Ben Hyland

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Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Benjamin Hyland,
a prisoner at HMP Leeds, on 11
December 2022
A report by the Prisons and Probation Ombudsman
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© 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 HM Prison and Probation Service 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 Benjamin Hyland was found hanged in his cell at HMP Leeds on 11 December 2022.
He was 29 years old. I offer my condolences to his family and friends.
Mr Hyland died less than 48 hours after he arrived at Leeds. Although he had several
significant risk factors for suicide and self-harm and had been identified as at risk by the
police in his escort record, prison staff who interviewed him on his arrival chose not to start
Prison Service suicide and self-harm prevention procedures.
My office has shared concerns with the Governor of Leeds and the Prison Group Director
for Yorkshire about deficiencies in identifying and assessing risk factors for suicide and
self-harm in newly arrived prisoners and it is troubling that I have had to raise these issues
again in this report.
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 August 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
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Summary
Events
1. On 9 December 2022, Mr Benjamin Hyland was remanded to HMP Leeds, charged
with terrorism offences. Police staff recorded in his escort record that he was at risk
of suicide and self-harm and had banged his head on a door frame while in their
custody. They also disclosed that he had a history of depression and anxiety. It was
Mr Hyland’s first time in prison.
2. An officer interviewed Mr Hyland on his arrival at Leeds, recording that he said that
he banged his head out of “frustration” and had no thoughts of suicide and self-
harm. The officer told us that he chose not to start Prison Service suicide and self-
harm prevention procedures (known as ACCT) because Mr Hyland interacted well
and appeared settled. Other staff who spoke to Mr Hyland on his first night reached
similar conclusions.
3. Prison staff provisionally identified that Mr Hyland was at high risk of inflicting
violence on a cellmate and allocated him a single cell.
4. At 9.50am on 11 December, an officer unlocked Mr Hyland’s cell but could not see
him in the cell. She spoke to a colleague, who had not seen Mr Hyland. Despite the
uncertainty about Mr Hyland’s whereabouts, neither officer took any further action.
5. At 11.58am, the same officer unlocked Mr Hyland’s cell for lunch. This time, she
went into the cell and found him hanged behind the toilet privacy curtain. Prison and
healthcare staff began cardiopulmonary resuscitation, but shortly after they arrived,
paramedics confirmed that Mr Hyland had died.
Findings
Identifying the risk of suicide and self-harm
6. Mr Hyland had risk factors for suicide and self-harm when he arrived at Leeds and
had been highlighted as at heightened risk in his escort record. Nevertheless, staff
who interviewed him relied on his body language and what he said to them when
considering whether to start ACCT procedures, rather than considering his range of
risk factors. This is an issue that we have previously highlighted to the Prison Group
Director for Yorkshire.
Other learning
7. Mr Hyland’s cell sharing risk assessment was not reviewed on his second day in
custody, as it should have been. His potential to share a cell was not therefore
reconsidered. Sharing a cell might have been a protective factor against his risk of
suicide and self-harm.
8. On the morning of his death, wing staff did not check on Mr Hyland’s whereabouts
and wellbeing when they did not know where he was.
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9. Prison and healthcare staff should not have tried to resuscitate Mr Hyland when
rigor mortis was established.
Recommendations
• The Prison Group Director for Yorkshire should meet the Ombudsman to discuss
what action she intends to take to improve the identification of risk of suicide and
self-harm at HMP Leeds.
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The Investigation Process
10. On 11 December 2022, HM Prison and Probation Service notified us of Mr Hyland’s
death. The investigator issued notices to staff and prisoners at HMP Leeds
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
11. The investigator visited Leeds on 20 December 2022. He obtained copies of
relevant extracts from Mr Hyland’s prison records.
12. The investigator interviewed five members of staff from Leeds in person and by
video conference between 6 February and 1 March 2023.
13. NHS England commissioned a clinical reviewer to review Mr Hyland’s clinical care
at the prison. They jointly interviewed healthcare staff.
14. We informed HM Coroner for West Yorkshire (Eastern) of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
15. The Ombudsman’s family liaison officer contacted Mr Hyland’s sister and former
partner to explain the investigation and to ask if they had any matters they wanted
us to consider. Mr Hyland’s former partner asked why his head was bruised and
whether he should have been watched more closely in prison, given the impact this
might have had on his mental health. We have addressed these concerns in this
report.
16. We shared the initial report with HM Prison and Probation (HMPPS). They did not
identify any factual inaccuracies. We have attached their action plan as Annex 7.
17. We also shared the initial report with Mr Hyland’s sister and former partner. They
did not respond.
