Benjamin Donnelly

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Independent investigation into
the death of Mr Benjamin
Donnelly, a prisoner at HMP
Cardiff, on 20 December 2022
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
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© Crown copyright, 2025
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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 Benjamin Donnelly was found hanged in the F Wing laundry at HMP Cardiff on 14
December 2022. He died a week later in hospital. He was 39 years old. I offer my
condolences to Mr Donnelly’s family and friends.
There were seven self-inflicted deaths at Cardiff in the three years before Mr Donnelly
died.
The day before he was found hanged, Mr Donnelly was sentenced via video link to an
extended determinate sentence of five years. He had been in prison for short periods
before for similar offences and he was not expecting such a long sentence. His telephone
calls that day showed his shock and distress at the outcome. We found no evidence that
Mr Donnelly was suicidal before he was sentenced.
In March 2021, the Director General of HMPPS required all prisons to introduce local
guidance to ensure prisoners attending court via video link are adequately risk assessed.
Mr Donnelly’s is the fifth death since then in which my office has found that the relevant
prison did not have a local policy as required, and that there was none or inadequate risk
assessment of prisoners following video court appearances. I make a national
recommendation to ensure consistency across all prisons.
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 June 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
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Summary
Events
1. Mr Benjamin Donnelly had a history of anxiety, depression, alcohol misuse and
substance misuse. He had a number of previous convictions for violence against
family members and partners and had served several short prison sentences.
2. On 15 October 2022, Mr Donnelly was arrested for assaulting his mother at her
home while under the influence of alcohol and drugs. He appeared at Cardiff
Magistrates Court on 17 October and was remanded to HMP Cardiff the same day.
3. On 18 October, the prison identified Mr Donnelly as a domestic violence perpetrator
and therefore suitable for offence-related monitoring of his prison telephone calls
and mail.
4. On 13 November, Mr Donnelly pleaded guilty and was convicted at Cardiff Crown
Court. On 18 November, a prison offender manager reviewed the monitoring of Mr
Donnelly’s telephone calls and mail and decided monitoring should stop.
5. On 13 December, Mr Donnelly appeared at Cardiff Crown Court via video link. He
was sentenced to an extended determinate sentence of five years, comprising four
years in custody and a year on licence. This meant that Mr Donnelly would be able
to apply to the Parole Board for release two thirds of the way through his four-year
custodial term.
6. An officer was present when Mr Donnelly was sentenced and took him back to his
cell afterwards. He said Mr Donnelly was quieter than usual but otherwise himself.
He told the wing movements officer that Mr Donnelly had been sentenced. Wing
staff did not make a subsequent welfare check on Mr Donnelly.
7. That afternoon Mr Donnelly made several calls to his aunt, mother and partner that
indicated he was extremely distressed by the length of his sentence and media
reporting of his case. He referred to ending his life more than once. Mr Donnelly’s
cellmate and a close friend were aware he was very distressed but did not think he
was at risk of harming himself and so did not tell staff.
8. The next morning at 7.51am, Mr Donnelly took a sheet and chair from his cell to the
prison laundry and hanged himself. His cellmate and close friend found him 15
minutes later and raised the alarm. Officers and nurses arrived promptly and
administered cardio-pulmonary resuscitation. Paramedics arrived 25 minutes later
and were able to restart Mr Donnelly’s heart. He was taken to hospital and put on
life support.
9. On 20 December, the hospital confirmed Mr Donnelly would not recover, life
support was withdrawn, and he died.
Findings
10. Although Mr Donnelly had some risk factors for suicide and self-harm, including a
history of domestic violence and substance misuse, we have found no evidence
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that he was in crisis until after he received a much longer than expected sentence
on 13 December.
11. We do not consider that Mr Donnelly was adequately risk assessed following his
court appearance, however we have seen no evidence to indicate that staff were
made aware of his increased risk on 13 December or had reason to initiate suicide
and self-harm support and monitoring.
12. When Mr Donnelly died there was no standard procedure at Cardiff for prison staff
to risk assess prisoners after video link court appearances. This was not in line with
national guidance to all prisons issued in 2021.
13. Mr Donnelly’s death is the fifth self-inflicted death since March 2021 in which we
have found that the relevant prison did not have the required procedure to risk
assess prisoners following a video court appearance. This needs to be addressed.
