Christopher Parker

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Independent investigation into
the death of Mr Christopher
Parker, a prisoner at
HMP Holme House, on 12
November 2020
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 Christopher Parker was found hanged in his cell on 12 November 2020, at HMP Holme
House. He was 35 years old. I offer my condolences to Mr Parker’s family and friends.
Mr Parker had a number of risk factors that indicated he was at high risk of attempted
suicide and self-harm. When he arrived at HMP Durham, staff did not start ACCT
monitoring.
After Mr Parker self-harmed on 22 October 2020, at HMP Holme House, staff started
ACCT monitoring. We found deficiencies in the way ACCT procedures were managed.
The investigation also found some weaknesses in the emergency response, although I
cannot say if these deficiencies affected the outcome for Mr Parker.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister, CB
Prisons and Probation Ombudsman June 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. In December 2017, Mr Christopher Parker was sentenced to four years and 10
months in prison for robbery. He was released on licence from HMP Holme House
in April 2020. He was recalled to HMP Durham in June after taking an overdose
and breaching his licence conditions. He returned to Holme House later that month.
Mr Parker had a history of attempted suicide, self-harm, mental illness and
substance misuse.
2. Reception staff at Durham did not identify that Mr Parker was at risk of suicide and
self-harm. Despite a range of risk factors being present, he was not managed
under the Prison Service suicide and self-harm prevention procedures (known as
ACCT).
3. On 29 June, Mr Parker transferred to Holme House.
4. On 22 October, Mr Parker self-harmed and prison staff started ACCT monitoring
procedures. The same day, Mr Parker told prison staff that he had taken an
overdose. Nurses assessed him in the prison’s inpatients unit.
5. On 28 October, a mental health assessment concluded that Mr Parker was not
mentally unwell. His mood was low as he believed that he was at risk from other
prisoners because of his offence.
6. On 10 November, Mr Parker had an ACCT case review and said that he had no
intention of harming himself. Those present assessed his risk as low and agreed to
stop ACCT monitoring.
7. On 12 November, Mr Parker told a custodial manager (CM) and a prison officer that
he was concerned about another prisoner who knew about the nature of his
offence. The CM agreed to move Mr Parker to another houseblock.
8. At 4.00pm, an officer carrying out a routine check found Mr Parker hanging from a
ligature attached to his toilet door. Staff and paramedics tried to resuscitate him,
but at 4.45pm, it was confirmed that Mr Parker had died.
Findings
HMP Durham
9. When he arrived at Durham, reception staff did not identify that Mr Parker was at
risk of suicide and self-harm. They did not start ACCT monitoring procedures as
they should have done.
HMP Holme House
10. There were a number of failings in the management of ACCT procedures at Holme
House. Observations were not always carried out in accordance with Mr Parker’s
ACCT plan, and they were often completed at predictable intervals.
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11. Case reviews were not always multi-disciplinary and the ACCT caremap did not
include specific actions to reduce Mr Parker’s risk. An ACCT case review did not
take place when there was a change in Mr Parker’s behaviour, which indicated an
increased risk of suicide and self-harm.
12. The officer who found Mr Parker unresponsive in his cell on 12 November 2020, did
not have a radio and was unable to call an emergency medical code. This caused
a slight delay in calling an ambulance.
13. The clinical reviewer concluded that Mr Parker’s mental and physical healthcare
was equivalent to that which he could have expected to receive in the community.
Recommendations
For HMP Durham
• The Governor of HMP Durham should ensure that reception, first night staff and
all others who assess risk:
• consider and record all the known risk factors of a newly arrived prisoner when
determining their risk of suicide or self-harm.
• note and consider all information from all available records including their
licence recall documents; and
• open an ACCT if a prisoner indicates that he is at risk of attempted suicide and
self-harm, irrespective of his demeanour.
For HMP Holme House
• The Governor should ensure that staff manage prisoners at risk of suicide and
self-harm in line with national guidelines. In particular, staff should:
▪ hold multi-disciplinary ACCT reviews which take place within the
set timescales.
▪ set effective caremap objectives which are specific, time-bound
and meaningful, aimed at reducing risk and updated at each case
review.
▪ carry out observations with the correct frequency.
▪ vary times of ACCT checks, while remaining within set observation
periods, to avoid prisoners being able to predict when they will be
checked; and
▪ ensure prisoners are reviewed after a change in their behaviour
that indicates an increased risk of suicide or self-harm.
