Colin Storr

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Independent investigation into
the death of Mr Colin Storr,
a prisoner at HMP Durham, on
22 March 2024
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 Colin Storr died in hospital on 22 March 2024, after being found hanging in his cell at
HMP Durham, on 16 March 2024. He was 63 years old. I offer my condolences to Mr
Storr’s family and friends.
Mr Storr was only at Durham for around 24 hours before he took his own life. Prison staff
appropriately started suicide and self-harm prevention procedures (known as ACCT) when
Mr Storr arrived. However, staff did not use the information available to them to properly
assess the seriousness of his risk, or the frequency of checks required. In addition,
healthcare staff did not have access to documentation which contained pertinent risk
information. An issue that comes up too frequently in my investigations.
That evening, staff did not check Mr Storr as they should have for five hours and a
member of staff later falsified the records to indicate that he had completed these checks.
There were five self-inflicted deaths at Durham between June 2021 and June 2024,
including two within 9 days of arrival at Durham. I am extremely concerned that, having
been assured that progress had been made following previous recommendations to the
prison, this investigation raises similar issues.
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 November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 11
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Summary
Events
1. Mr Colin Storr had a history of suicide attempts in prison and the community. On 15
March 2024, he was remanded to prison for breaching a sexual harm prevention
order. Staff at court assessed Mr Storr as a risk to himself. He was taken to HMP
Durham and constantly observed on his way there.
2. Prison staff began Prison Service suicide and self-harm support measures, known
as ACCT. They set Mr Storr’s observation levels at hourly. Mr Storr moved to the
first night centre (E Wing).
3. Staff were initially unaware that Mr Storr was on an ACCT and so did not carry out
ACCT observations between 5.45pm and 10.55pm. The night officer discovered Mr
Storr’s ACCT document at 10.55pm. ACCT observations were appropriately
undertaken from then.
4. On 16 March, Mr Storr declined to engage in the regime and presented as quiet and
withdrawn. Prison staff attempted to engage with Mr Storr during this time.
5. Staff went to Mr Storr’s cell at 2.35pm to complete his ACCT assessment. Mr Storr
had hanged himself from his bed. Staff entered the cell, radioed an emergency
medical code, cut the ligature and began CPR. Paramedics took over Mr Storr’s
care at 2.45pm and, after they had managed to establish a pulse, took him to
hospital.
6. Mr Storr did not regain consciousness, and on 19 March, hospital staff withdrew
treatment. Mr Storr was pronounced dead on 22 March.
Findings
7. Prison staff and healthcare staff in reception did not use the information available to
them to appropriately assess Mr Storr’s risk. Staff set observation levels based on a
standard approach, rather than a personalised assessment of Mr Storr’s risk to
himself.
8. E Wing staff were initially unaware that Mr Storr was on an ACCT and so his ACCT
observations were not undertaken for a five-hour period. A supervising officer (SO)
later falsified records stating that he had undertaken these checks and the
management check.
9. Reception is a busy area in the prison. Healthcare staff raised concerns about their
relationships with prison staff, not having access to relevant risk information, and
delays caused by the process. We have previously made recommendations to
Durham to ensure staff have access to relevant risk information and are not making
decisions based solely on a prisoner’s presentation. We were assured these issues
had been fixed, and we are frustrated to identify the same issues here.
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10. Information sharing in reception is an issue that comes up too frequently in PPO
investigations and we will be working with HMPPS and NHS England to identify
workable solutions.
Recommendations
• The Prison Group Director and NHS Commissioner should ensure that reception
staff have access to, review and appropriately consider all relevant information
when assessing a prisoner’s risk to themselves.
• The Prison Group Director should undertake a review of the ACCT quality
assurance process to satisfy themselves that systemic issues are identified, and
suitable remedial actions taken in response.
• The Governor should introduce a robust audit process to check the accuracy of
recorded ACCT checks against CCTV to assure himself that there is not a systemic
issue with false entries.
• The Governor should ensure that reception supervising officers understand their
responsibilities to inform first night centre staff if a prisoner is on an open ACCT and
introduce a quality assurance process to satisfy himself the process is embedded.