14. Staff did not call a code blue when they found Mr Donnelly, but this did not lead to a
delay in him receiving emergency aid from staff. There was a small delay before
staff on scene asked the control room officer to ring an ambulance.
15. Cardiff’s orderly officers (the managers responsible for running the prison day to
day) carry a mobile phone to aid communication with the ambulance service during
emergencies. Unfortunately, the phone did not work in this case which resulted in a
delay of seven minutes before the 999 operator dispatched an ambulance. This has
not been an issue in previous investigations and appears to have been a result of
the unusual location of Mr Donnelly’s death rather than a systemic problem. In both
calls to the 999 operator, prison staff were unable to tell them whether Mr Donnelly
was breathing. This is essential information they need before an ambulance is
despatched, although we accept in the second call an ambulance was dispatched
after two minutes.
Recommendations
• The Director General of HMPPS should issue guidance to ensure that prisons
are clear about their responsibilities to ensure that prisoners who attend court by
video link are assessed for their risk of suicide and self-harm and seen by
healthcare staff in the same way as prisoners attending court in person. Prison
Group Directors should monitor compliance with this guidance.
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The Investigation Process
16. HMPPS notified us of Mr Donnelly’s death on 20 December 2022.
17. The investigator issued notices to staff and prisoners at HMP Cardiff informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
18. The investigator obtained copies of relevant extracts from Mr Donnelly’s prison and
medical records. She obtained CCTV, radio traffic and body worn camera footage
from 14 December and listened to Mr Donnelly’s prison telephone calls from 13
December. The investigator obtained further information from Wales Ambulance
Service.
19. The investigator interviewed seven members of staff and two prisoners between 26
January and 2 March 2023.
20. Health Inspectorate Wales (HIW) commissioned a clinical reviewer to review Mr
Donnelly’s clinical care at the prison.
21. We informed HM Coroner for South Wales of the investigation. The Coroner did not
request a post-mortem examination. We have sent the Coroner a copy of this
report.
22. The Ombudsman’s family liaison officer contacted Mr Donnelly’s next of kin to
explain the investigation and to ask if they had any matters they wanted us to
consider. Mr Donnelly’s next of kin asked why he was in the laundry room on his
own and why Mr Donnelly was not subject to Prison Service suicide and self-harm
monitoring procedures (known as ACCT). We have answered these questions in
this report.
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Background Information
HMP Cardiff
23. HMP Cardiff holds around 750 remand and sentenced men, many of whom arrive
from local courts. Cardiff and Vale University NHS Health Board provides primary
physical and mental health services. Psychosocial substance misuse support is
provided by Dyfodol integrated partnership services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Cardiff was in July 2019. Overall, inspectors
reported that the prison had made real progress since the previous inspection in
2016. Much of this was attributed to the excellent relationships between staff and
prisoners. Inspectors were extremely worried about an increase in the level of self-
harm, which was over three times higher than during the previous inspection. They
found no clear strategy to reduce it, although all prisoners who harmed themselves
were being interviewed as part of a new initiative to understand the underlying
causes. PPO recommendations were not always embedded into practice.
Independent Monitoring Board
25. 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 August 2021, the IMB reported
that self-harm had reduced by a quarter in the reporting year. The prison was
relatively safe but the reduced regime operating during the COVID-19 pandemic
had affected the relationship between staff and prisoners and the ability of board
members to visit as often as they would have liked.
Previous deaths at HMP Cardiff
26. Mr Donnelly was the twelfth prisoner to die at Cardiff since January 2020. Of the
previous deaths, six were self-inflicted and five were from natural causes. We found
no significant similarities in the findings across these investigations. As Mr
Donnelly’s was the third self-inflicted death at Cardiff in 2022, the prison was
identified as a cluster site and is receiving additional support and monitoring from
regional and national safety teams.
Extended determinate sentence
27. Extended sentences are imposed in certain types of cases where the court has
found that the offender is dangerous, and an extended licence period is required to
protect the public from risk of serious harm. The judge decides how long the
offender should stay in prison and fixes an extended licence period up to a
maximum of eight years.