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Background Information
HMP Leeds
18. HMP Leeds is a local prison holding up to 1,218 men who are on remand, convicted
or sentenced. The prison serves the courts of West Yorkshire. Practice Plus Group
provides healthcare services, including mental health services. Midlands
Partnership Trust provides psychosocial substance misuse services.
HM Inspectorate of Prisons
19. The most recent full inspection of HMP Leeds was in June 2022. Inspectors
reported that the number of prisoners arriving each week was very high and that
reception processes were delivered well and early days work to support prisoners
was robust. They found that every new arrival had a custody care plan that aimed to
address previous weaknesses in assessing the risk of self-harm, which they
identified as an important improvement.
20. However, inspectors also reported that the induction process was not
comprehensive. They found that only 73% or prisoners surveyed said that they
received an induction and, of those, less than half found that it covered all that they
needed to know.
21. Inspectors reported that the number of deaths was high, including eight self-inflicted
deaths since their last inspection (in November 2019). However, they found that the
number of self-harm incidents was lower than at their last inspection and in similar
prisons.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to December 2020, the IMB reported
that they had raised concerns with the Governor about a first-time prisoner on a
long sentence who had died within five days of arrival to the prison. The IMB
reported that they were informed that such prisoners, and those on remand and
awaiting trials for serious offences, would be targeted by keyworkers to build a
relationship and to identify risks of self-harm.
Previous deaths at HMP Leeds
23. Mr Hyland was the twenty-eighth prisoner to die at Leeds since December 2019. Of
the previous deaths, eight were self-inflicted. Another prisoner took their life on the
same day as Mr Hyland, a few hours later. In four of the previous self-inflicted
deaths, we identified deficiencies in identifying and assessing risk factors for suicide
and self-harm in newly arrived prisoners.
24. In our report into the death of a prisoner in March 2022, we recommended that the
Prison Group Director (PGD) for Yorkshire write to the Ombudsman to set out what
action she had taken to satisfy herself that meaningful improvements had been
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made to the assessment and management of the risk of suicide and self-harm at
Leeds. The PGD responded in October 2022, saying that the national safety team
had completed a full review of reception and first night processes at Leeds,
including exploring how the risk of harm is recognised and shared. She identified
that a recent quality assurance of this process found that relevant information was
shared and that prisoners who had evident risks were being supported
appropriately.
25. Since Mr Hyland’s death, six more prisoners have taken their lives at Leeds
(including the prisoner who died on the same day). As a result, Leeds is receiving
additional support and monitoring from regional and national safety teams.
Assessment, Care in Custody and Teamwork
26. 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
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multi-disciplinary review meetings involving the prisoner.
27. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the support actions 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.
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Key Events
9 December 2022
28. On 9 December 2022, Mr Benjamin Hyland was remanded to HMP Leeds, charged
with multiple terrorism offences. It was his first time in prison. Police staff recorded
in the Person Escort Record (PER, which accompanies prisoners on all journeys
between police stations, courts and prisons to communicate risk factors) that Mr
Hyland was at risk of suicide and self-harm. They recorded that he had banged his
head on a door frame in police custody and had punched walls in the past. Police
staff also recorded that Mr Hyland had a history of depression and anxiety.
29. At around 3.50pm, Mr Hyland arrived at Leeds. An officer interviewed him in
Reception. He wrote on the PER that:
“[Mr Hyland] interacted well on reception interview – said the head banging
incident was borne out of frustration. Denies ever having had thoughts of
suicide/self-harm … ACCT not opened.”
30. The officer recorded on the prison case management system that Mr Hyland arrived
with a suicide and self-harm warning. He noted that he interviewed Mr Hyland “at
length” in Reception and that he “interacted well throughout”. The officer also
repeated his remarks from the PER about Mr Hyland’s motivation for banging his
head and denial of thoughts of suicide and self-harm.
31. The officer told us that Mr Hyland said that he banged his head because “them
bastards [referring to the police] were winding me up, they did my head in”. He said
that Mr Hyland appeared “very well” and was chatty, forthcoming with answers and
had good body language. The officer said that Mr Hyland’s main concern was that
he did not want to be on the same wing as a particular individual. (Mr Hyland did not
spend any time on the same wing as this prisoner.) The officer said that he chose
not to start ACCT procedures because of Mr Hyland’s “manner, his confidence, he
was very settled with his peers … very outgoing, very jovial”.
