised
and said he was not coping with the pain he was feeling. He said that ever since his
grandmother died, he had not felt the same. He said he was so far from home and
did not get to see anyone.
Contact with Mr Pearce’s family
49. On 6 April, the prison appointed a family liaison officer (FLO). Mr Pearce’s mother
lived in Southampton so the FLO asked staff at HMP Winchester to assist.
50. A FLO from HMP Winchester and the regional safety lead visited Mr Pearce’s
mother and told her of Mr Pearce’s death.
51. The Head of Safety at Swinfen Hall contacted Mr Pearce’s stepfather by telephone
and informed him that Mr Pearce had died.
52. The FLO kept in contact with Mr Pearce’s family over the following days, offering
support and advice.
53. Mr Pearce’s workshop instructor had a close relationship with Mr Pearce and was a
pallbearer at his funeral. The prison contributed to the costs of Mr Pearce’s funeral
in line with national policy.
Support for prisoners and staff
54. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
55. After Mr Pearce’s death, a prison manager individually debriefed the staff involved
in the emergency response to ensure they had the opportunity to discuss any
issues arising, and to offer support. The staff care team also offered support.
8 Prisons and Probation Ombudsman
56. The prison posted notices informing other prisoners of Mr Pearce’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Pearce’s death.
Post-mortem report
57. No post-mortem was undertaken. The Coroner recorded Mr Pearce’s cause of
death as hanging.
Prisons and Probation Ombudsman 9
Findings
Assessment of Mr Pearce’s risk of suicide and self-harm
58. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that should be followed when a prisoner is identified as being at risk of
suicide and self-harm. It sets out the risk factors and triggers that could indicate
increased risk.
59. Staff supported Mr Pearce using ACCT on two occasions. When he arrived at
Swinfen Hall in April 2019 and in July 2020. Mr Pearce did not require the support
of ACCT after that.
60. In the lead up to his death, Mr Pearce gave no indication to staff that he was at risk
of suicide or self-harm. We are satisfied that staff could not have foreseen Mr
Pearce’s death.
61. Mr Pearce’s grandmother died in April 2022. The approaching anniversary of her
death could have been a factor in Mr Pearce’s decision to end his life. We are
satisfied that the prison provided appropriate support to Mr Pearce when his
grandmother died and that he gave no indication that he was struggling in the lead
up to the anniversary of her death.
62. There were some indicators that Mr Pearce might have been involved in the drugs
trade at Swinfen Hall. He discussed the movement of money during telephone calls
to friends and selling vapes for drugs, he mentioned that he owed money, and he
assaulted another prisoner who was known to be in debt. Two weeks before Mr
Pearce died, staff smelt cannabis smoke coming from his cell.
63. Another prisoner told us that he had heard that Mr Pearce was in debt for drugs.
However, other prisoners and staff told us that they were not aware of any debts or
other issues with Mr Pearce. Even if Mr Pearce was in debt, we found no evidence
that he was being threatened or that it was causing Mr Pearce distress. It would
appear from his telephone calls that he had access to funds so there was no
indication that he was unable to repay his debt.
64. There was no indication that Mr Pearce was at increased risk of suicide and self-
harm due to his possible involvement in the drugs trade at Swinfen Hall.
Emergency response
65. PSI 03/2013 Medical Emergency Response Codes says that all Governors should
have a Medical Emergency Response Code protocol in place that enables staff to
quickly convey the nature of the medical emergency. This should ensure that staff
take the relevant equipment to the incident and that an ambulance is called
immediately. Swinfen Hall uses the emergency codes ‘code blue’ (to indicate
unconsciousness) and ‘code red’ (to indicate heavy bleeding).
66. When Officer A found Mr Pearce hanging at 5.36am on 6 April, he used his radio to
say that there was an immediate threat to life, but he did not call a code blue. When
10 Prisons and Probation Ombudsman
the control room asked what was wrong, he said that the cell occupant had
ligatured. He remained outside the cell while waiting for other staff to arrive.