• The Governor should review the current provision of radios to ensure it is
sufficient to meet the needs of the prison.
• The Governor should share this report with CM A and Officer A and arrange for
a senior manager to discuss the Ombudsman’s findings with them.
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The Investigation Process
14. The investigator issued notices to staff and prisoners at HMP Holme House
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Parker’s prison and
medical records.
16. NHS England commissioned a clinical reviewer to review Mr Parker’s clinical care
at the prison. The investigator and clinical reviewer interviewed 14 members of
Holme House staff on 10 December 2020 and 17 June 2021. The interviews were
conducted by video because of the restrictions in place during the COVID-19
pandemic.
17. We informed HM Coroner for Teeside of the investigation. The coroner gave us the
results of the post-mortem examination. We have sent the coroner a copy of this
report.
18. We wrote to Mr Parker’s nominated next of kin, his mother, to explain the
investigation and to ask if she had any matters, she wanted the investigation to
consider. Mr Parker’s family wanted to know:
• how did Mr Parker receive the gash on his face?
• was Mr Parker taking any illicit substances when he died?
• was Mr Parker being monitored under ACCT procedures?
• was there any evidence that Mr Parker had self-harmed or attempted to take
his own life in the prison before he died?
• how often did prison staff check on Mr Parker?
19. We have answered the family’s questions in this report.
20. Mr Parker’s family received a copy of the initial report. They did not raise any
further issues, or comment on the factual accuracy of the report.
21. 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 Holme House
22. HMP Holme House is a category C training prison holding over 1200 men. G4S
provides health services at the prison. There is a 24-hour healthcare unit with 16
beds.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Holme House was in February and March 2020.
Inspectors reported that the safer custody team had undertaken some recent work
to improve the quality of the ACCT case management process through stringent
quality assurance, but it was too soon to judge its effectiveness. Inspectors found
that in the sample of ACCTs they reviewed, case managers were not always
consistent, and reviews were not always multidisciplinary. Some caremaps lacked
detail and observational entries were often limited. The prisoners they spoke to
who were being monitored under ACCT had mixed views about the quality of staff
care and support.
Independent Monitoring Board
24. 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 ending 31 December 2020, the IMB
reported that staff referred 638 prisoners for ACCT monitoring during 2020.
Inspectors said that the safer custody team encouraged active management and
reviewing of the ACCT plan so that the case was not open for longer than
necessary while the prisoner was kept safe
Previous deaths at HMP Holme House
25. Mr Parker was the 16th prisoner to die at Holme House since October 2018. Of the
previous deaths, 12 were from natural causes, two were self-inflicted and one was
drug related. There have been seven deaths since Mr Parker’s death, three from
natural causes, three were self-inflicted and one is awaiting classification.
26. In a previous investigation into the death of a prisoner at HMP Holme House in July
2020, we were concerned about the management of ACCT and recommended that
observations are carried out at the correct frequency and at irregular intervals. The
Prison Service accepted our recommendation and issued an action plan, which said
that Holme House would issue a Governor’s Order which highlighted the need for
observations to be carried out at the frequency recorded in the ACCT document
and that they must not be undertaken at predictable times. Holme House also
introduced a weekly ACCT Quality Assurance and Coaching meeting to identify
recurring issues in the ACCT process. It is disappointing that we are having to
repeat this recommendation again.
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Assessment, care in custody and teamwork (ACCT)
27. 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.
28. 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 multidisciplinary 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.
29. 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 64/2011, Management of prisoners at risk of harm, to
self and from others (Safer Custody).
Incentives and Earned Privileges (IEP) Scheme
30. Each prison has an Incentives and Earned Privileges scheme which aims to
encourage and reward responsible behaviour, encourage sentenced prisoners to
engage in activities designed to reduce the risk of re-offending and to help create a
disciplined and safer environment for prisoners and staff. Under the scheme,
prisoners can earn additional privileges such as extra visits, more time out of cell,
the ability to earn more money in prison jobs and to wear their own clothes. There
are three levels: basic, standard and enhanced.
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Key Events
31. On 4 October 2017, Mr Christopher Parker was remanded to HMP Durham. On 18
December, he was sentenced to four years and 10 months in prison for robbery.
On 30 June 2018, he transferred to HMP Holme House. On 1 April 2020, Mr Parker
was released on licence to an Approved Premises. He was recalled to Durham on
13 June, after taking an overdose (believed to be heroin) and breaching the
conditions of his licence. Mr Parker transferred to Holme House on 29 June.
