Brendan Teague

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Independent investigation into
the death of Mr Brendan
Teague, a prisoner at HMP
Garth, on 7 October 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
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© Crown copyright, 2026
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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 Brendan Teague died on 7 October 2023, after being found hanged in his cell at HMP
Garth. He was 46 years old. I offer my condolences to Mr Teague’s family and friends.
Mr Teague had a significant history of using substances, attempted suicide and self-harm,
depression and anxiety. In December 2020, he contracted COVID-19 and was
hospitalised. This had a traumatic impact on him and he suffered from anxiety, that later
affected his day to day living in prison.
Mr Teague’s anxiety led to him being appropriately supported under suicide and self-harm
procedures (known as ACCT) on two occasions in May and September 2023. He received
good one-to-one psychology input to help him manage his anxiety, and generally staff
were responsive and supportive to his needs.
The clinical reviewer concluded that the healthcare Mr Teague received at Garth was of a
reasonable standard and equivalent to that which he could have expected to receive in the
community.
Mr Teague had medication in his system when he died which had not been prescribed to
him. The prison is taking proactive steps to reduce drug supply and the diversion of
medication.
I make no recommendations.
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 September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 16
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Summary
Events
1. On 29 March 2017, Mr Brendan Teague was remanded to prison, charged with
attempted murder, and taken to HMP Durham. This was not his first time in prison.
On 27 October, he was sentenced to 18 years imprisonment. He had a history of
attempted suicide and self-harm, substance misuse and depression with panic
attacks.
2. In November 2017, Mr Teague transferred to HMP Garth.
3. In December 2020, Mr Teague contracted COVID-19 and was admitted to hospital.
While he made a full recovery, he stated that the illness caused him to experience
flashbacks and he had anxiety. He was prescribed antidepressant medication.
4. In May 2023, Mr Teague referred himself to the mental health team because of his
anxiety. He was assessed and diagnosed with a high level of depression and
severe anxiety. He was referred to a psychologist and from July, regularly received
one to one support.
5. During his time at Garth, Mr Teague was supported under ACCT procedures on two
occasions, in May and September 2023. On both occasions he reported feelings of
anxiety. Staff stopped ACCT monitoring on 27 September. Mr Teague was not
being supported by ACCT procedures when he died.
6. On the morning of 7 October, during a routine check, prison staff found Mr Teague
hanged in his cell. Prison and healthcare staff provided emergency care. At 6.09am,
paramedics confirmed that Mr Teague had died.
7. After he died, toxicological analysis showed that Mr Teague had several
medications in his system which had not been prescribed to him.
Findings
8. Mr Teague had several risk factors for suicide and self-harm. He had a history of
attempted suicide and self-harm, substance misuse and depression and anxiety.
Broadly, we concluded that Mr Teague received good support from the ACCT
process. However, we identified some omissions in the management of the second
ACCT, and particularly the ACCT review on 27 September. We do not think that
there was evidence that Mr Teague was at imminent risk of suicide at the time,
however. Garth is currently investigating these issues so we make no further
recommendation.
9. Neither prisoners nor prison staff observed any obvious signs that Mr Teague was
in crisis in the ten day period leading to his death. We have concluded that he hid
the extent of his anxiety, and it was reasonable that staff did not identify him to be
an imminent risk of suicide.
10. The post-mortem found that Mr Teague had taken olanzapine, mirtazapine and
clonazepam before he died. None of these medications had been prescribed to him,
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so he must have obtained them illicitly. Garth has reviewed their drug strategy and
we are satisfied that they are taking appropriate steps to tackle drug misuse and
medication diversion.
11. The clinical reviewer concluded that Mr Teague’s healthcare was of a good
standard and at least equivalent to that he could have expected to receive in the
community.
12. We make no recommendations.
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The Investigation Process
13. HMPPS informed us of Mr Teague’s death on 7 October 2023. The investigator
issued notices to staff and prisoners at HMP Garth informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded.
14. The investigator obtained copies of relevant extracts from Mr Teague’s prison and
medical records, CCTV and body worn video camera (BWVC) footage. He also
obtained North West Ambulance Service records.
15. The investigator interviewed ten members of staff at Garth and three prisoners.
16. NHS England commissioned a clinical reviewer to review Mr Teague’s clinical care
at the prison. The clinical reviewer and the investigator jointly interviewed staff.
17. We informed HM Coroner for Lancashire and Blackburn with Darwen of our
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
18. The Ombudsman’s office contacted Mr Teague’s parents to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Teague’s parents asked about the circumstances that led to their son’s death,
including whether COVID-19 had contributed and what mental health support he
had received in prison. We have answered these questions in this report.