28. Two thirds of the way through the prison term the offender can apply for parole. If
not released before, the offender will be automatically released at the end of their
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custodial term. In either case, following release, they will be subject to the licence
where they will remain under supervision until the expiry of the extended period.
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Key Events
29. Mr Benjamin Donnelly had a history of anxiety, depression, alcohol and substance
misuse. He had a number of previous convictions for violence against family
members and partners and had served several short prison sentences.
15 October 2022 – 12 December 2022
30. On 15 October 2022, Mr Donnelly was arrested for assaulting his mother at her
home while under the influence of alcohol and drugs. Police completed a
suicide/self-harm warning form because their records showed Mr Donnelly had
threatened to harm himself in 2001, 2012 and 2019. Mr Donnelly’s last recorded act
of self-harm was on 12 April 2019 when he made superficial cuts in police custody.
31. On 17 October, Mr Donnelly appeared at Cardiff Magistrates Court and was
remanded into custody charged with assault occasioning actual bodily harm. He
arrived at HMP Cardiff the same day.
32. Mr Donnelly told a nurse at an initial health assessment that he had a history of
depression and was prescribed Sertraline (an antidepressant). He said he had last
self-harmed about five years previously and had no intention of doing it again. He
said he intended to plead guilty and was expecting a sentence of around six or
seven months.
33. During the assessment Mr Donnelly took a urine test which was positive for
cannabinoids and the nurse referred him to the substance misuse team for
assessment. He said he only drank alcohol between two to four times a month and
so the nurse did not complete the alcohol use questionnaire. As he was prescribed
antidepressants, the nurse referred him to the mental health team. A GP at Cardiff
continued his prescription for Sertraline.
34. The next day, 18 October, Mr Donnelly saw a nurse a mental health nurse. He said
he had no current mental health issues or feelings of suicide or self-harm. The
nurse advised him that he could contact the mental health team if his situation
changed. At a second day health assessment he told another nurse that he had
hurt his arm during his arrest, and she referred him to the GP.
35. Mr Donnelly also saw a nurse from the substance misuse team. He denied using
drugs or alcohol. She advised him how he could contact the team if he had any
future issues.
36. Also on 18 October, a Supervising Officer (SO) from the prison’s offender
management unit (OMU) identified Mr Donnelly as a domestic violence perpetrator
and therefore suitable for offence-related monitoring of his prison telephone calls
and mail. (All prison telephone calls are recorded but in general, staff only listen to
calls when they have specific reason. When a prisoner is subject to monitoring,
control room staff listen to each day’s calls overnight. The decision to monitor a
prisoner’s calls is subject to regular review.)
37. On 19 October, a worker from Dyfodol (the psychosocial substance misuse service)
assessed Mr Donnelly. Mr Donnelly reported a history of recreational alcohol and
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cocaine use and said he would like support. She gave him harm minimisation
advice. She assessed him as suitable for the brief intervention service (for prisoners
not deemed to be at high risk from substance misuse) and added him to the waiting
list. Staff shortages meant Dyfodol did not see Mr Donnelly before he died.
38. The same day Mr Donnelly attended a resettlement assessment. He said he had
been working with Dyfodol in the community to address his alcohol and drug issues
and also the mental health charity MIND. The worker made appropriate referrals to
both for when Mr Donnelly was released from prison. Mr Donnelly spoke to his
keyworker. He said everything was fine and he would like to get a prison job
working in the canteen. A prison GP examined his arm and decided he needed
further examination in hospital.
39. Also on 19 October, a multi-agency risk assessment meeting put in place a non-
contact order preventing Mr Donnelly from contacting his partner, at her request.
40. On 20 October, staff took Mr Donnelly to hospital. An X-ray showed he had a
broken bone in his forearm and his arm was put in a cast and sling. On 22 October,
he told a GP in the prison, that he had fallen in the shower and made his arm
worse. The GP prescribed anti-inflammatory pain medication.
41. On 26 October, Mr Donnelly told a prison offender manager (POM) that he had his
own business in the community and his two employees were keeping it going while
he was in prison. He said he had put effort into making positive changes in his life.
Mr Donnelly said he had been with his current partner for two and half years and
she was a supportive influence.