32. A nurse completed an initial health screen. She recorded that it was Mr Hyland’s
first time in prison. The nurse recorded that Mr Hyland had a wound on his head,
which he said was from banging his head on a door frame out of frustration. She
noted that Mr Hyland said that he had not done that before and that he denied
thoughts of suicide or self-harm. The nurse also recorded that Mr Hyland said that
he had anxiety and depression and felt that he should be on medication. She
referred him to the mental health team.
33. An officer completed a cell sharing risk assessment (designed to assess the risk of
violence a prisoner poses either to or from a cellmate) and recorded that the nature
of Mr Hyland’s offence meant that he was not suitable to share a cell. A Custodial
Manager (CM) reviewed the cell sharing risk assessment and recorded that a
second day assessment was required because information about previous
convictions from the Police National Computer was not available at the time. He
noted that Mr Hyland would be allocated a single cell as a high-risk prisoner on his
first night in custody. There is no record that the second day cell sharing risk
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assessment took place. Prison staff allocated Mr Hyland a single cell on D Wing
(the first night and induction unit).
34. An officer conducted a fist night interview. She recorded that Mr Hyland said that he
did not have any immediate concerns about being in prison for the first time. The
officer also noted that Mr Hyland did not report any current or historic thoughts of
suicide and self-harm, although he reported a history of anxiety and depression.
She noted that Mr Hyland engaged well and concluded that ACCT procedures were
not required as there were “no concerns”.
10 December 2022
35. The night patrol officer recorded that Mr Hyland slept through the night and that
there were no issues.
36. An officer conducted Mr Hyland’s induction, as part of a group of new prisoners.
She recorded that this included information about the prison regime, healthcare
services and support avenues.
11 December 2022
37. At 9.50am, the officer looked through the observation panel of Mr Hyland’s cell and
unlocked the door so that he could come out for domestic activities. She then spent
around two minutes standing on the wing landing with her back towards Mr
Hyland’s cell.
38. At 9.52am, the officer looked through the observation panel, opened the door and
put her head inside. She told us that she could not see Mr Hyland in the cell, so
she shouted in case he was on the toilet behind the privacy curtain at the back of
the cell. The officer said that there was no response. She then locked the cell and
walked further down the landing. The officer told us that she assumed that another
officer, who was helping her unlock the landing, had already unlocked Mr Hyland’s
cell.
39. The officer said that she then asked the other officer whether she had unlocked Mr
Hyland’s cell, and that the other officer could not remember. The other officer told
us that the first officer asked her if Mr Hyland had come out of his cell, and that she
said that she did not know as she had not been looking in that direction. Neither
officer returned to check Mr Hyland’s cell.
40. At 11.57am, the first officer began unlocking cells on the landing for lunch. At
11.58am, she arrived at Mr Hyland’s cell and looked through the observation panel
The officer then spoke to the other officer, who was on the landing near her. She
told us that she asked the other officer whether anyone had moved from the cell
that morning, and that the other officer said “no”.
41. Around 20 seconds after arriving, the officer unlocked the cell. She found Mr Hyland
hanged from a ligature behind the toilet privacy screen. The other officer cut the
ligature and radioed a medical emergency code blue, indicating a life-threatening
situation. The control room operator telephoned for an ambulance.
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42. An officer began cardiopulmonary resuscitation (CPR) on rotation with colleagues.
At 12.00pm, two nurses arrived at the cell and took over the resuscitation. A nurse
recorded that rigor mortis appeared to be present around Mr Hyland’s mouth.
43. At 12.10pm, paramedics arrived at Mr Hyland’s cell. At 12.11pm, they stopped the
resuscitation and confirmed that Mr Hyland had died.
44. Mr Hyland left a note in his cell addressed to his son, the content of which appeared
to indicate that he intended to take his life.
Contact with Mr Hyland’s family
45. Mr Hyland named his solicitor as his next of kin when he arrived at Leeds. Police
officers subsequently identified Mr Hyland’s former partner and notified her of his
death.
46. A Supervising Officer (SO), the prison’s family liaison officer, told us that the police
asked prison staff to wait before they contacted Mr Hyland’s family. He said that he
was unsure why this was but thought that it might relate to the nature of Mr Hyland’s
offence.
47. On 15 December, the family liaison officer was given permission to contact Mr
Hyland’s family, and subsequently spoke to his sister to explain the sequence of
events and how prison staff could support the family in the upcoming weeks,
including with funeral costs. He also contacted Mr Hyland’s former partner.
Support for prisoners and staff
48. After Mr Hyland’s death, a CM 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.
49. Prison staff checked the welfare of prisoners who lived in cells near to Mr Hyland.
They conducted additional case reviews for all prisoners who were being monitored
under ACCT procedures. On 12 December, Samaritans attended Leeds to help
Listeners provide support to those prisoners who had been affected following two
self-inflicted deaths on the same day.