HMP Durham
32. Mr Parker arrived at HMP Durham on 13 June. A prison officer completed his first
night induction. Mr Parker’s recall notification said that he was at the risk of death,
given his recent overdose on what was believed to be heroin. It is not known
whether this was an intentional or accidental overdose. The officer noted that Mr
Parker did not have any thoughts of suicide or self-harm.
33. A nurse completed Mr Parker’s initial health screen. She noted that he had a
history of substance misuse and alcohol abuse, and was not taking any prescribed
medication. Mr Parker said that he did not have any thoughts of suicide or self-
harm. The nurse made a referral to the Drug and Alcohol Recovery Team (DART).
HMP Holme House
34. On 29 June, Mr Parker transferred to Holme House.
35. Prison staff completed a cell sharing risk assessment (CSRA), which recorded that
Mr Parker was a standard risk for sharing a cell. In line with COVID-19 restrictions,
Mr Parker was placed in isolation for 14 days. On 13 July, he was allocated a
single cell on Houseblock 1. Mr Parker was not allocated a keyworker due to the
COVID-19 restrictions. Prison staff completed regular welfare checks.
36. A nurse completed Mr Parker’s initial health screen. She noted that he had cerebral
arteriovenous malformation (abnormal blood vessels connecting arteries and veins
in the brain) and was not receiving any medication or treatment for this condition. A
prison GP saw Mr Parker in a virtual clinic and noted that he was under the care of
the Royal Hallamshire Hospital. He referred Mr Parker to the complex care register,
and nurses contacted the hospital about his consultant appointment on several
occasions. Mr Parker did not see a consultant before he died.
37. On 12 August, prison staff found Mr Parker in possession of hooch (illicit alcohol).
He was placed on the basic regime under the Incentives and Earned Privileges
(IEP) scheme for a period of seven days.
38. On 7 September, Mr Parker referred himself to the prison’s mental health team. On
12 September, a mental health nurse completed an initial assessment. Mr Parker
said that he was feeling very anxious and was not sleeping. He told her that he had
a history of self-harm in the community. She referred him for a secondary mental
health assessment.
39. A mental health nurse saw Mr Parker on 23 September. Mr Parker said that he felt
stressed because he suspected his victim’s grandson was a prisoner at Holme
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House. He also said that he had a history of self-harm and alcohol abuse in the
community. She noted that Mr Parker did not have any mental health symptoms
but was fearful for his safety. She told the investigator that she spoke to the Safer
Custody team about Mr Parker’s concerns and was told that the other person was
not a prisoner at Holme House. She did not inform Mr Parker of this.
40. The next day, a prison GP prescribed Mr Parker sertraline (an antidepressant used
to treat anxiety). Mr Parker was allowed to keep the medication in his cell. The
same day, an officer completed a welfare check. Mr Parker said that he felt settled
on Houseblock 1 and spent his time watching television, going on the exercise yard
and using the kiosk.
41. On 3 October, a prison officer completed a welfare check. Mr Parker did not raise
any issues or concerns and said that he was coping well with the restricted regime.
42. On 18 October, Officer A completed a welfare check. He noted that Mr Parker was
in a good mood and he did not report any issues. Mr Parker was enjoying his new
job as a wing painter because it occupied his time and gave him a routine outside of
his cell.
Events of 22 October
43. At approximately 6.40pm on 22 October, Mr Parker self-harmed by cutting himself.
A nurse saw Mr Parker and noted that he had made multiple superficial wounds to
his skin, two small marks to each cheek and long multiple lacerations to both sides
of his chest. None of Mr Parker’s wounds needed stitches.
44. At 6.50pm, an officer began ACCT procedures because Mr Parker said that he had
made cuts to his chest and face because he wanted pain relief medication and his
mental health was ‘through the roof’. A Senior Officer (SO) completed Mr Parker’s
immediate action plan and placed him on one observation an hour. A SO was
appointed as the ACCT manager.
45. Mr Parker rang his cell bell at 8.30pm and asked about his painkillers. An officer
noted that Mr Parker appeared disorientated. Prison staff found illicit alcohol in his
cell.