42. Later the same day, an officer formally notified Mr Donnelly of the non-contact order
with his partner, and Mr Donnelly signed a form to say he understood.
43. On 30 October, an officer discovered during telephone call monitoring that Mr
Donnelly was in touch with his mother via his aunt and they had passed a message
to him from his partner. As his mother was the victim of his offence, but also a close
family member, she was allowed to contact him, but the prison needed to be certain
she was happy with the contact first. (The no contact order prevented Mr Donnelly
from contacting his partner directly, although he does not appear to have done this
at this stage.)
44. The officer submitted a security information report, and, on 31 October, Mr Donnelly
was charged with breaking prison rules and required to attend a prison disciplinary
hearing (known as an adjudication). The Head of Security later dismissed the
charge. Cardiff was unable to locate the record of this hearing, so we do not know
exactly why the charge was dismissed. However, it is difficult to see which prison
rule Mr Donnelly broke given that there was no evidence in this conversation that he
had been in direct contact with his partner.
45. The same day, Mr Donnelly went to hospital for a check up on his arm. Records
showed the fracture was well-aligned and he had a good range of motion in his
elbow.
46. On 8 November, the POM told Mr Donnelly that his mother had withdrawn her
support for the charges against him but that the Crown Prosecution Service might
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continue with the case because of his pattern of similar offences. Mr Donnelly told
her that he intended to plead guilty so that his mother did not have to attend court.
47. On 13 November, Mr Donnelly pleaded guilty at Cardiff Crown Court and was
convicted of assault occasioning actual bodily harm.
48. On 18 November, a prison offender manager reviewed the monitoring of Mr
Donnelly’s phone calls and mail. He noted Mr Donnelly had not breached public
protection measures since 30 October and decided monitoring should stop. His
decision was authorised by the then Head of OMU on 20 November.
49. Also on 20 November, Mr Donnelly told an officer during a keywork session that he
was keen to start a prison job. He said he had just resolved issues with his bank
and was feeling fine.
50. On 28 November, Mr Donnelly started a job in one of the workshops. On 2
December, he moved to a job in the prison canteen.
Events of 13 December
51. On 13 December, Mr Donnelly appeared at Cardiff Crown Court via video link. The
prison’s video link court list showed that his hearing finished at 10.35am. The Judge
sentenced him to an extended determinate sentence of five years, comprising four
years in custody and a year on licence. This meant that Mr Donnelly would be able
to apply to the Parole Board for release two thirds of the way through his four-year
custodial term.
52. An officer was present for Mr Donnelly’s sentencing. He said he knew Mr Donnelly
from previous periods in Cardiff and that he was a model prisoner, always polite
and good spirited. He said Mr Donnelly was quiet in court and very apologetic to the
Judge. When they were walking back to F Wing, Mr Donnelly asked him what his
sentence meant and how long he would have to serve in prison. He said he
explained to Mr Donnelly what it meant for him and that he would probably be
transferred to HMP Parc to serve his sentence. He offered to ask someone from the
offender management department to visit Mr Donnelly and explain his sentence to
him.
53. The officer said Mr Donnelly was quieter than usual but otherwise himself. When
they got back to F Wing, he told the movements officer that Mr Donnelly had
returned from court and that he had been sentenced. Wing staff did not make a
subsequent welfare check on Mr Donnelly.
54. Between 10.41am and 5.41pm, Mr Donnelly made 41 phone calls from his cell.
Only twelve of these connected. He spoke to his solicitor twice and these calls were
not recorded due to legal privilege. It was clear from the other calls that Mr Donnelly
was aware that his solicitor intended to appeal his sentence.
55. My Donnelly spoke to his aunt twice. He cried throughout both calls and told her he
could not serve three years in prison and that his life was over. He spoke to his
mother three times via his aunt’s number. Mr Donnelly was clearly upset and told
his mother he could not serve three years. In one call he said would kill himself but
then apologised to her and said he did not mean it and was just angry. He said in
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another call that he would not see her again. Mr Donnelly’s mother tried to calm him
down and promised she would speak to his solicitor and visit him, which seemed to
reassure him.