19. Mr Teague’s family received a copy of the initial report. They did not make any
comments.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Garth
21. HMP Garth is a category B training prison and holds long-term and life-sentenced
prisoners. It is part of the Long-Term High Security Estate (LTHSE). Greater
Manchester Mental Health NHS Foundation Trust provides physical healthcare 24
hours a day. Mental health, social care, clinical substance misuse treatment are run
in the core day. There are seven residential wings and a segregation unit next to
the prison’s healthcare department. Prisoners live in a mixture of single and double
cells.
HM Inspectorate of Prisons
22. The most recent inspection of HMP Garth was in November 2022. Inspectors noted
that self-harm had reduced. The safer custody department had worked hard to train
staff in ACCT case management, but the quality of support was inconsistent.
Inspectors noted that although the prison had worked to reduce drug supply, drugs
remained easily available and the mandatory drug testing rate had reduced. Garth
offered a range of mental health services, interventions and support, but there were
long waits for some psychological therapies. There was limited evidence of
additional mental health training for officers.
Independent Monitoring Board
23. 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 30 November 2022, the Board
noted that the effects of the COVID-19 pandemic had begun to lessen and the
prison had started to move towards a more normal regime, although this had not yet
been fully achieved. On the whole, prisoners had responded positively to the
required restrictions but some frustrations had begun to manifest themselves. The
report noted that Garth had ongoing staff recruitment and retention problems which
meant that there were many inexperienced staff in the prison. Safety had been
improved by physical changes to the prison.
Previous deaths at HMP Garth
24. In the three years prior to Mr Teague’s death, 14 prisoners died at Garth. Ten of
these were due to natural causes, two were self-inflicted, and one was due to
drugs. None of the investigations following these deaths raised issues relevant to
Mr Teague’s death. To the end of July 2024, there have been two deaths since that
of Mr Teague, one of which was due to drugs and one was self-inflicted.
Assessment, Care in Custody and Teamwork (ACCT)
25. 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.
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26. 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. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
ACCT plan should not be closed until all the actions of the caremap have been
completed.
27. 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
24. In March 2017, Mr Brendan Teague was arrested, charged with the attempted
murder of his stepbrother and remanded to HMP Durham. This was not his first time
in prison. He had a history of attempted suicide and self-harm, substance misuse
and depression and panic attacks. Shortly after committing the alleged offence, he
had tried to take his own life by taking heroin, an overdose of several different types
of prescription medication and drinking vodka.
25. On 27 October, Mr Teague appeared in court and was sentenced to 18 years
imprisonment.
HMP Garth
26. On 9 November 2017, Mr Teague transferred to HMP Garth. When he arrived, a
nurse recorded that he had a history of attempted suicide and self-harm and
substance misuse, including the use of Subutex (a type of opioid drug) and heroin
and crack cocaine. He was currently prescribed methadone as well as
antidepressant medication. Both these medications were continued on his arrival.
Mr Teague denied that he had any thoughts of suicide or self-harm. The nurse
referred him the substance misuse and mental health teams. Mr Teague was seen
by substance misuse clinical staff at regular intervals to monitor his methadone
prescription.
2020
27. On 9 December 2020, Mr Teague tested positive for COVID-19 and was isolated in
a single cell, in line with prison service guidelines. A healthcare COVID-19 care plan
was initiated.
28. On 13 December, Mr Teague was admitted to hospital after a decline in his physical
health. He was initially located in the Intensive Care Unit and was placed on a
ventilator until 21 December, after which his condition improved. On 27 December,
he was moved to a less acute ward. On 29 December, he was discharged from
hospital and returned to Garth.
29. It was recorded in Mr Teague’s medical records that, following this hospital
admission, he experienced flashbacks and anxiety.
2022
30. On 22 March 2022, at the request of the hospital physician who was following up on
all COVID-19 patients who had been admitted to hospital, healthcare staff
completed a number of tests on Mr Teague. No abnormalities were recorded.
31. On 13 July, Mr Teague again tested positive for COVID-19. Due to his previous
experience of being hospitalised, Mr Teague was reluctant to accept treatment.
However, once healthcare staff explained to him why checks and observations were
necessary, he consented. Healthcare staff monitored Mr Teague and also provided
him with a pulse oximeter (to monitor his blood oxygen levels and pulse) to assist
him in identifying the early risk factors associated with COVID-19.
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32. Healthcare staff completed daily welfare checks until 19 July. Mr Teague reported
that he felt well on each occasion and had not experienced any adverse symptoms
of COVID-19. His physical health observations were all within the normal range.
2023
33. On 15 March 2023, Nurse A, from the mental health team (who worked with the
substance misuse team), completed the regular review of Mr Teague’s methadone
treatment. Nurse A undertook an assessment of Mr Teague’s withdrawal signs that
indicated that he was not experiencing any withdrawal symptoms. Staff made no
change to his methadone dosage and a further review was planned.