46. At approximately 10.43pm, Mr Parker told prison staff that he had taken an
overdose of sertraline and paracetamol. A nurse saw him and noted that he was
alert and fully mobile and appeared intoxicated from illicit alcohol. Mr Parker
refused to attend hospital, so he was admitted to the prison’s inpatients unit.
Nurses assessed Mr Parker using the National Early Warning Scale (NEWS2 - an
assessment to determine a patient’s level of illness) and noted that he scored 0.
This is the lowest level on the scale and indicated a low level of clinical risk. Nurses
referred him to the prison’s mental health team.
ACCT: 23 October to 10 November
47. At 11.20 am on 23 October, a mental health nurse saw Mr Parker for an initial
mental health assessment. She noted that Mr Parker’s mood was low, and that he
believed he was at risk from other prisoners because of his offence.
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48. At 2.40pm, an officer carried out an ACCT assessment in the prison’s inpatients
unit. Mr Parker said that he had obtained illicit alcohol and had taken all his
medication because he felt stressed and anxious. He said that he had no current
thoughts of suicide or self-harm. He noted that Mr Parker needed to see the mental
health team and have his medication reviewed.
49. At 3.30pm, a Custodial Manager (CM) completed the first ACCT case review. Mr
Parker said that he had self-harmed while under the influence of illicit alcohol.
There was no healthcare or mental health input. The CM noted that Mr Parker did
not feel safe on a normal location houseblock due to the nature of his offence. The
CM assessed Mr Parker as a low risk of suicide and self-harm. He added three
actions to Mr Parker’s caremap about his alcohol and substance misuse, the
suitability of his pain relief medication and an application for his transfer to another
prison.
50. A nurse saw Mr Parker again at 5.28pm, for a comprehensive mental health
assessment. She concluded that Mr Parker was not mentally unwell, and he did not
meet the criteria to be on the secondary mental health team’s caseload. Mr
Parker’s stress was related to his view that other prisoners were going to assault
him. She referred Mr Parker to the primary mental health team to receive support
with coping strategies for stress. She told the investigator that the waiting time for
an appointment was approximately two to four weeks.
51. At 6.15pm, healthcare staff and prison staff completed Mr Parker’s formal discharge
from the prison’s inpatients unit before he returned to Houseblock 1. Mr Parker said
that he was happy to move and had no feelings of suicide or self-harm.
52. On the 26 October, Mr Parker was referred for low intensity cognitive behaviour
therapy to focus on managing stress. The same day, a nurse saw Mr Parker to
assess if he was suffering from alcohol withdrawal or struggling with alcohol issues.
Mr Parker showed no sign of withdrawal and did not need any treatment.
53. On 27 October, a SO carried out an ACCT case review. Mr Parker said that he felt
safe on the houseblock and that drinking illicit alcohol had led to his self-harm and
increased feelings of paranoia. Mr Parker said that he had no thoughts of suicide or
self-harm. The SO assessed Mr Parker’s risk as low and reduced his observations
to one in the morning and afternoon, three observations during the night and one
conversation a day.
54. On 30 October, a prison officer completed a welfare check. Mr Parker was polite
and respectful and did not report any issues or concerns.
55. A SO completed an ACCT review on 3 November. There was no healthcare input.
Mr Parker said that he regretted self-harming and drinking illicit alcohol. He did not
have any feelings of suicide or self-harm. An officer reviewed Mr Parker’s caremap.
He considered that Mr Parker’s risk remained low and reduced his observations to
one during the day and one conversation.
56. On 9 November, a prison GP reviewed Mr Parker’s medication because he wanted
to stop taking sertraline. She noted that a GP should speak to Mr Parker before his
medication was stopped and that another GP had arranged to speak to Mr Parker
on the telephone on 11 November.
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57. A SO completed an ACCT review on 10 November. An officer attended and there
was no healthcare input. Another officer noted that Mr Parker was happy and
engaged well. Mr Parker said that he had no thoughts of suicide and self-harm. Mr
Parker’s risk level remained unchanged and the actions on his caremap were
complete. Both officers agreed to stop ACCT monitoring. The SO noted that the
post-closure phase would end on 17 November. An alert to this effect was added to
Mr Parker’s NOMIS record (electronic prison record).
Events of 12 November
58. At approximately 11.00am, Mr Parker spoke to Officer A and said that he was
concerned about another prisoner on the wing who he knew from HMP Durham and
who was aware about the nature of his offence. Mr Parker told him that he had
asked another officer if he could share his cell with the other prisoner (from
Durham). The officer said that Mr Parker intended to assault the other prisoner so
that he would be moved to the segregation unit. Mr Parker recognised that this was
inappropriate but was concerned for his safety.