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The Investigation Process
11. HMPPS notified us of Mr Colin Storr’s death on 22 March 2024.
12. The investigator issued notices to staff and prisoners at HMP Durham informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
13. The investigator visited Durham on 4 April. She obtained copies of relevant extracts
from Mr Storr’s prison and medical records.
14. The investigator interviewed 11 members of staff at Durham in May. The
investigator interviewed six members of staff via Microsoft Teams in May and June.
15. NHS England commissioned a clinical reviewer to review Mr Storr’s clinical care at
the prison. She attended all interviews jointly.
16. We informed HM Coroner for Country Durham of the investigation. At the time of
writing, the post mortem report was not available. We have sent the Coroner a copy
of this report.
17. The Ombudsman’s Office contacted Mr Storr’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. Mr Storr’s brother asked
us to consider:
• Was the prison aware of Mr Storr’s autism and was he receiving the right care?
• Did the prison give Mr Storr his medication?
• Was the prison aware of Mr Storr’s previous suicide attempt in prison and was
he suitably cared for?
18. These questions have been answered in this report.
19. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
20. Mr Storr’s brother received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Durham
21. HMP Durham is a local prison, serving the courts of Tyneside, Durham and
Cumbria. Spectrum Community Health CIC provides primary healthcare services.
Tees, Esk and Wear Valleys Foundation NHS Trust provides mental health
services.
HM Inspectorate of Prisons
22. The most recent inspection of Durham was in November 2021. Inspectors reported
that new arrivals had the opportunity to discuss their concerns but late admissions
and a busy first night centre sometimes impacted on the quality of the service
provided. Recorded levels of self-harm were lower than at similar prisons, and there
was good interrogation of self-harm data. The quality of support delivered through
ACCT case management varied, with care maps poorly completed and records of
daily interaction often missing. Prisoners’ healthcare was affected by serious staff
shortages in the department.
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 November 2021 to October 2022,
the IMB reported that the prison was a safe environment. The Board raised
concerns about the consistency of ACCT, particularly completion of supervisor daily
checks and the quality assurance process.
Previous deaths at HMP Durham
24. In the three years before the death of Mr Storr, there were 11 deaths at Durham.
Seven of these were due to natural causes, and four were self-inflicted. Up until the
end of August 2024, there had been two self-inflicted deaths and one due to natural
causes since that of Mr Storr.
25. We have previously made recommendations about reception staff properly
assessing risk based on prisoners’ risk factors and not solely on their presentation.
In response to an action plan in 2022, the National Safety Team delivered risks,
triggers and protective factors training to all custodial managers and supervising
officers at Durham. Healthcare staff continued to access ACCT awareness training.
26. We have also made recommendations, following two deaths in November 2022,
about all staff involved in completing initial risk assessments having access to
relevant information, including digital person escort records (DPERs), suicide and
self-harm warning forms and prison records. We were told in July 2023 that a
partnership meeting was held with healthcare and the prison to review reception
processes and an action plan produced. Monitoring was due to take place to ensure
risk information was readily available to all staff when assessing risk.
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27. The death of Mr Storr has highlighted that the response to previous PPO
recommendations has not been effective or sufficient.
Assessment, Care in Custody and Teamwork
28. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and self-harm. The purpose of ACCT is to try to determine the level of
risk, how to reduce the risk and how best to monitor and supervise the prisoner.
After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
29. As part of the process, a care plan (plan of care, support, and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the care-map
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
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Key Events
Background
30. Mr Colin Storr had a history of suicidal thoughts and had been admitted to
psychiatric hospitals to keep him safe. He had previously been in HMP Durham
between November 2013 and May 2014. In March 2014, Mr Storr attempted to
hang himself in his cell at Durham. He had attached a ligature made of bedding to
his bed. He was cut down by his cellmate at the time. Mr Storr said he had done
this because he had been remanded in prison charged with new offences. When
released, he received a 10-year Sexual Harm Prevention Order (SHPO - a court
order to prevent a person from engaging in a particular activity) due to end in May
2024.