67. PSI 24/2011, Management and Security of Nights, says that under normal
circumstances authority to unlock a cell at night must be given by the night orderly
officer and no cell will be opened unless two or three (subject to local risk
assessment procedures) members of staff are present, one of whom should be the
night orderly officer. However, it says that the preservation of life must take
precedence over usual arrangements for opening cells and where there is, or
appears to be, immediate danger to life, cells may be unlocked without the authority
of the night orderly officer and an individual member of staff can enter the cell on
their own. Staff should do a dynamic risk assessment to decide whether it is safe to
enter a cell alone.
68. Officer A told the investigator that he had been trained to wait for additional staff
support and could only go into a cell at night if he felt it was urgent. Once the OSG
arrived, Officer A still did not go in. It was not until 5.38am, that Officer B went in
and cut the ligature.
69. It is not possible to say whether the delay in the emergency response impacted on
the outcome for Mr Pearce, but we know that in a medical emergency, a delay of a
few minutes could be critical. Officer A was very new to the service and was
inexperienced. The Governor told us that the delay in the emergency response had
been identified as an area for learning and that measures had been taken to remind
staff of their responsibilities during medical emergencies.
70. On 27 April, Swinfen Hall issued a notice to staff setting out the correct procedures
for calling a medical emergency and entering a cell during night state. However, at
his interview in June, Officer A still maintained that he could not go into a cell at
night without three staff present. This demonstrates that notices to staff are not
effective ways to communicate correct practices or change staff behaviours. Staff
not understanding that they can enter cells alone, or with fewer staff than standard,
in order to preserve life is an issue we see time and time again in our investigations.
We recommend:
The Executive Director for Transforming Delivery and the Operational
Security Group Director should ensure that relevant training and guidance
equips staff to understand when and how to enter a cell in a medical
emergency, including the priority that must be given to acting quickly to
preserve life, whilst maintaining their own safety.
Location
71. In his note to his mother, Mr Pearce said that he was far from home and did not get
to see anyone. Mr Pearce’s family lives in Hampshire but they had visited him at
Swinfen Hall up to August 2022. Other prisoners suggested that Mr Pearce had
asked his family to stop visiting him because that might help him get moved to a
prison closer to them.
72. Mr Pearce had received his category C status and staff were exploring the
possibility of him moving to a prison closer to his family home. However, Mr Pearce
was serving a life sentence and still had a long time to serve. It would have been
Prisons and Probation Ombudsman 11
challenging at that stage of his sentence for him to fit the criteria for the category C
prisons located close to his family’s home.
Key work
73. All prisoners in the male closed estate are supposed to receive weekly key worker
sessions. However, Mr Pearce did not receive any key worker sessions after
January 2022. He had received regular key worker sessions up to June 2021 but
none in the 14 months before his death.
74. The Governor of Swinfen Hall told the investigator that delivering key worker
sessions to prisoners had been difficult due to staffing levels. There was a high staff
attrition rate and reduced staffing meant that running the prison regime had had to
be prioritised over the routine delivery of key work. Key worker sessions were
delivered only to prisoners in vulnerable groups (which Mr Pearce was not).
75. The Governor said a lot of work had been done to try to improve the retention of
staff, by creating a more supportive environment. This was starting to have an
impact as the attrition rate had fallen from 26% to under 10% and there were now
139 officers in post against a target of 146.
76. It is difficult to say whether Mr Pearce would have shared how he was feeling with a
key worker. Mr Pearce’s workshop instructor, who had a close relationship with Mr
Pearce, said that Mr Pearce did not show his emotions. It is possible therefore that
key worker sessions would have made no difference to the outcome for Mr Pearce.
Nevertheless, key worker sessions are important in establishing good relationships
between prisoners and staff and should be resumed as soon as staffing levels
allow.
Clinical care
77. Mr Pearce had little contact with healthcare staff during his time at Swinfen Hall.
The clinical reviewer concluded that the care Mr Pearce received at the prison was
equivalent to that which he could have expected to receive in the community.
Good practice
78. We consider that the actions of Officer B showed considerable professionalism.
Despite reluctance from her colleagues already at the cell, she went in, cut the
ligature and single-handedly supported Mr Pearce to the floor. The Governor should
commend her for her actions.
Inquest
79. The inquest, held from 14 to 16 May 2024, concluded that Mr Pearce died by
suicide.
12 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