59. At approximately 11.30am, Mr Parker went to the wing office and spoke to CM A.
Mr Parker shared his concerns about the other prisoner and asked for a move to
Houseblock 4. The CM told the investigator that she checked Mr Parker’s NOMIS
and noted that he was able to associate with other prisoners without any
restrictions. Mr Parker was assessed as suitable to share a cell.
60. CM A spoke to Officer A and asked him to arrange for Mr Parker to be moved to
Houseblock 4 and a note was left in the wing office. There was no entry in Mr
Parker’s NOMIS record. The officer could not remember being asked to arrange for
Mr Parker to move to Houseblock 4. He told the investigator that Mr Parker was
upset and distressed before he went to his cell. He was not aware that Mr Parker
was in the post-closure phase of ACCT monitoring.
61. At approximately 4.00pm, Officer A started a routine roll count at the end of
afternoon association and went to Mr Parker’s cell. He looked through the
observation panel and saw Mr Parker hanging from the toilet door. Because he did
not have a radio, he called for assistance from a colleague and pressed the
emergency alarm. Another officer entered Mr Parker’s cell and used his fish knife
to remove the ligature. He started cardiopulmonary resuscitation (CPR), assisted
by an officer. At 4.08pm, an officer radioed an emergency code blue (indicating a
prisoner is unconscious or having breathing difficulties). The control room
immediately called an ambulance.
62. Three nurses arrived at Mr Parker’s cell and took over CPR. One nurse inserted an
airway into Mr Parker’s nasal passage to help him breathe and attached a
defibrillator, which did not detect a shockable rhythm. Paramedics arrived at
4.16pm and took control of Mr Parker’s care. Mr Parker remained unresponsive
and at 4.45pm, the paramedics confirmed that Mr Parker had died.
Contact with Mr Parker’s family.
63. The prison appointed two family liaison officers (FLO) and identified Mr Parker’s
mother as his next of kin. At 11.50am, they visited Mr Parker’s mother at her home,
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but she was not there. Both FLOs went to Mr Parker’s mother’s work address and
broke the news of his death.
64. The prison contributed towards the cost of Mr Parker’s funeral, in line with Prison
Service guidance.
Support for prisoners and staff.
65. A prison manager held a debrief on the day of Mr Parker’s death to offer support to
the staff involved in the emergency response and to ensure they had the
opportunity to discuss any issues. The staff care team also offered support.
66. The prison posted notices informing other prisoners of Mr Parker’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Parker’s death.
Post-mortem report
67. The pathologist concluded that Mr Parker died from hanging.
68. The toxicology report detected an alcohol concentration of 80mg/100ml in Mr
Parker’s blood. The pathologist said that this is the level at which driving a motor
vehicle is permitted in England and Wales. This level may be associated with
decreased reaction times and impaired judgment, although it was very much
dependent on an individual’s tolerance to alcohol.
Inquest
69. An inquest held on 15 May 2024, concluded a narrative verdict and said ‘… the
deceased deliberately chose to suspend himself from a bedsheet but it is unclear
whether he determined the outcome to be fatal …’
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Findings
Management of Mr Parker’s risk of suicide and self-harm
70. Prison Service Instruction (PSI) 64/2011 on safer custody, requires all staff who
have contact with prisoners to be aware of the triggers and risk factors that might
increase the risk of suicide and self-harm, and take appropriate action. (The risk
factors were also listed in our thematic report published in 2014.) Mr Parker had
several of these risks including previous self-harm, poor mental health, and licence
recall.
71. Mr Parker’s licence was revoked after he took an overdose in an Approved
Premises. The recall paperwork said that it was not known if the overdose was
intentional or accidental. There is no evidence that prison staff assessed Mr
Parker’s risk of suicide or self-harm when he arrived at Durham on 13 June. We
consider that given Mr Parker’s recent self-harm, Durham should have started
ACCT monitoring. We recommend that:
The Governor of HMP Durham should ensure that reception, first night staff
and all others who assess risk:
• consider and record all the known risk factors of a newly arrived
prisoner when determining their risk of suicide or self-harm;
• note and consider all information from all available records including
person escort records (PERs); and
• open an ACCT if a prisoner indicates that he is at risk of attempted
suicide and self-harm, irrespective of his demeanour.