15 March 2024
31. On 15 March 2024, Mr Storr was charged with breaching his SHPO and remanded
to prison. Court staff recorded concerns about Mr Storr’s low mood and behaviour
(including rocking and head banging) on Mr Storr’s Digital Person Escort Record
(DPER – an electronic form that provides relevant details on a prisoner, including
risk alerts). They noted that he had reacted badly to being remanded to custody and
had been trying to get the drawstrings out of his trousers. Court staff completed a
paper Suicide and Self-Harm (SASH) form for Mr Storr noting that he was ‘lying in a
foetal position rocking. Since coming down from court he seems a lot more
emotional and mental health appears to have deteriorated’. Staff observed him
constantly during the journey from court to Durham.
32. Supervising Officer (SO) A and a mental health nurse completed a joint interview
with Mr Storr in reception when he arrived at Durham. The SO noted that Mr Storr
disclosed being autistic (there was no formal diagnosis of this in his clinical record)
and had arrived with a SASH form. He could not specifically recall reviewing Mr
Storr’s DPER but stated that all DPERs are checked. He noted that Mr Storr said
that he had lost everything and felt he wanted to die but had no plans to kill himself.
33. The mental health nurse recorded that Mr Storr denied wanting to die but said he
had thoughts to harm himself but no plan or intent to do so. She recorded that Mr
Storr was ‘tearful on occasions however smiled and laughed on some occasions’.
She told us that she asked him directly if he wanted to end his life and he said he
did not. She did not have access to the DPER and said she had never seen a
DPER for any prisoner. She told us that she had reviewed Mr Storr’s clinical records
but, in interview, seemed unaware of key information contained within those records
including Mr Storr’s previous stay in a psychiatric hospital and incidents of self-harm
in the community.
34. The SO started prison suicide and self-harm monitoring and support procedures,
known as ACCT, and placed Mr Storr on hourly observations. During interview, he
stated that hourly observations was standard practice at Durham, and he believed
Mr Storr would be sharing a cell which would mean he would have someone to talk
to. He told us that he would have increased the level of observations if he had
known Mr Storr would be in a single cell. He was unaware that Mr Storr had
previously attempted to hang himself whilst in a shared cell. The mental health
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nurse agreed with the hourly observations. She also said that in general when
opening an ACCT, hourly observations were standard unless staff had major
concerns about the prisoner. There is no evidence that any referrals for specialist
support or assessment were made following Mr Storr’s disclosure that he was
autistic.
35. A nurse completed Mr Storr’s healthcare screening and noted that he was tearful
and withdrawn, disengaged, and had thoughts of suicide with plans. She stated that
she told the mental health nurse about her concerns following her contact with Mr
Storr and the mental health nurse replied that they had already opened an ACCT.
The mental health nurse told us she could not recall this conversation. The nurse
confirmed that she had not reviewed Mr Storr’s DPER or SASH form, nor was she
aware of Mr Storr’s suicide and self-harm history. She also did not see his ACCT
document. During interview, she stated that she believed Mr Storr’s observations
should have been more frequent.
36. The nurse completed Mr Storr’s Medication in Possession Risk Assessment
(MIPRA – considers the ability of a prisoner to hold and safely manage their
medication based on risk). Mr Storr’s score indicated that he could hold his own
medication. (The clinical reviewer concluded that this was based on inaccurate
information because the nurse had answered several questions wrongly, including
that Mr Storr was not subject to ACCT monitoring.) However, she overrode this
outcome and did not permit Mr Storr to hold his own medication. A pharmacy
technician later assessed Mr Storr as suitable for in-possession medication. She
told us that she had searched Mr Storr’s clinical record for ‘overdose’ and ‘self-
harm’ and found no issues.
37. An officer completed Mr Storr’s first night induction in reception. During interview,
she recalled that Mr Storr was very tearful and stated that he had ‘lost everything’.