56. Mr Donnelly spoke to his partner four times (he had added her to his contacts under
a different name after the prison stopped monitoring his calls). Again, he cried
throughout their conversations. He said he was ringing to say goodbye and wanted
her to move on. He told her that he was “that close to killing myself”. She reassured
him that she would not leave him. They discussed his medication, and he told her
he intended to complete offence related courses so he could move to open
conditions as soon as possible. Mr Donnelly became upset after she told him his
case had appeared on the Wales Online website. He asked several questions about
who had seen it, whether anyone had commented on it and whether it was “on
Facebook”. His partner tried to distract him, but he kept returning their conversation
to the article.
57. In their last conversation at 5.41pm, Mr Donnelly sounded quiet and said that
everyone would be sharing the Wales Online article. He kept going back to the
article and asked her to read it out. He said it was a “really bad story”. He promised
to come out of prison a better person and said that he would talk to doctors about
changing his medication. He said his credit was running out and they agreed to talk
until that happened. They told each other they loved each other, and he said he
would call her at 11.00am the next morning if he had more credit.
58. Prisoner A said he had shared a cell with Mr Donnelly for about five weeks and had
known Mr Donnelly since the age of six. He said before he was sentenced Mr
Donnelly had been his usual happy self. When he returned from work at lunchtime
on 13 December, Mr Donnelly was sitting in their cell with his head in his hands. He
was deeply upset and depressed about his sentence. He said Mr Donnelly had
served short sentences before and this one was as long as all of them put together.
He said Mr Donnelly had not expected such a long sentence.
59. Prisoner A said Mr Donnelly was “a mess”. He tried to comfort him and told him that
he would be able to apply for category D status and move to an open prison after
about eight months. He said he did not think this was necessarily true but had
wanted to make Mr Donnelly feel better.
60. Prisoner B said he had known Mr Donnelly for many years and had been in prison
at the same time as him on different occasions. He also lived on F Wing and
worked in the same workshop as Mr Donnelly. He said before he was sentenced,
Mr Donnelly appeared to be his usual self. He was a little bit worried about being
sentenced but had been expecting to be released relatively quickly.
61. Prisoner B said he spoke to Mr Donnelly at work in the afternoon. He thought the
length of the sentence had come as a bit of a surprise to him. The prisoner
explained to him what an extended determinate sentence was and how long it
would be before he could apply for parole. He told him to see him if he needed
anything or wanted to talk. He said Mr Donnelly appeared a bit low, but he had not
been concerned for his welfare. He said that if he had been worried about Mr
Donnelly he would have alerted staff.
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Events of 14 December
62. Prisoner A said in the morning of 14 December Mr Donnelly told him, “I can’t do this
anymore”. He tried to reassure Mr Donnelly that he would get through his sentence,
but Mr Donnelly just stared into space with tears in his eyes. He said he saw Mr
Donnelly briefly that morning and thought he seemed OK. He told Mr Donnelly he
would see him in a bit and went to collect his medication.
63. The prison showed the investigator CCTV footage from 7.50am. It was not time
stamped and so the times below have been calculated from time elapsed and
comparison with time stamped body worn video camera footage (BWVC) and radio
traffic.
64. At 7.51am, Mr Donnelly asked a member of staff to unlock the wing laundry which
was diagonally opposite his cell. Prisoner B said the laundry was often unlocked for
workers in the morning as they were allowed to leave their washing in there before
going to work.
65. At 7.56am Mr Donnelly walked from his cell into the laundry carrying what appeared
to be a sheet. He immediately returned to his cell and carried a chair into the
laundry at 7.57am. No one else entered the laundry until Prisoners A and B at
8.11am.
66. Prisoner B said he saw Prisoner A at the medication hatch and, once they had both
had their medication, they went to look for Mr Donnelly. They could not see him out
on the wing so, on the way to Mr Donnelly’s cell, they looked in the laundry.
Prisoner B said he did not think Mr Donnelly was in the laundry when he first went
in. He only saw him when he turned around to leave the room. Mr Donnelly was
hanging from the pipes behind the door. He had made a noose by twisting a sheet
tightly to form a rope and was fully suspended with his feet off the floor. Prisoner B
said he held Mr Donnelly up while Prisoner A shouted for staff. Two officers
responded immediately, followed by another.