34. On 18 May, Mr Teague told staff that he wanted to self-isolate on the wing. He said
he was not scared but wanted to take some time out to reflect on how ill he had
been when he had COVID-19 in 2020. He said he wanted some quiet time away
from everyone on the wing. Staff reminded Mr Teague of the support available to
him and said that they would continue to monitor him.
35. On 22 May, Mr Teague applied to see the mental health team. He stated that he felt
on edge when around people and he would start to shake. He said the impact of
having COVID-19 and being hospitalised had “ripped a huge part of his soul away”
and he did not know what to do. An appointment was booked for him to see a
nurse.
36. The same day, Officer A saw Mr Teague for a key work session. Mr Teague told the
officer that he had self-isolated the previous week because he wanted a change in
his methadone dose and felt that he needed to “get his head around” this. However,
since then, he had fully engaged with the regime and said he felt much better. He
was also working in a prison workshop.
37. On 23 May, when Mr Teague attended the medication hatch, he told Nurse A that
he was struggling on his dose of methadone. Nurse A scheduled an appointment
later that day to discuss his concerns. However, when Mr Teague attended the
appointment, he said that he had no issues with his methadone dose but instead
wanted to talk about other issues. He talked about his history of anxiety and
depression with panic attacks and that he had experienced panic attacks the last
time that he left prison. He admitted that he had been struggling and had self-
isolated. He said he had only self-isolated for one day, as he felt this would not
resolve his problems and would only make things worse. Mr Teague was unable to
identify any specific trigger to his behaviour but said that the increased noise levels
on the wing and being around more people affected him. He said he had not
attended work recently as the noise in the workshop affected him too. He said he
would only attend the medication hatch at the end of a session when there were
fewer people there. Mr Teague said that the time he had spent in the ICU at
hospital, after contracting COVID-19, had been very traumatic for him. He said he
had experienced hallucinations and paranoid thoughts.
38. Nurse A undertook two assessments on Mr Teague using Generalised Anxiety
Disorder assessment (GAD7, a screening tool to for anxiety) and a Patient Health
Questionnaire (PHQ9, a screening tool for depression). The results highlighted that
Mr Teague had a high level of depression and severe anxiety. Mr Teague said that
he wanted to address his anxiety but did not want to address his past traumatic
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experiences, which he disclosed included being sexually abused. Nurse A referred
Mr Teague to the mental health team for a medication review and to explore
treatment options available to him.
39. At the mental health team’s referral meeting the next day, Mr Teague was placed
on the waiting list to see the psychologist to be assessed for an anxiety treatment
plan. The psychiatrist reviewed Mr Teague’s medication and increased the dose of
his sertraline (antidepressant) medication.
40. On the morning of 29 May while administering medication, mental health Nurse B
noticed a red mark on Mr Teague’s neck which appeared to be from a ligature.
When asked why he had a red mark around his neck, Mr Teague stated that he had
had a lot going on but was now okay. As he walked away from the medication
hatch, he stated that the marks were two weeks old. Nurse B telephoned
Supervising Officer (SO) A, the wing supervisor, and informed her of his concerns
regarding Mr Teague and requested that a welfare check be completed.
41. Shortly afterwards, SO A spoke to Mr Teague in the wing office. Mr Teague said
that the marks on his neck were two weeks old and had occurred when he had
been self-isolating and wanted to be alone. When probed further, Mr Teague
assured SO A that he no longer had any issues and had had no thoughts of suicide
or self-harm. He said that he did not talk to staff at the time but after his
conversation with SO A, felt that he could do so in the future, if his mood was low.
SO A noted that she had no concerns for Mr Teague’s welfare at that time.
42. In the meantime, Nurse B had discussed Mr Teague with Nurse A. Nurse A and
Nurse B agreed to attend the wing to review Mr Teague and did so that afternoon.
Mr Teague repeated that he had made a ligature two weeks previously. When the
nurses viewed the marks around Mr Teague’s neck, they believed that they had
been made more recently. Nurse A thought that he would have noticed the marks if
they had been there the previous week, as he had seen Mr Teague on 23 May. Mr
Teague refused to engage any further in the discussion about the incident. Nurse A
started ACCT procedures. Staff placed Mr Teague on four ACCT observations an
hour.
43. The next morning, 30 May, SO A chaired a multidisciplinary ACCT case review,
which included a representative from the mental health team. Mr Teague was
initially reluctant to engage and said that being on an ACCT contributed to his
anxiety. He was adamant that the ligature markings on his neck were two weeks
old. He said that at the time he was struggling with anxiety and the loud noise in the
workshop along with the current regime. However, since then he said he had
resolved his issues and had no thoughts of suicide or self-harm. SO A said that Mr
Teague should speak to her whenever he attended the workshop and if his
problems continued, they would find a way to manage this.