38. An Advanced Nurse Prescriber (ANP) reviewed Mr Storr at 6.06pm. He sent a
request to obtain Mr Storr’s community medical record. Mr Storr was prescribed
amitriptyline (a painkiller), paracetamol and sertraline (an antidepressant). Mr Storr
did not receive any medication while at Durham due to the short length of his time
there.
39. An officer (referred to as a runner who moves prisoners from reception to the first
night centre) took Mr Storr and his wing file to the first night centre (E Wing). Mr
Storr’s wing file contained his vulnerabilities assessment, completed by SO A in
reception, (which did not identify that he was on an ACCT), ACCT document and
Cell Sharing Risk Assessment (CSRA - this identifies prisoners who cannot safely
share a cell with others). Mr Storr was assessed as suitable to share a cell. At
Durham, ACCT documents are usually put in a separate white folder but the prison
had run out of them so staff put it in his wing file. No one from reception informed E
Wing staff that Mr Storr was on an ACCT as they should have done.
40. CCTV shows that Mr Storr arrived on the first night centre at 6.17pm and was left
alone for around three minutes before an orderly prisoner (who supports others)
approached him. An officer left the wing office at 6.22pm and showed Mr Storr to
his cell. This was the last time Mr Storr was seen on CCTV before the emergency
event.
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41. Officer A began his night shift at 9.00pm and completed a roll check (a check
conducted to confirm the number of prisoners on the wing) shortly afterwards. He
confirmed both the count and the number of ACCTs on the wing to the manager in
charge of the prison overnight. Having checked their records, the manager phoned
him at 10.55pm to tell him that there was an additional open ACCT on the wing. The
officer then found Mr Storr’s ACCT document in his wing file. He told us that staff
completed no ACCT checks on Mr Storr between 5.45pm and 10.55pm as they had
been unaware that Mr Storr was on an ACCT.
42. Officer A was sure that checks had not been recorded in Mr Storr’s ACCT
document between 5.45pm and 10.55pm on 15 March. However, when the PPO
reviewed the ACCT document, checks were signed as being completed by SO B at
6.30pm, 7.27pm, and 8.27pm. The SO had also signed the supervisor entry check
at 9.22am on 16 March. CCTV shows that no checks were done on Mr Storr by
prison staff on the first night centre until the officer’s check at 10.55pm. During
interview, the SO could not recall making these entries or account for why CCTV
showed that no checks had been carried out.
43. A nurse completed three routine healthcare first night checks on Mr Storr overnight
through his observation panel. During the first of these at 9.59pm, Mr Storr was
vaping and said that he was okay.
16 March 2024
44. On 16 March at 12.26am, the nurse checked Mr Storr and noted that he was vaping
on his bottom bunk. Officer A submitted a security intelligence report at 1.00am
regarding the missed ACCT checks the evening before.
45. Officer A completed Mr Storr’s ACCT checks between 10.55pm on 15 March and
6.00am on 16 March. He told us that that Mr Storr was crying and shaking on the
bed. When asked if he was feeling suicidal, Mr Storr said that he was not. The
officer checked on him more regularly through the night due to his concerns. He
stated that he managed to get Mr Storr ‘laughing and smiling’ and then Mr Storr
settled down to sleep. The nurse also checked Mr Storr at 5.12am and noted that
he was asleep.
46. An officer completed four ACCT checks on Mr Storr between 9.20am and 12.05pm.
He recorded that Mr Storr declined access to the exercise yard and did not want to
engage. He told us that Mr Storr was quiet and thoughtful. He did not assess Mr
Storr as being in distress or anxious.
47. Another officer completed the second day induction with Mr Storr at approximately
9.40am. She told us that he was not crying as much as he was on the first day but
that he did not want to share a cell. The chaplain visited Mr Storr at 9.56am and
tried to engage Mr Storr in conversation but said that he barely responded.
48. Another officer went to Mr Storr’s cell five times between 12.00pm and 2.19pm. She
told us that she tried to engage with Mr Storr, but he was very quiet, and he said he
found it difficult to speak to people as he was autistic. She asked him whether he
was okay and he replied he was ‘fine’. She informed Mr Storr that his ACCT case
review would take place that afternoon. She told us that she had no concerns Mr
Storr was a risk to himself.