67. Officer A said he ran to the laundry as soon as he heard prisoners calling for staff.
He entered the laundry just behind Officer B. He and Prisoner B held Mr Donnelly
up while Prisoner A and Officer C tried to remove the noose. Officer C said he tried
to use his cut-down tool to cut the sheet from around Mr Donnelly’s neck, but it was
too thick. They managed to remove it with their hands and laid Mr Donnelly on the
floor.
68. Officer C said Mr Donnelly was not breathing. Officer A started cardio-pulmonary
resuscitation (CPR). He said he had attended a CPR refresher course three months
previously and was confident he knew what to do. He said he did not radio a code
blue emergency because his priority was to start CPR. He told Officer B to get help.
69. CCTV showed that Prisoner B became upset and angry when he left the laundry
and Officer B intervened to calm him down. Many prisoners had gathered outside
the laundry and the scene was very crowded. No one called a code blue
emergency.
70. A nurse and a Healthcare Assistant (HCA) were in the wing treatment room. The
HCA heard a loud commotion, saw many prisoners on the landing and officers
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running from the wing office. He said he assumed a fight was taking place and
pressed the general alarm button. Radio traffic showed the general alarm was
pressed at 8.11am.
71. A Custodial Manager (CM) was the B Wing manager that morning. He said he
heard a general alarm on the radio and went to F Wing. He said a general alarm
usually indicated a violent incident, often a fight between prisoners. When he
arrived, there were a lot of prisoners out of their cells waiting to go to work.
Someone directed him to the laundry, and he saw Mr Donnelly on the floor with
officers giving him CPR.
72. The CM radioed the control room for an ambulance and more healthcare staff to
attend the scene. Radio traffic showed he did this at 8.13am. At Cardiff, the orderly
officer carries a mobile phone for use in emergencies. As the first manager on
scene, the CM retained responsibility for managing the incident and the orderly
officer gave him the mobile phone.
73. Not long after the general alarm, an officer told the HCA and the nurse they were
needed in the laundry but did not say why so they did not take the emergency
equipment. The nurse and the HCA entered the laundry at 8.14am. The nurse said
Mr Donnelly was on the floor with Officer A performing CPR. She collected the
emergency equipment bags from the wing office and returned to the laundry.
74. The nurse inserted an airway to give Mr Donnelly oxygen and attached a
defibrillator to his chest. As she was doing so, another nurse arrived and took
control of the scene.
75. The second nurse said she was working in C Wing treatment room when she heard
the radio call for an ambulance. As this indicated an emergency, she made her way
to F Wing to provide support. On arrival, she helped her colleague with the oxygen
cylinder and Ambu-bag and, as the most experienced nurse, assumed control of the
scene. The nurses and officers continued CPR according to the instructions of the
defibrillator. The defibrillator did not identify a shockable heart rhythm, so they
continued with oxygen and chest compressions.
76. Ambulance records and call recordings showed the control room officer telephoned
999 at 8.15am and asked for an ambulance. The call handler asked if the patient
was awake, and the officer said he did not know but would put her through to the
CM at the scene. He gave her the CM’s mobile number in case he got cut off. He
could not connect at the first attempt, so radioed the CM to ask for his nearest
landline extension. The CM said the mobile line was clear again, so the officer tried
again to put the call handler through to him. When this did not work, the call handler
agreed to call the mobile phone direct.
77. When the call handler phoned the mobile it went to voicemail, and she left a
message asking the prison to re-dial 999.
78. The CM said the mobile phone did not ring that morning. He said it had worked in
other emergencies he had attended, and in hindsight he thought that the laundry
might have been an area of poor reception.
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79. Ambulance records and call recordings showed the control room officer called 999
again at 8.20am. A different call handler started the process of triaging the
emergency from the beginning. The officer said he needed an ambulance urgently.
The call handler asked if the patient was breathing. The officer said he did not know
but that there were three people working on the patient and they were using a
defibrillator. The call handler continued to ask whether the patient was breathing
and several other questions. The officer repeated that he only knew what he had
already told her. The call lasted almost nine minutes, although an ambulance was
dispatched with priority one (indicating a response target of within 15 minutes) after
two minutes at 8.22am.