Post-mortem report
50. A post-mortem examination confirmed that Mr Hyland died of hanging. The post-
mortem report identified a partially healed superficial abrasion on the centre of Mr
Hyland’s forehead near the hairline. The pathologist recorded that this was in
keeping with a reported self-inflicted injury.
51. It is likely that this is the bruising to which Mr Hyland’s former partner referred in her
correspondence with us, and which was seemingly caused by him banging his head
in police custody.
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Findings
Identifying the risk of suicide and self-harm
52. PSI 64/2011, which governs ACCT suicide and self-harm prevention procedures,
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. We have considered whether staff at Leeds should have
identified Mr Hyland as at risk and begun ACCT procedures to support him.
53. Mr Hyland had some significant risk factors for suicide and self-harm when he
arrived at Leeds. It was his first time in prison. He was charged with multiple
terrorism offences and likely to receive a long sentence if found guilty. He had
harmed himself in police custody and had identified a history of depression and
anxiety. PSI 64/2011 also recognises that prisoners are at increased risk of suicide
and self-harm in their first days in custody.
54. The PER identified these risk factors and highlighted that Mr Hyland was at risk of
suicide and self-harm. The reception officer told us that he chose not to start ACCT
procedures because Mr Hyland denied having any further thoughts of harming
himself and that his manner indicated that he was not at risk. The officer who
conducted the first night interview also concluded that there were no concerns
about Mr Hyland’s risk.
55. We have said repeatedly in our reports that staff should consider an individual’s
range of risk factors, rather than just what they say or how they present. Mr Hyland
was identified as at risk in police custody and harmed himself the day before he
was sent to prison, yet staff chose not to start ACCT procedures.
56. We have previously expressed concerns about staff identifying the risk of suicide
and self-harm at Leeds. In September 2022, we made a recommendation to the
Prison Group Director (PGD) for Yorkshire asking her to set out the actions she
intended to take in response to our concerns. The PGD responded in October 2022,
saying that the national safety team had completed a full review of reception and
first night processes at Leeds, including exploring how the risk of harm is
recognised and shared. She identified that a recent quality assurance of this
process found that relevant information was shared and that prisoners who had
evident risks were being supported appropriately. Nevertheless, this investigation
has again highlighted poor risk assessment. We make the following
recommendation:
The Prison Group Director for Yorkshire should meet the Ombudsman to
discuss what action she intends to take to improve the identification of risk of
suicide and self-harm at HMP Leeds.
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Governor to note
Cell sharing risk assessment
57. x PSI 20/2015 instructs that the cell sharing risk assessment must be completed as
part of the reception process when prisoners are first received into custody. It states
that “if the Police National Computer record is not available on the first day in
custody, this must be checked so that the risk assessment is finalised the next
working day”.
58. Mr Hyland did not receive a ‘Day 2’ cell sharing risk assessment and therefore
remained provisionally high risk for cell sharing and in a single cell. We do not know
what the outcome of a ‘Day 2’ risk assessment might have been and it is possible
that it might have concluded that he could share a cell. Sharing a cell is usually a
protective factor for those at risk of suicide and self-harm and it is important that
assessments are completed promptly and appropriately.
Events of 11 December
59. The officer could not see Mr Hyland in his cell when she unlocked it at 9.50am.
Although she spoke to another officer about Mr Hyland’s potential movements, it is
apparent from both officers’ accounts of this conversation that they were not certain
where he was at the time. Neither took any further action to establish where Mr
Hyland was or to check his wellbeing.
60. Mr Hyland was found hanged behind the privacy curtain in his cell a little over two
hours later, with rigor mortis beginning to establish. While we cannot be sure, it is
possible that he was in this position when the officer looked into the cell earlier in
the morning. A more thorough earlier check on his whereabouts and welfare might
have led to a different outcome.
Cardiopulmonary resuscitation
61. European Resuscitation Council Guidelines 2015 state that, “Resuscitation is
inappropriate and should not be provided when there is clear evidence that it will be
futile”. A nurse identified the presence of rigor mortis and told us that she did not
consider stopping the resuscitation as she thought that it had to continue until
paramedics arrived. She said that she was not aware of the guidelines about when
not to perform cardiopulmonary resuscitation.
62. The clinical reviewer highlighted that rigor mortis is a sign of irreversible death and
that its presence means that resuscitation should not be attempted.
Inquest
63. The inquest into Mr Hyland’s death concluded on 10 June 2024, and recorded a
verdict of hanging.
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