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49. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to prison radio communications from 16 March. She also obtained
information from the North East Ambulance Service. The following account has
been taken from all sources.
50. At 2.34pm, a SO and an officer attended the first night centre to complete Mr Storr’s
ACCT assessment and case review. The SO looked through the flap in Mr Storr’s
cell door and saw that Mr Storr had a ligature made of bedsheets around his neck
attached to the bed. He was in a seated position with his legs touching the floor but
his bottom suspended.
51. The SO radioed a code blue (an emergency code used when a prisoner is having
difficulty or is not breathing) at 2.35pm. Control room staff immediately called an
ambulance. The SO and officer went into Mr Storr’s cell, and the SO cut the ligature
using their anti-ligature knife, laid Mr Storr on the floor and the officer started
cardiopulmonary resuscitation (CPR). A Healthcare Assistant (HCA) was working
on the wing and went straight to the cell, arriving within a minute of the code blue
being called. She left to collect the emergency healthcare bag, oxygen and
defibrillator. She returned as three nurses also got to the cell. Staff attached the
defibrillator and followed its instructions. Staff continued CPR.
52. Paramedics reached Mr Storr at 2.45pm and took over his treatment. They
managed to obtain a return of spontaneous circulation (where there is a sustained
heart rhythm that spreads through the body after a cardiac arrest). Paramedics took
Mr Storr to hospital.
53. Police found two final notes in Mr Storr’s cell. In one, Mr Storr referred to not
wanting to be a burden anymore. In the second, Mr Storr referred to losing his
home and dog, and expressing anger at the police.
54. Mr Storr did not regain consciousness and, on 19 March, hospital staff withdrew
treatment. Mr Storr died at 4.34pm on 22 March.
Contact with Mr Storr’s family
55. The prison appointed two family liaison officers (FLOs). Mr Storr had not nominated
a next of kin when he arrived at Durham. On 17 March at 10.00am, the police
provided prison staff with Mr Storr’s brother’s contact details. One FLO phoned Mr
Storr’s brother immediately and told him that Mr Storr was in hospital. She remained
in contact with Mr Storr’s brother via telephone while Mr Storr was in hospital.
56. The FLO phoned Mr Storr’s brother on 22 March to tell him that Mr Storr had died.
In line with national policy, Durham offered a contribution to the cost of Mr Storr’s
funeral.
Support for prisoners and staff
57. On 16 March, a senior manager debriefed prison and healthcare staff involved in
the emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
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58. The prison posted notices informing other prisoners of Mr Storr’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 Storr’s death.
Post-mortem report
59. At the time of writing this report, the post-mortem report was not available.
Inquest
60. At the Coroner’s inquest, held from 11 February to 17 February 2026, the jury
concluded that Mr Storr died by suicide.
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Findings
Assessment and management of risk
61. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), contains national requirements
on the assessment and management of suicide and self-harm risks in prisons. The
instruction lists risk factors and potential triggers that staff should be alert to and act
appropriately to address. Any prisoner identified as at risk of suicide and self-harm
must be managed under ACCT procedures.
62. Mr Storr identified as autistic, hopeless, and having lost everything he cared about.
He told staff that he wanted to die, and a nurse believed he had plans to harm
himself. He was last in prison ten years previously when he had tried to take his
own life by hanging himself, he had a history of suicide attempts in the community
and had been admitted for inpatient psychiatric care due to his suicide risk. When in
court on 15 March, court staff noted concerns about his risk to self based on his
presentation. He was constantly observed while being transported from court to
prison. On arrival at Durham, SO A, in agreement with the mental health nurse,
appropriately started ACCT procedures for Mr Storr.
Initial action plan
63. The SO and the mental health nurse set observation levels at hourly pending the
ACCT assessment and first case review. They said that this was routine practice
when starting an ACCT in reception at Durham.