44. The case review team noted that Mr Teague sounded irritable during the meeting
when he was asked questions about triggers to his self-harming behaviour and
whether he would seek staff support. Mr Teague said that he preferred to speak to
his peers, not staff, if he had any concerns. Despite stating that he was struggling
with noise due to a change of prison regime, he declined the offer of a move to
smaller and quieter wing. The mental health nurse agreed to discuss Mr Teague at
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their next team meeting. Staff set ACCT observations at three per hour and
scheduled the next review for 5 June.
45. On the same day, Officer A saw Mr Teague for a key work session and raised no
concerns.
46. At his key work session on 5 June, Mr Teague said that he felt much better and did
not need to be monitored by ACCT procedures. He said his peers on the wing had
supported him. His key worker noted that Mr Teague still worked in the prison
workshop and complied with the prison regime.
47. On the same day, SO A chaired a multidisciplinary ACCT case review, which
included a representative from the mental health team. Mr Teague became
frustrated and tearful at times but eventually opened up about losing six family
members, being imprisoned and spending time in the hospital with COVID-19,
leading to him having anxiety and to tie a ligature. He explained that going to work
in the woodwork workshop caused him anxiety due to the loud environment. The
case review team reassured Mr Teague that if he could not cope in the workshop
he would be moved. Mr Teague stated that, for now he was okay as his workshop
had been closed since his last ACCT review. He was happy to wait to see how he
felt. He said he was keen to work with the mental health team and requested to see
a psychologist due to his extreme mood swings, stating that he preferred one to one
support. The review team agreed to refer Mr Teague to the psychologist (he had
already been referred on 24 May) and mental health team. Mr Teague appeared
happy with the actions proposed and stated that he had spoken to his family and
had a support system in place. The staff agreed to lower his ACCT observations to
two per hour and scheduled his next ACCT review for 9 June.
48. The next day, 6 June, the mental health team discussed Mr Teague and assigned
Ms A, assistant psychologist, to work with him.
49. SO A chaired a multidisciplinary ACCT case review on 9 June. She had no
concerns about Mr Teague. Mr Teague said he had no thoughts of suicide or self-
harm, although he had still not been seen by the psychologist. SO A agreed to
follow this up. Mr Teague confirmed that he was not currently attending work as the
workshop tutor was unwell. The case review team reduced Mr Teague’s ACCT
observation to one per hour.
50. At his multidisciplinary ACCT review on 15 June, SO A noted that Mr Teague had
no thoughts of suicide or self-harm, was settled and happy. It was confirmed that he
had an upcoming appointment with the psychologist. He requested to work part-
time in the workshop to reacclimatise himself to the workshop environment. The
case review team agreed that the ACCT could be closed.
51. On the same day, Nurse A completed Mr Teague’s 13-week review of his
methadone treatment. Mr Teague engaged well and said he had no thoughts of
suicide or self-harm. His methadone dose remained the same and a further review
was booked for 13 weeks.
52. On 23 June, during a key work session, Mr Teague said that he felt better now that
he was no longer being monitored by ACCT procedures. It was agreed that Mr
Teague could reduce to part time hours in the workshop due to his mental health.
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53. On the same day, SO A attempted to conduct Mr Teague’s ACCT post-closure
interview with him but Mr Teague refused to engage. Mr Teague did state, however,
that he had no thoughts of suicide or self-harm and that he was now working part
time in the workshop.
54. At his key working sessions on 5 July and 13 July, Mr Teague reported that he had
no issues on the wing and said he enjoyed associating with his peers and attended
work regularly.
55. On 21 July, Ms A assessed Mr Teague. He said that he had struggled with anxiety,
felt unmotivated to get up in the mornings and had lost his ’zest for life’ and
confidence in himself. His anxiety had increased when he attended the workshop
(so he had now stopped going) and when around groups of people. He said that he
did not speak to his family much because of his anxiety and did not want them to
know that he was struggling. He talked about his history of depression, the death of
family members and being hospitalised because of COVID-19. He said he had
experienced hallucinations and flashbacks ever since. Mr Teague said that he had
regular thoughts of killing himself but had no intention of acting on these. He did not
want to be monitored by ACCT procedures and felt that being on ACCT increased
his anxiety. He said that his peers supported him, although admitted that he would
not talk to them in any depth about his difficulties. Ms A agreed to see Mr Teague
weekly to support him and to continue her assessment.
56. In further psychology sessions over the coming weeks with Mr Teague, Ms A
discussed ways of recognising and coping with his anxiety, created a crisis plan for
him and provided him with in cell work to complete. Mr Teague described himself as
an overthinker. He told Ms A that he was not very open with staff, and although he
presented as consistently anxious, Ms A noted that he tried to engage in the
sessions. Mr Teague talked about his childhood trauma and family bereavements.
