Davina Canning

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Independent investigation
into the death of
Ms Davina Canning,
a prisoner at HMP Hewell,
on 29 July 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, 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.
Ms Davina Canning, a transgender prisoner, was found hanged in her cell at HMP Hewell
on 29 July 2023. She was 59 years old. I offer my condolences to Ms Canning’s family and
friends.
Ms Canning was a very challenging prisoner to manage. Throughout her two weeks at
Hewell she engaged in persistent anti-social and self-harming behaviour. While staff
monitored Ms Canning using suicide and self-harm prevention procedures (known as
ACCT) throughout, the procedures did not provide the framework for managing Ms
Canning’s needs, risks and vulnerabilities that they should have.
On the night that she died, Ms Canning repeatedly pressed her emergency cell bell,
exposed herself to two female staff, tied clothing around her neck and attempted to
electrocute herself. Even considering her behaviour in the previous two weeks, this
demonstrated an escalation in risk. The staff on her houseblock managed Ms Canning
with patience and professionalism, but there should have been more input from the night
manager with proper consideration given to the risk she posed.
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 March 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 21
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Summary
Events
1. On 15 July 2023, Ms Davina Canning, a transgender prisoner, was remanded to
HMP Hewell charged with a domestic violence offence and assault of a police
officer. In court, Ms Canning told staff that she would take her life were she sent to
prison. Prison staff started suicide and self-harm prevention procedures (known as
ACCT) when she arrived at Hewell.
2. During her time at Hewell, Ms Canning displayed difficult and challenging behaviour.
She tied ligatures with her clothing or tied fabric around her limbs to try to stop blood
flow. Ms Canning sometimes scratched herself. She pressed her emergency cell bell
dozens of times a day, including for much of the night, and was unpopular with other
prisoners as a result.
3. On the night of 28-29 July, Ms Canning continuously pressed her emergency cell
bell and engaged in other antisocial behaviour. She poured water into the electric
sockets and placed her wet fingers in the socket. She tied clothing around her neck.
At around 4.35am, the night staff found Ms Canning on the floor of her cell,
unresponsive, with a ligature tied around her neck. Resuscitation attempts were
unsuccessful, and, at 5.33am, paramedics confirmed that Ms Canning had died.
Findings
4. While prison staff appropriately started ACCT procedures when Ms Canning arrived
at Hewell, there was insufficient strategic consideration given to managing her risks
effectively. Her level of risk was underestimated, and observations set too
infrequently as a result. More could have been done to identify and review support
actions, that might have helped to address Ms Canning’s ongoing issues.
5. Ms Canning’s behaviour on the night that she died was particularly disruptive and
difficult to manage. The night staff on her houseblock dealt with her behaviour
professionally throughout. However, there was apparently only one conversation
between the night manager and the junior staff on the houseblock about Ms Canning
at the beginning of the night shift.
6. Despite her persistent and challenging behaviour, and history of mental ill-health, Ms
Canning was not prioritised for a mental health assessment.
Recommendations
• The Governor should review the quality and compliance with policy of ACCT
management in the previous 12 months, identify any improvements required,
and devise a plan to deliver those improvements.
• The Head of Healthcare should ensure that prisoners who present with
persistent and challenging behaviours are assessed according to their level of
risk and need, with consideration given to their most suitable location.
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• The Head of Healthcare should ensure that all emergency response staff attend
medical emergency codes immediately.
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The Investigation Process
7. The Prisons and Probation Ombudsman (PPO) was notified of Ms Canning’s death
on 29 July 2023.
8. The investigator issued notices to staff and prisoners at HMP Hewell informing them
of the investigation and asking anyone with relevant information to contact him. One
prisoner responded, who was interviewed.
9. The investigator obtained copies of relevant extracts from Ms Canning’s prison and
medical records.
10. NHS England commissioned a clinical reviewer to review Ms Canning’s clinical care
at the prison. In October, the investigator and clinical reviewer jointly interviewed four
prison and healthcare staff and one prisoner. The investigator also interviewed three
prison staff.
11. Between April and June 2024, another investigator interviewed a custodial manager
and four healthcare staff with the investigator and obtained further information from a
senior manager. She also completed a follow up interview with a member of staff
who had previously been interviewed.