64. The investigator conducted a spot check of six open ACCT documents and two post
closure ACCT documents on the first night centre and A-Wing on 1 May 2024. Of
these, six were initially put on hourly observations, one was set at five times an hour
(in line with the policy for segregated prisoners), and one was transferred in on an
ACCT from another prison and so the frequency of checks remained unchanged.
The prisoner in the segregation unit was reduced to hourly observations following
the initial case review, despite stating that he ‘100% wanted to die’ and disclosing
that he was hearing voices. The concern forms reviewed (which note the reasons
for beginning ACCT procedures) detailed a prisoner tying a ligature around his neck
and attaching it to the light fitting, a prisoner cutting his arms and stomach, and a
prisoner disclosing struggling with thoughts of self-harm and their mental health.
65. The investigator spoke to several members of staff at Durham and was concerned
about staff attitudes towards the ACCT process, including staff not taking it
seriously enough. One member of staff that said that they rarely opened ACCT
procedures because most prisoners who expressed thoughts of suicide or self-harm
were manipulative.
66. The mental health nurse and SO A did not appropriately assess Mr Storr’s
individual level of risk, details of which were contained in the DPER, SASH form,
prison record, and clinical record. The nurse relied almost entirely on what Mr Storr
told her. A nurse did not review relevant documents, including the SASH form, and
was not able to see the ACCT document as SO A had kept it so that he could
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complete the initial parts of it. The mental health nurse and the other nurse did not
have access to the DPER.
67. When the nurse discussed Mr Storr with the mental health nurse, she said that the
mental health nurse told her that the ACCT had already been opened.
68. Mr Storr’s level of risk was not holistically assessed using all of the available
evidence and, as a result, we consider that staff underestimated his risk to himself.
Observation levels were insufficient and were based on a standard level for new
prisoners rather than a personalised risk assessment. The Head of Safety told us
that staff who set ACCT observation levels have completed the relevant learning to
do so, and so will be aware that there is no ‘standard’ frequency. He sent out an
email to prison staff re-iterating these requirements.
69. Following two deaths in November 2022, the PPO recommended that all staff
involved in prisoner risk assessments have access to and consider relevant
information, including DPERs and prison records. We also recommended that staff
do not rely on a prisoner’s presentation alone when assessing suicide and self-
harm risks. In July 2023, the prison told us that prison staff and healthcare staff had
access to relevant information necessary for risk assessment. We were also
informed that prison staff underwent risk, triggers and protective factors training with
the National Training Team. Healthcare staff continued to access ACCT training.
70. The Mental Health Team Manager confirmed in July 2024 that work was ongoing to
ensure that mental health nurses based in reception had access to DPERs.
However, at the time of writing, only one mental health nurse out of 12, had access
to the appropriate account. The Head of Healthcare stated that work was
undertaken at the end of 2023 to ensure healthcare staff had access to DPERs.
She said that she was continuing to work with the prison regarding access for new
healthcare staff. Since Mr Storr’s death, the Head of Healthcare has also asked that
DPERs are printed out in the interim to ensure staff have access to them.
71. It is deeply troubling that we have raised these concerns repeatedly with little sign
of improvement, particularly in light of previous assurances that our concerns had
been addressed. The clinical reviewer shares our concerns. We therefore make the
following recommendation:
The Prison Group Director and NHS Commissioner should ensure that
reception staff have access to, review and appropriately consider all relevant
information when assessing a prisoner’s risk to themselves.
The Prison Group Director should undertake a review of the ACCT quality
assurance process to satisfy themselves that systemic issues are identified,
and suitable remedial actions taken in response.
72. We are concerned, however, that issues around information sharing in reception,
and particularly healthcare staff access to DPERs, is an issue that we identify in too
many cases. HMPPS has agreed that this issue requires focus and we will be
meeting HMPPS and NHS England colleagues to discuss.
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ACCT management
73. CCTV showed that the ACCT checks signed by a SO B at 6.30pm, 7.27pm, and
8.27pm, were not completed. It appears that he falsely signed these ACCT checks,
and the supervisor check, as complete after Mr Storr’s death.