Ms A noted that Mr Teague’s mood improved after he spoke to his family,
something he had not done for around six weeks. When he talked about the friends
he had on the wing, he explained that he spoke to them around once a day and
kept the conversations superficial. Mr Teague said he still had regular thoughts of
suicide, particularly at night, when there was less to distract him, but he had no
plans or intent to harm himself.
57. During the later sessions, Mr Teague reported that he felt much better, and his
mood was good. He was thankful for the support he got from attending his
psychology sessions and said the contact he had had since with his father, also
helped. His anxiety remained the main issue that he wanted to address and said
this would help him to live a ‘normal life’. Mr Teague understood that self-isolating
and not going to work supported his anxiety short term but not long term. He also
recognised that when there had been restrictions on movement in the prison due to
COVID-19, and the corridors were quieter, he found going to work easier. Now that
the routine and regime had changed, he struggled more with his anxiety. He
recognised that he was not as used to being around people and this worsened his
anxiety and isolating from people increased his overthinking.
58. At his key work session on 31 July, Mr Teague said that he was settled on the wing.
He said he had not attended work lately due to being ill but was feeling better now.
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59. When Ms A saw Mr Teague on 30 August for his psychology session, he spoke
about how frustrated he had felt the previous day, after he had attended the
medication hatch twice, only to find lots of prisoners queuing. He said that he had
initially felt scared. These feelings then turned into anger and frustration and
resulted in him having a verbal altercation with staff, during which he threatened
violence. Mr Teague said that he did not mean to do this and it was part of the
difficulties he had when trying to manage his cycle of anxiety. He said he had had
thoughts of "ending it all” but stated that he had this regularly and had no plans or
intent to act on these thoughts. Mr Teague spoke about coming off methadone in
preparation for his parole hearing. Ms A agreed to see Mr Teague for a further
session the following week.
60. On 6 September and 12 September, Mr Teague did not attend his sessions with Ms
A. Ms A attempted to contact Mr Teague on his in-cell phone, to ascertain why he
had not attended. He did not answer the calls. At interview, Ms A told us that she
had eventually managed to speak to Mr Teague. Mr Teague told her that he had not
attended the sessions because he felt anxious about walking to the healthcare unit,
where the sessions were held. Ms A arranged for future sessions to be conducted
on Mr Teague’s wing.
61. On 16 September, SO B conducted an annual review of Mr Teague’s enhanced IEP
level. It was noted that there had been a recent decline in Mr Teague’s behaviour
as he had received a few negative entries. These related to him refusing to attend
work.
62. On 18 September, the substance misuse team noted that Mr Teague had tested
negative for illicit drug use.
63. On the same day, Ms A saw Mr Teague. Mr Teague said that he had struggled for
the past couple of weeks. He said that he had made a noose two days earlier,
although he had no intention to end his life. Ms A explained to Mr Teague that his
actions showed that he was at risk and although Mr Teague stated that he did not
want to be managed by ACCT procedures (because it made him feel worse), Ms A
started ACCT procedures. SO B completed the ACCT Immediate Action Plan and
put Mr Teague on hourly observations. He noted that Mr Teague could access
Listeners (prisoners trained by the Samaritans to provide confidential peer support)
and was provided with distraction packs to use in his cell.
64. On 19 September, Officer B, completed Mr Teague’s ACCT assessment. Mr
Teague said that he was frustrated that he was now being monitored by ACCT
procedures and felt that the disclosure he had made to Ms A, and her informing
others, was a breach of his trust. He said he had no intention to take his life and he
had just had a fleeting thought about it. He said he had no current thoughts to harm
himself and was happy on the wing. He said he was not attending work as he still
struggled when around big groups of people. He said that was receiving
psychological support for this, however, was unsure if he now wanted to attend any
further sessions because he no longer believed the service was a confidential one.
Officer B noted that Mr Teague not attending work was a warning sign of his
increasing risk.
65. SO B, case co-ordinator, later chaired the first ACCT case review. Officer B and Ms
A both attended. Staff had no concerns about how Mr Teague presented or his
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demeanour during the review. Mr Teague said that he had been struggling but was
currently doing better. He said that he had always had thoughts to end his life but
had no plans or intent to act on these. He said that he was being supported by wing
staff and the weekly psychology sessions he attended had helped him with his
difficulties. He also now spoke to his father and sister regularly and they acted as
part of his support network. SO B told us at interview that Mr Teague had reiterated
several times during the review that he had not harmed himself, and his actions
were a result of him feeling stressed. The staff agreed that they would reduce Mr
Teague’s ACCT checks to three conversations a day and it was noted in the ACCT
care plan that Mr Teague should try and attend one workshop session. Staff
scheduled the next ACCT review for 27 September.
66. On 22 September, a member of the chaplaincy team visited Mr Teague and
conducted a welfare check. No concerns were noted. At a key work session the
next day, staff again raised no concerns.