12. We informed HM Coroner for Worcestershire of the investigation. He provided us
with a copy of the post-mortem and toxicology reports. We have sent the Coroner a
copy of this report.
13. The Ombudsman’s office contacted Ms Canning’s husband to explain the
investigation and to ask if he had any matters he wanted us to consider. Ms
Canning’s husband asked one question that we have addressed in separate
correspondence.
14. Ms Canning’s husband received a copy of the initial report. They did not identify any
factual inaccuracies.
15. The prison also received a copy of the report. They did not identify any factual
inaccuracies.
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Background Information
HMP Hewell
16. HMP Hewell is a large category B local prison in Worcestershire, holding adult male
prisoners. Hewell has six residential houseblocks.
17. Healthcare services are provided by Practice Plus Group (PPG) and mental health
and substance misuse services are sub-commissioned to Midlands Partnership NHS
Foundation Trust (MPFT). MPFT provide an integrated mental health and substance
misuse service known as ‘Inclusion’ and are commissioned to be on site at Hewell
between 9.00am and 5.00pm Monday to Friday, with regional on-call cover available
at the weekends. MPFT also provide a Targeted Care Pathway (TCP) at Hewell
which is covered by two mental health nurses, seven days a week. The TCP is for
people who have been deemed to require increased mental health support due to
their needs and are seen for daily reviews.
HM Inspectorate of Prisons
18. HMIP carried out a full inspection of Hewell in November/December 2022.
Inspectors reported that the prison had made excellent progress since their last
inspection and was now cleaner, more decent and safer. Assaults on staff and
prisoners had significantly reduced and the prison felt safe and calm.
19. Inspectors remained concerned that not enough progress had been made to
address previous concerns raised about support for those prisoners who are at most
risk of suicide or self-harm. They found some of the processes to protect the most
vulnerable were weak. Inspectors noted the minutes of the weekly safety
intervention meeting showed good examples of support and individualised care.
There were fewer prisoners receiving support when at risk of suicide or self-harm
than at the time of the previous inspection, and staff awareness of prisoners in crisis
was generally good. However, inspectors found the quality of ACCT documentation
was variable and prisoners on the main units felt that staff did not have enough time
to support them.
20. Transgender prisoners told inspectors that they felt well supported even though they
were frustrated by some delays in the delivery of some gender-specific purchases.
21. Inspectors found mental health services were stretched because of staffing
pressures and high health needs. An early days in custody pathway, which assessed
prisoners arriving at the prison, had ceased and staff were prioritised to manage
those with high-level mental health needs and those in crisis. The number of
referrals was high, at around five a day, and waiting times for an initial assessment
often took four weeks, which was too long. Staff had reduced capacity to undertake
meaningful one-to-one interventions as most time was spent assessing new patients
or supporting those being managed by suicide and self-harm measures. Psychiatry
provision was good.
22. Inspectors returned to Hewell in November 2023, to undertake an independent
review of progress. They identified there had been insufficient progress in key areas,
including that too little had been done to reduce levels of self-harm. There was no
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specific strategy to reduce self-harm and the recorded rate of incidents was on an
upward trend. The quality of ACCT assessment and management remained
variable. Inspectors noted the challenges of staff resources, the impact of the rising
prison population and that Hewell had a 40% increase in new arrivals. Inspectors
found that healthcare delivery had improved.
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 annual report for the year to 30 September 2023, the IMB reported
that the Governor and staff at Hewell had striven to deliver a safe, fair, and humane
regime.
24. The IMB reported that self-harm incidents had risen by 28.4% compared to the
previous reporting year. Although they noted that an increase was expected due to
the rise in the prisoner population, this was still high compared to similar prisons.
There had been an increase in the use of suicide and self-harm procedures following
additional training for all staff and a push to make reviews more multi-disciplinary.
The IMB observed that while these were dutifully completed, they often lacked depth
and analysis. Almost without exception, the opportunity for prisoners to contribute
was not taken and the page for their views was blank.
Previous deaths at HMP Hewell
25. Ms Canning was the eleventh prisoner to die at Hewell since July 2020. Of the
previous deaths, five were self-inflicted and five were from natural causes. There are
no significant similarities between our findings in these deaths and Ms Canning’s.