72. When Mr Parker self-harmed at Holme House on 22 October, staff appropriately
decided that he should be managed under the ACCT suicide and self-harm
prevention procedures.
73. We consider that the ACCT procedures did not effectively support Mr Parker
because the overall management of the ACCT was poor and not fully in line with
PSI 64/2011. ACCT case reviews were not always multi-disciplinary and only two
ACCT reviews were conducted by Mr Parker’s case manager. Prison staff did not
always complete observations in accordance with his ACCT document and
observations were not always irregular.
74. Caremaps should reflect the prisoner’s needs, level of risk and the triggers of their
distress. Instructions say they should aim to address issues identified in the ACCT
assessment interview and later reviews, and consider a range of factors including
health interventions, peer support, family contact and access to diversionary
activities. Each action on the caremap should be tailored to the individual needs of
the prisoner, be aimed at reducing risk and be time bound. Mr Parker’s caremap
did not refer to his mental health, despite this being one of the triggers for starting
ACCT monitoring.
75. Mr Parker was in the post-closure phase of ACCT monitoring when he hanged
himself on 12 November. We consider that the decision to stop ACCT monitoring
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was appropriate. There were reasonable grounds to assess that Mr Parker’s risk
had reduced and the actions on his caremap were complete.
76. On 12 November, Mr Parker approached Officer A and CM A because he was
worried about another prisoner who had arrived on Houseblock 1. The CM agreed
to move Mr Parker to another houseblock and asked the officer to arrange this. Mr
Parker’s anxiety was caused by concern for his own safety, and this was listed as a
trigger on his ACCT plan. His behaviour was a cause for concern and suggested
an increased risk of suicide and self-harm. We consider that the CM should have
arranged an urgent case review to assess Mr Parker’s risk and whether the ACCT
needed to be re-opened. We consider that Holme House need to take steps to
improve the ACCT process. We recommend that:
The Governor should ensure that staff manage prisoners at risk of suicide
and self-harm in line with national guidelines. In particular, staff should:
• hold multi-disciplinary ACCT reviews which take place within the
set timescales;
• set effective caremap objectives which are specific, time-bound
and meaningful, aimed at reducing risk and updated at each case
review;
• carry out observations with the correct frequency;
• vary times of ACCT checks, while remaining within set
observation periods, to avoid prisoners being able to predict
when they will be checked; and
• ensure prisoners are reviewed after a change in their behaviour
that indicates an increased risk of suicide or self-harm.
Mental and clinical healthcare
77. The clinical reviewer concluded that Mr Parker’s mental and physical healthcare
was at least equivalent to that which he could have expected to receive in the
community.
78. Mental health nurses saw Mr Parker after he self-harmed and completed two
comprehensive assessments. Although Mr Parker said he was suffering from
anxiety, the nurses considered that this was due to his concerns about other
prisoners being aware of the nature of his offence. Mr Parker was referred to the
primary mental health team for further support. The clinical reviewer said that the
waiting time to access this service was comparable to waiting times in the
community.
79. Mr Parker had cerebral arteriovenous malformation, which had caused him to suffer
from seizures. He was not receiving any treatment for this when he came into
prison. The clinical reviewer considered that Mr Parker’s clinical care was
appropriate, although there was a significant delay from the hospital in providing Mr
Parker with any treatment advice or to give him a consultant appointment. We
make no recommendation.
12 Prisons and Probation Ombudsman
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Emergency response
80. Although staff responded quickly when Mr Parker was found unresponsive, Officer
A, who was first on scene, was unable to call an emergency medical code because
he did not have a radio. He pressed the emergency alarm to alert staff that there
was an emergency. The failure to call an emergency code would have caused a
slight delay in calling an ambulance. We cannot say whether these delays would
have made a difference to the outcome in Mr Parker’s case but could make a
critical difference in other medical emergencies.
81. We are concerned that a lack of available radios could cause unnecessary delays in
other circumstances and could put officers at risk if they are unable to call for
assistance. We recommend that:
The Governor should review the current provision of radios to ensure it is
sufficient to meet the needs of the prison.
Learning lessons
82. We consider it essential that staff learn the lessons from our reports. We therefore
recommend that:
The Governor should share this report with CM A and Officer A and arrange
for a senior manager to discuss the Ombudsman’s findings with them.
Prisons and Probation Ombudsman 13
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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