67. On 26 September, Ms A saw Mr Teague. Mr Teague described himself as being
content and settled and although he said that he frequently had suicidal thoughts,
he had no plans or intent to act on these. He said that he had been practising some
of the strategies learnt during his psychology sessions and that they had helped him
to calm down during times when he had struggled. He said he struggled when he
attended the medication hatch and work because of the loud and busy environment
of these areas. Ms A noted that Mr Teague’s mood was good and he talked about
his future and aspirations he had in his working life. She scheduled her next session
with Mr Teague for 7 October. Ms A told us at interview that she intended to
continue sessions with Mr Teague focusing on his anxiety. She said that Mr Teague
engaged well in this session and was motivated to work on issues that challenged
him.
68. At 9.30am, SO A recorded in Mr Teague’s ACCT document that she had chaired an
ACCT review with him. (She recorded this on prison computer records, at 9.42am).
At interview, she confirmed that this had taken place in the wing office. CCTV
shows that Mr Teague and SO A went into the wing office for two minutes that
morning between 9.23am and 9.25am.
69. SO A did not record that any other staff were present but at interview she told us
that a wing officer was present. She also said that healthcare staff were invited to
the review and had said they would provide verbal input, but they did not. SO A
noted that Mr Teague engaged well in the review. He talked about not wanting to
always burden staff with how he felt, but agreed that if he ever needed to, he would
ask staff to contact the mental health or psychology team for additional support. Mr
Teague said that he had no thoughts of suicide or self-harm and felt that being
monitored by ACCT procedures was a little “overboard”, especially as he had not
actually harmed himself. He had still not recently attended work due to his anxiety,
although he said he was happy and was able to deal with his feelings a lot better
now. SO A had received positive feedback from wing staff about Mr Teague’s
general behaviour. She recorded that staff agreed to stop ACCT monitoring and
scheduled an ACCT post-closure interview for 5 October. The ACCT care plan was
updated noting that the only action on it (for Mr Teague to attend work) had been
completed (despite Mr Teague still not attending work).
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70. At 9.36am, a different member of staff recorded on Mr Teague’s computerised
record that he had refused to attend his ACCT review. Staff noted that, as Mr
Teague had had a period of settled behaviour and had not had any attempted
suicide and self-harm incidents, ACCT monitoring would be stopped.
71. On the same day, mental health Nurse C and Ms B, a recovery worker from the
substance misuse team, saw Mr Teague for his 13-week review of his methadone
treatment. They assessed that Mr Teague was not experiencing any withdrawal
symptoms. As he only had two years left of his prison sentence before he was
released on parole, Mr Teague requested the formulation of a reduction plan for his
methadone prescription. He said that he wanted to be drug free upon his release
from prison. Staff advised Mr Teague that a reduction (of 2mls) would be added to
his care plan and the prescriber would ensure that his dose was changed.
72. On 29 September, a member of the chaplaincy team conducted a welfare check on
Mr Teague. No concerns were noted.
73. Prisoner A, who lived on the same wing as Mr Teague, said that he last had a
conversation with him around the beginning of October. He believed that that Mr
Teague had given up on life and was worried about being released.
74. On 5 October, SO B completed Mr Teague’s seven-day ACCT post closure review.
He had no concerns about Mr Teague and the ACCT remained closed.
75. On 6 October, Ms B recorded that a recovery peer mentor (a fellow prisoner trained
to support peers with substance misuse issues) on C Wing, had spoken to Mr
Teague. Mr Teague had told the mentor that he wanted support from the substance
misuse team. Ms B sent a task to the admin team to arrange for someone to meet
Mr Teague.
76. Due to technical issues with the downloading of Mr Teague’s phone calls, we were
unable to listen to the calls he made in the days before his death. However, the
HMPPS Early Learning Review which took place after he died noted that Mr
Teague called his father and stepmother at 10.31am. The review noted that the call
lasted approximately 30 minutes and Mr Teague did not raise any concerns.
77. Staff raised no concerns about Mr Teague during the day. When Operational
Support Grade (OSG) A completed the evening routine check (a regular check
undertaken by prison staff to ensure that the prisoners are in their cells and are
accounted for) at 7.20pm, he had no concerns about Mr Teague. During his checks,
OSG A noted that several prisoners, including Mr Teague, had covered their
observation panels (which is not allowed). He told these prisoners to uncover the
panels, which they did. Mr Teague was not subject to any further checks during the
night and did not press his emergency cell bell.
Events on 7 October
78. The investigator watched CCTV footage and body worn video camera (BWVC)
footage from 7 October. He also obtained information from the North West of
England Ambulance Service. The following account has been taken from all
sources.