Assessment, Care in Custody and Teamwork
26. ACCT is the Prison Service care planning system used to support prisoners at risk of
suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise prisoners. As part of
the process, a support plan which includes support and intervention, should be in
place. The ACCT plan should not be closed until all the actions of the support plan
have been completed. Guidance on ACCT procedures is set out in Prison Service
Instruction (PSI) 64/2011 on safer custody.
Incentives and Earned Privileges Scheme (IEP)
27. Each prison has an incentives and earned privileges (IEP) 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 wear their own clothes. There are
four levels, entry, basic, standard and enhanced.
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Key Events
Background
28. Ms Davina Canning had served previous custodial sentences and was last released
from prison on 17 June 2022. During a previous sentence in 2016, Ms Canning self-
strangulated and was supported under suicide and self-harm prevention procedures,
known as ACCT. During her previous prison sentences, Ms Canning identified as
male and was known as Arthur or David Canning.
29. Following her release in June 2022, Ms Canning began to identify as female. She
had not had gender reassignment surgery or hormone therapy and did not have a
gender recognition certificate (which is necessary to obtain a new birth certificate
recognising the acquired gender).
30. On 12 July 2023, Ms Canning was admitted to hospital after she was found
unconscious. It was later established that she had drunk alcohol with diazepam,
which she had recently been prescribed (for anxiety). Ms Canning told her
community GP that she had not taken an overdose. However, the GP noted that Ms
Canning said she felt suicidal because of life events, which included issues relating
to her mental health. (Ms Canning was diagnosed with anxiety and depression,
behavioural disorder, psychosis and attention deficit hyperactivity disorder.)
31. On 13 July, Ms Canning was arrested following an alleged incident of domestic
violence. During her arrest she assaulted a police officer.
HMP Hewell
32. On 15 July, Ms Canning appeared in court, where she told staff that if she was sent
to prison she would kill herself. Ms Canning was monitored five times an hour while
held in court cells.
33. Ms Canning pleaded guilty to the assault of a police officer, and she was remanded
in custody to await sentencing, and taken to HMP Hewell. Ms Canning was next due
to appear in court on 4 August.
34. The person escort record (PER - a document that accompanies all prisoners when
they move between police stations, courts and prisons which sets out the risks they
pose) noted Ms Canning’s previous history of self-harm, which included banging her
head in a police van, punching herself and that she had attempted to self-strangulate
with clothing while in prison. It was also noted that Ms Canning had taken an
overdose the night before her arrest and had a history of depression, anxiety, and
paranoia.
35. When Ms Canning arrived at Hewell, the escort officer told a Supervising Officer
(SO) that Ms Canning was at a hight risk of suicide or self-harm and had been
checked five times an hour by court staff. Ms Canning told the SO that she enjoyed
being monitored and had told court staff that she had felt suicidal for attention. Ms
Canning said that the thought of sharing a cell caused her anxiety. The SO told Ms
Canning that she would be given a single cell (because she was transgender), which
he noted alleviated a lot of her concerns.
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36. During the first night interview, an officer noted that warnings had been raised in
court about Ms Canning’s risk of suicide and self-harm. Ms Canning told the officer
that she had felt ‘low’ while in police custody and had ‘wanted to end it’, but that this
was because she had smoked cannabis the previous Monday. He noted that it was
not Ms Canning’s first time in prison, that she said she had no dependants or family
and was in rent arrears which caused her stress. He concluded that Ms Canning
should be assessed by the mental health team. (He did not make a referral to the
mental health team, although the reception nurse made one that same evening.)
37. A nurse started ACCT procedures and noted that Ms Canning had been kicking the
cell wall and hitting herself in the head. He recorded that Ms Canning had a history
of psychotic depression, anxiety and stress and used self-harm as a means to
control this. A Custodial Manager (CM) completed an immediate action plan and set
observations at once every two hours with two significant conversations a day. Ms
Canning said that she was awaiting confirmation of the numbers that could be added
to her prison phone account (because her husband was the victim of the alleged
offence he was not automatically added). The CM noted that she had no current
thoughts of self-harm. He recorded on the immediate action plan that the mental
health team should attend the first ACCT case review.