80. CCTV showed paramedics arrived at the laundry at 8.36am. They gave Mr Donnelly
adrenaline and attached a Lucas machine (an automated chest compression
system). At 8.46am, Mr Donnelly’s heart started beating again. Paramedics took
him to hospital where he was put on a life support machine. Staff did not apply
restraints at any time.
81. On 20 December, the hospital confirmed Mr Donnelly would not recover, staff
withdrew life support, and he died.
Contact with Mr Donnelly’s family
82. The prison appointed a family liaison officer, who contacted Mr Donnelly’s next of
kin as soon as he had been taken to hospital. A prison chaplain went to the hospital
to meet the family that day. When it became apparent that Mr Donnelly would not
recover, the family accepted the prison’s offer for the Roman Catholic chaplain to
give a service for Mr Donnelly. Mr Donnelly’s family were with him when he died.
The prison offered a financial contribution to the funeral costs in line with national
guidance.
Support for prisoners and staff
83. After Mr Donnelly’s death, a senior prison manager debriefed the staff involved in
the emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team and Trauma Risk Management
(TRiM) team also offered support. One member of staff was escorted home. The
prison chaplain spoke to Prisoners A and B.
84. The prison posted notices informing other prisoners of Mr Donnelly’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. Prisoners A and B both said
they had been well supported by the chaplaincy and staff. They both said they
would have liked more support from healthcare as they had found it hard to sleep.
Prisoner A said he was not offered counselling and would have liked to have had
some. (He was released on 26 January 2023.)
Post-mortem report
85. HM Coroner for South Wales did not hold a post-mortem examination. He gave the
cause of death as hypoxic brain injury due to hanging.
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Coroner’s inquest
86. The Coroner’s Inquest concluded on 18 June 2025 and the jury returned a verdict of
suicide.
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Findings
Assessment of Mr Donnelly’s risk
87. Although Mr Donnelly had some risk factors for suicide and self-harm, including a
history of domestic violence and substance misuse, we have found no evidence
that he was in crisis until after he received a much longer than expected sentence
on 13 December.
88. Prisoners A and B were aware that Mr Donnelly was extremely distressed by his
sentence but neither considered he was at risk of taking his life and so did not
speak to staff. Mr Donnelly’s phone calls also showed his distress, but these were
not being monitored at the time.
89. As discussed below, we do not consider that Mr Donnelly was adequately risk
assessed following his court appearance, however we have seen no evidence to
indicate that staff were made aware of his increased risk on 13 December or had
reason to initiate suicide and self-harm monitoring.
Mr Donnelly’s court appearance by video link on 13 December
90. Prison Service Order (PSO) 3050, Continuity of healthcare for prisoners, says that
events such as attending court or sentencing at court, are factors that might have a
significant impact on the health of a prisoner. When prisoners pass through
reception on their return from court, prisons are required to have protocols in place
for risk assessing them to identify any potential suicide and self-harm issues. Prison
Service Instruction (PSI) 07/2015, Early days in custody, states that there must be
arrangements in place to assess prisoners whose status or demeanour may have
changed after a court appearance by video link.
91. As these prisoners do not leave the prison, they are not always subject to the
standard screening procedures that they would receive when returning to the prison
and passing through reception.
92. Several PPO investigations in 2020, when the Covid-19 pandemic meant all court
appearances were remote, found that prisoners were not being risk assessed after
attending court by video link. We made a national recommendation to HMPPS to
review their guidance. In March 2021, the Director General wrote to all Governors
and Directors requiring them to review local processes to ensure that similar health
screening arrangements, and the same processes for assessing risk of suicide or
self-harm, were followed after video link appearances, as in reception following a
physical appearance in court.
93. Also in March 2021, HMPPS issued a safety briefing on assessing the risk of harm
in prisoners attending court by video link. In April 2021, they followed this up with
another safety bulletin containing early learning review analysis of several issues
including video court appearances. Both documents advised that it was vital that
staff engage with prisoners after a video court appearance, and that they assess
the prisoner’s risk on the basis of official information, as well as the individual’s
presentation. They also advised that a verbal handover of key information should be
given to wing staff and any new risk information should be recorded and shared on
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the prisoner’s record (NOMIS) and the wing observation book. If necessary,
concerns should be escalated, including starting ACCT procedures where
appropriate.