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79. At around 5.00am, OSG A and OSG B started their morning routine check on C
Wing. At 5.04am, when OSG B arrived at Mr Teague’s cell, the observation panel
was covered and Mr Teague failed to respond when she called his name. OSG B
continued to check cells close to Mr Teague’s before returning to his cell to try
again to rouse a response. When she could not, OSG B alerted OSG A who
attended and also tried to get a response from Mr Teague by shouting his name
and banging on his cell door. Mr Teague did not respond.
80. According to Garth’s local security policy, three officers must be present to unlock a
cell during the night. At 5.12am, OSG A radioed for the Intervention Team to attend
the wing, so he could enter Mr Teague’s cell. Officer C, Officer D and Officer E
arrived at Mr Teague’s cell at 5.15am. When they unlocked and entered Mr
Teague’s cell, they immediately saw him hanging from a ligature (made from a
bedsheet) attached to the ceiling light fitting.
81. At 5.16am (according to the control room log) Officer D radioed a medical
emergency code blue (used when a prisoner is unconscious or having difficulty
breathing). Staff in the control room called an ambulance immediately and
instructed the prison healthcare team to go to Mr Teague’s cell.
82. Officer C supported Mr Teague’s body while Officer E cut the ligature and they laid
him on the floor. Mr Teague showed no signs of life. Officer E started
cardiopulmonary resuscitation (CPR) and rotated this with Officer C and Officer D.
83. Nurse D arrived within three minutes of the emergency code blue call. She checked
Mr Teague for signs of life and noted he was totally unresponsive, was cold to touch
but was not stiff. She used emergency equipment that included a defibrillator and
oxygen to treat Mr Teague.
84. The first ambulance paramedics arrived at 5.32am and took over the care of Mr
Teague. A second paramedic crew arrived at 5.37am. At 6.09am, paramedics
confirmed that Mr Teague had died.
Contact with Mr Teague’s family
85. The prison appointed Officer F and Officer G as family liaison officers. They left the
prison at 10.00am and at 1.05pm, they arrived at Mr Teague’s father’s home
address and broke the news of Mr Teague’s death. In line with HMPPS policy,
Garth offered a contribution to the cost of Mr Teague’s funeral.
Support for prisoners and staff
86. The prison posted notices informing other prisoners of Mr Teague’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 his death.
87. After Mr Teague’s death, the staff involved in the incident were given the
opportunity to discuss any issues arising and were also offered support by the staff
care team.
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Post-mortem report
88. The post-mortem report concluded that Mr Teague died from hanging. Toxicology
results found methadone (which he had been prescribed) in his system. The
toxicology report also noted that Mr Teague had olanzapine (an antipsychotic),
mirtazapine (an antidepressant) and clonazepam (used to treat seizures and panic
disorder) in his system. These drugs had not been prescribed to him.
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Findings
Management of Mr Teague’s risk of suicide and self-harm
89. Prison Service Instruction (PSI) 64/2011 on safer custody sets out the procedures
(known as ACCT) that staff should follow when a prisoner is assessed as at risk of
suicide and self-harm. It requires that ACCT case reviews are multidisciplinary and
that the case coordinator ensures that healthcare staff (or other appropriate staff,
such as mental health staff involved in their care) are always invited to attend the
first case review or provide a written contribution to them and any subsequent case
reviews where they are relevant to supporting the prisoner.
90. Mr Teague was supported under ACCT procedures on two occasions at Garth: from
29 May for 17 days and from 18 September 2023 for nine days. On both occasions,
he had apparently made a noose and stated that he had had suicidal thoughts. Mr
Teague said several times that he had thoughts of suicide but had no plan or
intention to act on these. Broadly, we are satisfied that Mr Teague received
reasonable support from the ACCT process, and in particular, recognise that Nurse
A conducted an appropriate holistic assessment of Mr Teague’s risk factors which
led to the opening of the first ACCT.
91. However, we found conflicting recorded information as to whether the ACCT case
review on 27 September took place, at which the ACCT was closed. This was the
last ACCT review before Mr Teague’s death. SO A recorded that she had held the
ACCT review. Six minutes later, staff recorded that Mr Teague had refused to
attend the review. SO A told us at interview that the review did take place and she
chaired it. CCTV showed that Mr Teague had only attended the wing office (where
the review took place) for two minutes (from 9.23am to 9.25am). No healthcare staff
attended or provided a written contribution – an omission given Mr Teague was
working closely with Ms A, the psychologist.
92. The PSI states that at the first ACCT case review, a prisoner’s most pressing needs
in relation to his risk of suicide and self-harm should be identified and a care plan
should be completed, giving detailed and time-bound actions aimed at reducing the
level of risk posed. When Mr Teague’s ACCT was first opened, the care plan noted
that he should attend a session of workplace activity to help address his anxiety.