38. A nurse completed Ms Canning’s initial health screen. He noted that Ms Canning
had a history of psychosis, depression, anxiety and insomnia and was being treated
for several physical health conditions. He recorded that Ms Canning had arrived with
her medication including zopiclone (to aid sleep), fluoxetine (an antidepressant),
olanzapine (an antipsychotic) and diazepam (used to treat anxiety and help with
alcohol withdrawal). He noted that she had a history of alcohol abuse. He assessed
that Ms Canning was unsuitable to hold her medication in possession (meaning she
would have to collect it each day and take it in front of a nurse). He referred Ms
Canning to the prison’s substance misuse service, mental health team and prison
GP, who prescribed continuing medications.
39. An officer completed a cell sharing risk assessment (CSRA) and noted that Ms
Canning was significantly vulnerable to assault as a transgender prisoner and that
she was granted vulnerable prisoner status. He also noted that she wanted to be
referred to as Davina and to use female pronouns.
40. Ms Canning was allocated a cell on Houseblock 2, the induction unit. (Typically,
those with vulnerable prisoner status are held separately to other prisoners. Hewell
has a mixed induction wing, because of limited availability on the vulnerable prisoner
unit (VPU), where prisoners are unlocked at different times to access the regime.
They remain there until they have completed the induction and are then moved to
the VPU when a space becomes available.)
41. At around 9.50pm, Ms Canning told a CM that she might cut herself with a plastic
knife (which had been given to her to eat meals) if it was left in her cell. Ms Canning
handed over the knife as well as shoes and some clothing ‘just in case’, as she said
she did not know how she would feel later in the night. An officer spoke at length
with Ms Canning and reminded her of the support available, should she feel upset or
anxious. Ms Canning said that she would call the Samaritans if she needed to talk.
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Sunday 16 July
42. On 16 July, a nurse completed a secondary health screen. He recorded that Ms
Canning was being monitored under ACCT procedures and had some bruising to
her leg from kicking the cell door in court, but that she denied any current thoughts of
self-harm or suicide. He noted that Ms Canning was to be prescribed diazepam to
manage alcohol withdrawal and that the substance misuse service would monitor
her daily. (Daily monitoring for alcohol withdrawal did not happen.) He also warned
Ms Canning about taking illicit substances while in prison. He referred Ms Canning to
the prison’s mental health team.
43. A SO completed Ms Canning’s ACCT assessment. Ms Canning said she was
disappointed at being returned to prison and said that she believed the relationship
with her husband was now over. Ms Canning told the SO that she had been
diagnosed with anxiety, depression, paranoia, and gender dysphoria and that she
self-harmed to control feelings of anxiety.
44. Ms Canning said that the previous night she had made a scratch to her leg and tied
fabric around her neck as a cry for help. (These events were not recorded in Ms
Canning’s ACCT ongoing record, and we do not know if night staff were aware.) She
denied any suicidal ideation. Ms Canning told the SO that her usual method of self-
harm was to punch herself in the body and face, which was triggered by issues at
home, alcohol use and mental health issues. She said she had no external support,
other than her husband, who she was not allowed to contact due to her offence. The
SO noted that Ms Canning was forward thinking, was planning ahead of her
sentencing and how on release she hoped to get her own property and live a normal,
healthy life.
45. The SO noted that a transgender board would be arranged. (This is to consider any
offence related risks, risks to the safety of the individual, risks to other prisoners/staff
and agree what support is required to support the wellbeing and safety of a
transgender prisoner.) He recorded that Ms Canning’s triggers for self-harm included
her return to custody, mental health issues, and her next court appearance on 4
August. He noted that specific consideration should be given to Ms Canning’s
transgender status and poor literacy and that she had been referred to the prison’s
mental health team.
46. Another SO then chaired the first ACCT case review, attended by the previous SO, a
learning disability nurse from the mental health team, and Ms Canning. She noted
much the same information that the previous SO had recorded during the ACCT
assessment and that had been gathered and recorded over the previous day.
47. Ms Canning told the review that she felt vulnerable and wanted to move to the
vulnerable prisoners’ unit. The SO noted that she would make the necessary
arrangements, and Ms Canning would move when a space became available and
when she had completed her induction. She noted that although Ms Canning had
access to women’s underwear, her outer clothing was awaiting approval by the
transgender board. Ms Canning said that wearing her own clothes outside of her cell
would make her happy. She planned for Ms Canning to be able to shower on her
own.