74. In interview, SO B stated that he could not recall completing these checks or
recording them in the ACCT document. He said that he may have incorrectly
recorded checks on another prisoner in Mr Storr’s ACCT document. However, he
also told us that he could not recall doing any ACCT checks on the wing. We are
unconvinced by his version of events, particularly in light of Officer A’s account that
he was sure there were no checks logged at those times when he found the ACCT
document at 10.55pm. He submitted an intelligence report about this at the time.
75. We referred the matter to the local police, who decided not to investigate further.
The Head of Safer Custody at the time of Mr Storr’s death was aware that ACCT
checks had been falsified by SO B and confirmed that a managerial enquiry was
commissioned. The SO was on long-term sick leave at the time of writing this report
and, as such, the enquiry has not been completed. We trust that Durham will deal
with this matter appropriately. During interview, the Head said that she did not think
that falsification of ACCT checks was common at Durham. We consider this
conclusion can only be reached following a robust analysis of evidence. We make
the following recommendation:
The Governor should introduce a robust audit process to check the accuracy
of recorded ACCT checks against CCTV to assure himself that there is not a
systemic issue with false entries.
76. During interviews with staff, it became clear that they regularly put ACCT
documents into a prisoner’s wing file, rather than the white ACCT folder. Staff
interviewed did not think that this meant ACCTs were missed because wing staff
should open the wing file to review the CSRA and vulnerabilities assessment and
so should see the ACCT document. In Mr Storr’s case this did not happen.
However, Durham has changed the process to ensure that ACCTs are placed in the
separate white folder and cannot be so easily missed.
77. A senior manager told us that the reception supervising officer should also inform
the first night centre when an ACCT is opened. He said that this process was in
place at the time of Mr Storr’s death. Our interviews concluded that this process
was not known about or implemented by reception staff; certainly, SO A did not tell
staff on the first night centre that Mr Storr was on an open ACCT.
The Governor should ensure that reception supervising officers understand
their responsibilities to inform first night centre staff if a prisoner is on an
open ACCT and introduce a quality assurance process to satisfy himself the
process is embedded.
Reception
78. Reception is a busy area of the prison, with 23 new prisoners arriving on 15 March
2024 and 21 on 16 March 2024. SO A told us that he could not ensure that all
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prisoners went through the correct process and that mistakes happened due to time
constraints.
79. SO A and a nurse stated that relationships between healthcare staff and prison staff
could be difficult, with an ‘us versus them’ mentality. This, combined with a busy
reception department, sometimes did not promote collaborative working. Some
healthcare staff did not seem confident in challenging prison staff and those who
said they would be confident were not sure they would be listened to. The Head of
Healthcare assured us that she is working with the prison to ensure a more
collaborative way of working. Reception hours have been extended to try to reduce
the pressure on staff and she said relationships have improved between officers
and nurses in reception, with a clearer understanding of roles and responsibilities
evidenced across teams. As this issue appears to be improving, we make no
recommendation.
Clinical Care
80. The clinical reviewer concluded that the care Mr Storr received was of a moderate
standard and partially equivalent to that which he could have received in the
community. This was partly based on issues already discussed in assessing Mr
Storr’s risk to himself but she also identified several other issues which the Head of
Healthcare will wish to address, one of which is detailed below.
Head of Healthcare to note
Medicine in possession risk assessment (MIPRA)
81. The nurse incorrectly input information into the MIPRA during her assessment with
Mr Storr, including that he was not subject to ACCT procedures. This resulted in an
incorrect MIPRA outcome. The nurse did not check whether she had answered
questions correctly but did override the assessment and assessed Mr Storr as not
suitable to have his medication in his possession based on his presentation.
61. However, this decision was reversed. This would have resulted in Mr Storr, who
posed a risk to himself, being provided medication to hold in his cell. During
interview, a colleague recognised her error in not checking whether Mr Storr was on
an open ACCT. In any event, Mr Storr did not receive any medication due to the
short amount of time he was at Durham. The Head of Healthcare will wish to ensure
staff accurately complete MIPRAs and that they consider all available information if
overriding the outcome of a MIPRA.
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