When ACCT monitoring was stopped on 27 September, Mr Teague had still not
attended work. His care plan was closed although this action had not been
completed. Furthermore, the “Risk, Triggers and Protective Factors” sections were
blank.
93. Overall, we consider it would have been difficult for SO A, within the two-minute
time frame and without any supporting input from healthcare staff, to make an
appropriate assessment of Mr Teague’s risk. While we do not think that the decision
to end ACCT monitoring on 27 September, 10 days before Mr Teague’s death, was
plainly wrong in the circumstances, we do not think it offered staff the best
opportunity to holistically assess his risk. Garth began an investigation into the
issues associated with this ACCT review, but had not completed the investigation
by July 2024.
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94. Since Mr Teague’s death, Garth has introduced and completed additional ACCT
training for case coordinators along with an improved quality assurance process for
the management of ACCTs, and in light of the ongoing internal investigation, we
make no recommendation.
95. After the ACCT was closed, several staff, including a member of the mental health
and substance misuse team, a member of the chaplaincy team and an SO (who
completed the ACCT post-closure review) saw Mr Teague and none raised any
concerns about him or observed any obvious signs that he was in crisis leading up
to his death. We have concluded that Mr Teague hid the extent of his anxiety, and it
was reasonable that staff had not identified him as at imminent risk of suicide when
he died.
Clinical care
96. The clinical reviewer concluded that the clinical care Mr Teague received was of a
good standard and was equivalent to that which he would have received in the
community.
97. Mr Teague’s next of kin asked about how COVID-19 may have affected him. The
clinical reviewer did not identify any concerns regarding Mr Teague’s clinical care
related to COVID-19 and is satisfied that his increased risk was managed
satisfactorily by the healthcare staff at Garth. It was noted, however, that Mr Teague
experienced unpleasant symptoms due to COVID-19, including hallucinations and
at the time of his hospitalisation, felt that the hospital doctors were trying to harm
him. These experiences had a detrimental effect on him in the subsequent years
and clearly had an effect on his mental state.
Mental health
98. Mr Teague was appropriately treated with medication for depression. After he
referred himself to the mental health team in May 2023, when he said that he was
struggling with anxiety, he received a comprehensive, one-to-one assessment and
support from the psychology team. The mental health team thought that Mr Teague
would benefit more from a psychological approach in relation to his anxiety than
medication and he was still engaging with this treatment plan at the time of his
death. The clinical reviewer agreed with this approach and found that Mr Teague’s
mental health care was appropriate.
Substance misuse and the availability of illicit medication
99. Mr Teague had a long history of substance misuse and was treated with methadone
throughout his time at Garth. He was regularly reviewed by the substance misuse
service. The clinical reviewer concluded that his substance misuse care was
appropriate.
100. However, the toxicology report identified that Mr Teague had mirtazapine,
olanzapine and clonazepam in his system. As none of these medications had been
prescribed to him, he must have obtained them illicitly. The prison was unaware that
Mr Teague was taking illicitly obtained medication while he was there and there had
been no previous suspicions that he was using illicit substances.
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101. We do not know how Mr Teague obtained these medicines. He may have obtained
them from another prisoner who was prescribed them or they may have been illicitly
brought into the prison.
102. The prison has an Integrated Substance Misuse Strategy dated December 2021
which sets out the actions that Garth plans to take to eliminate the supply of drugs,
reduce demand and promote user recovery. Following the death of a prisoner from
drugs at Garth in November 2022, we recommended that further work needed to be
done to reduce the availability of illicit drugs and diverted medication. Garth
reviewed their drug strategy in April 2024, so that it continued to reflect changes in
local or national policy and was responsive to any emerging threats. The strategy
includes measures to prevent the diversion of medication. We make no
recommendation but clearly the Governor and drug strategy lead will want to
continuously review the local strategy to ensure it remains relevant to issues at
Garth.
Governor to note
Emergency response
103. Mr Teague’s observation panel was covered at 5.04am when staff did their routine
check. The two OSGs tried for some time to rouse a response from Mr Teague,
before eventually calling for other staff to attend eight minutes later. We understand
that staff could not see into the cell and therefore did not want to go in without the
required three officers being present, as required by Garth’s local security strategy.
Strictly speaking, staff should have radioed a code blue when Mr Teague was not
responding but we can understand why they chose not to do that given the early
hour and the possibility that Mr Teague was asleep. In any event, once more staff
were requested they went straight to Mr Teague’s cell and radioed a code blue.
104. While it seems unlikely that the delay affected the outcome for Mr Teague, given a
nurse said he was cold to the touch, the Governor will wish to consider whether
there is any learning from this incident to ensure there is no delay to staff requesting
assistance and going into cells in emergency situations.
Inquest
105. The Coroner’s inquest held on 27 May 2025 determined the medical cause of death
to be hanging. The jury returned a narrative conclusion, stating that Mr Teague
hanged himself.
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