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48. Ms Canning told the review that she had no intention of taking her own life but might
harm herself. She said she would tell staff if she felt her mental health was
deteriorating. The SO added three support actions; for Ms Canning to move to the
vulnerable prisoners’ unit, referral to the substance misuse team (which had already
been submitted), and for Ms Canning to attend a transgender board.
49. The review panel agreed to keep Ms Canning’s observations at every two hours and
for staff to record two quality conversations with her a day. The SO noted that it
would be helpful for a member of the transgender board to offer support at the next
review, which was set for 20 July, and that a keyworker would be allocated from the
vulnerable prisoners’ unit to support Ms Canning’s transition to the unit when it
happened.
50. In the afternoon, a nurse met Ms Canning as part of the process to identify prisoners
who might require treatment or support from the mental health team.
51. The nurse recorded Ms Canning’s history of alcohol misuse, which contributed to her
risk of self-harm, and of psychosis and depression. Ms Canning disclosed she had
previously been under the care of mental health services during her last period of
prison custody and had spent time in a psychiatric hospital. The nurse recorded Ms
Canning’s current presentation was stable and that there was no evidence of thought
disorder.
52. The nurse explained to Ms Canning that she would continue to be under the care of
the prison GP, as she would have in the community, for all her healthcare needs. A
care-coordinator from Inclusion (the integrated substance misuse and mental health
service) would gather further information through assessment and observation, and
she would be offered ongoing support. The nurse made a clinical plan for Ms
Canning to be seen by Inclusion and that she would be added to the Multi-
Professional Complex Case Clinic (MPCCC) for discussion. (There is no evidence in
her medical record that Ms Canning was discussed at MPCCC.) The nurse told Ms
Canning that if she had any future concerns she could self-refer to the mental health
team. She encouraged Ms Canning to take part in activities as this would be
beneficial for her mental health and wellbeing. Ms Canning was not added to the
mental health team’s caseload.
53. Later, a nurse sent a task to the GP at Hewell to review Ms Canning’s prescribed
medication. (There is no evidence that Ms Canning’s prescription was ever
reviewed, and it therefore remained at the dose she had been prescribed before
prison.)
54. Staff noted in Ms Canning’s ACCT record that she continuously pressed her cell bell
(which is intended for emergencies) during the night. Listeners saw her at 11.00pm.
Wednesday 19 July
55. During the morning, Ms Canning asked an officer when she would be moved to the
vulnerable prisoners’ unit. He replied that they were waiting for a space. During the
afternoon, an officer noted that Ms Canning had spent time with a friend, had taken
part in the regime and appeared in high spirits.
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56. During the night, staff gave Ms Canning three negative behaviour warnings for
misusing her emergency cell bell and swearing at staff.
Thursday 20 July
57. At around 8.00am, Ms Canning pressed her cell bell and staff found her with her
jumper knotted around her neck. Ms Canning said it was too tight, asked for help to
remove it and said that she had attempted to strangle herself because she had had
enough. Ms Canning then showed staff her underwear to confirm her desire to
transition and said that she wanted to move to Houseblock 5 (the vulnerable prisoner
unit) as she felt vulnerable.
58. A CM chaired an interim ACCT review, following Ms Canning’s attempt to self-
strangulate, with two officers also present. The CM noted that Ms Canning had
pressed her cell bell ‘relentlessly’ during the night. She recorded that Ms Canning
was in good humour and did not appear distressed. Ms Canning showed the CM her
underwear and told her that she wanted to come out onto the landing wearing it. The
CM told her that this would not be appropriate, might anger other prisoners, and that
she should only come out onto the landing fully clothed. The CM noted that she had
no concerns about the incident of self-harm and that Ms Canning just wanted to
come out of her cell to talk to staff that she liked about her transitioning. She did not
increase Ms Canning’s observations and informed her that the ACCT would be
reviewed again later in the day.
59. A nurse from the mental health team saw Ms Canning as an officer had taken her to
the healthcare centre. She recorded that when Ms Canning arrived, she was
laughing with the officer. She noted that Ms Canning had also made very small
scratches to her thighs.
60. During the morning, an officer noted that Ms Canning had to be removed from other
prisoners’ doors for shouting abuse. During the afternoon, Ms Canning repeatedly
misused her cell bell and spoke to wing staff about her wish to move to Houseblock
5.