94. When Mr Donnelly died there was no standard procedure at Cardiff for prison staff
to risk assess prisoners after video link court appearances. Aside from an officer
telling a member of staff in the wing office that he had been sentenced, none of the
measures required across HMPPS guidance were taken. This was a significant
missed opportunity to identify that Mr Donnelly’s risk to himself had increased.
95. After Mr Donnelly died, Cardiff immediately introduced a procedure requiring the
officer present in the video court to tell wing staff about changes in a prisoner’s
status and write entries on NOMIS and in the wing observation book. While we
welcome this and commend the speed with which it was brought in, it does not fully
comply with the Director General’s instruction and Safety Briefing advice that
prisoners receive the same standard of risk assessment following a court
appearance of any type, including being seen by healthcare.
96. Mr Donnelly’s death is the fifth self-inflicted death since March 2021 in which we
have found that the relevant prison did not have the required procedure to risk
assess prisoners following a video link court appearance. We are concerned that
despite previous national guidance, prisons still do not have the required local
procedures in place and therefore are not robustly risk assessing prisoners after
they have appeared in court via video link. We make the following recommendation:
The Director General of HMPPS should issue guidance to ensure that prisons
are clear about their responsibilities to ensure that prisoners who attend
court by video link are assessed for their risk of suicide and self-harm and
seen by healthcare staff in the same way as prisoners attending court in
person. Prison Group Directors should monitor compliance with this
guidance.
The emergency response
97. PSI 03/2013, Medical Emergency Response Codes, requires governors to have
a two-code medical emergency response system. As is usual, Cardiff use code blue
to indicate an emergency when a prisoner is unconscious, or having breathing
difficulties, and code red when a prisoner is bleeding. Calling an emergency code
should automatically trigger the control room to call an ambulance.
98. CCTV showed that the wing was very crowded and the first staff to respond were
confronted by several prisoners including Mr Donnelly’s two friends, one of whom
was clearly distressed and angry about what had happened. The situation was
further confused by a nurse pressing the general alarm. In the evident confusion, no
one radioed a code blue emergency. Despite this, Mr Donnelly received prompt
CPR from officers and nurses.
99. The absence of a code meant the control room officer did not automatically ring for
an ambulance. This caused a delay of four minutes, and it was only requested after
a manager had radioed asking for one. There was a further delay of seven minutes
between this initial call and the ambulance service dispatching an ambulance. This
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was mostly due to the failure of the prison’s mobile phone which would not work in
the laundry.
100. However, some of the delay was due to control room staff not having sufficient
information to answer the 999 operator’s questions for them to dispatch an
ambulance. Both times they called they could not tell ambulance staff whether Mr
Donnelly was breathing. The first time this resulted in the 999 operator
unsuccessfully trying to call the allocated prison mobile phone. The second time,
they dispatched the ambulance two minutes into the call. 999 operators need to
know whether the patient is breathing before they can send an ambulance. In
October 2023, we made a recommendation to the Director General of HMPPS that
they review the emergency response policy to provide clarity about this issue. This
is currently being considered by HMPPS, so we make no further recommendation.
101. It is extremely unlikely that this delay affected the outcome for Mr Donnelly. He had
been fully suspended by the neck for up to 15 minutes when he was found, which is
long time for the brain to be deprived of oxygen. We did not identify delays in calling
a code blue or inefficient communication with the ambulance service as an issue in
any of the self-inflicted deaths at Cardiff in the three years before Mr Donnelly died.
The CM said the mobile phone (which in other circumstances might well have been
highlighted as an example of good practice) had worked well in other emergencies
and its failure in this case appears to have been a result of the unusual location of
Mr Donnelly’s death, rather than a systemic problem. We therefore make no
recommendation. However, the Governor will want to consider the learning from Mr
Donnelly’s death.
Clinical care
102. The clinical reviewer concluded that Mr Donnelly’s clinical care was equivalent to
that he would have expected in the community. They have made several
recommendations, not related to Mr Donnelly’s death, which the Head of Healthcare
will wish to consider.
Governor to note
103. As a domestic violence perpetrator, Mr Donnelly’s telephone contacts should have
been checked by staff, but he was able to contact his partner by adding her under a
different name.
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