61. In the afternoon, a SO chaired an ACCT case review. An occupational therapist from
Inclusion also attended. The SO recorded that Ms Canning appeared to be in good
spirits. Ms Canning said that her actions in the morning had been a cry for help and
that she wanted to move off the induction unit. Ms Canning said she did not feel safe
and had received abuse from other prisoners during association periods. Ms
Canning said that other prisoners had been spitting through the side of her cell door.
The SO noted that this was an ongoing problem with vulnerable prisoners on the
induction unit, which she raised with other managers.
62. During the review, Ms Canning had a shoelace tied tightly around her arm, which
she said she used to cut off the circulation to her hand. Ms Canning allowed staff to
remove the shoelace and staff removed another shoelace from her cell at her
request. The occupational therapist reassured Ms Canning that she had been
referred to Inclusion and that someone would come to see her soon (an appointment
had been made for 25 July). The SO told Ms Canning that an officer, who had
worked with other transgender prisoners, had been allocated as her keyworker.
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63. The SO noted that having conversations with staff made Ms Canning feel better and
that she spent the duration of the ACCT review laughing and joking. She noted that
Ms Canning’s location on Houseblock 2 was limiting her ability to associate with
others and feel safe. She also recorded Ms Canning had spoken to Listeners since
the last review, and that she had been taken to Houseblock 5 to speak to another
transgender prisoner, which Ms Canning had said she found helpful. The SO noted
that it was a priority to move Ms Canning to Houseblock 5 as soon as possible.
64. Ms Canning said that she was only sleeping for a couple of hours a night, because
she was given her diazepam at 4.00pm which kept her awake. The SO noted that
Ms Canning enjoyed reading but did not have her glasses and had asked the
chaplaincy if they had any spare glasses. She made applications for Ms Canning to
see the optician and dentist.
65. Ms Canning showed the SO her foot and ankle, which were swollen after she had
kicked her prison cell door in frustration. The SO contacted healthcare for them to
examine Ms Canning’s foot. She noted that Ms Canning benefited more from
meaningful conversations rather than observations and told us that this was because
she liked to talk and appreciated the attention from staff. Ms Canning denied having
any current thoughts of suicide or self-harm and the panel set conversations at one
in the morning and afternoon and observations every two hours during patrol state
(when prisoners are locked in their cells). The SO updated the support actions and
noted referrals to the optician and dentist, a request for reading glasses and a
referral to healthcare for Ms Canning’s foot to be assessed. The next ACCT review
was scheduled for 27 July.
Friday 21 July
66. An officer noted that Ms Canning had asked for painkillers during the night, but she
was told she would have to wait until the morning. Ms Canning slept from midnight
until morning and raised no issues.
67. In the morning, a Healthcare Assistant (HCA) examined Ms Canning’s foot. Ms
Canning said she had placed a ligature around her neck and all four limbs and that
officers had used their anti-ligature knives to release her. (There is no evidence of
this event in either the prison or healthcare record.) Ms Canning said she had some
pain in her neck and told the nurse that she had tied the ligature because she was
not receiving sleeping medication. The HCA recorded that Ms Canning had told her
that she wanted to move to Houseblock 5 so that she would feel safer, as other
prisoners were calling her names and spitting through her cell door. Ms Canning
denied any current thoughts of self-harm and the HCA said that she would escalate
concerns to the emergency response nurse. (There is no evidence this was done.)
68. During the morning, an officer noted that Ms Canning had spoken to him and
another officer ‘many times’ and that Ms Canning had used her cell bell constantly.
In the afternoon, he noted that Ms Canning had collected her dinner and medications
and was happy because she had vapes. Nothing was noted in the ACCT in relation
to the evening observations and conversations.
69. An officer noted that Ms Canning saw Listeners during the night. Ms Canning asked
him about moving to Houseblock 5. He recorded that, during the night, Ms Canning
rang her cell bell for ‘random things’ and that it seemed she wanted attention.
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Saturday 22 July
70. During the morning, Ms Canning asked if she could see a nurse because of pain in
her leg and symptoms of diarrhoea but raised no other issues. An officer recorded
that Ms Canning ‘showed a displeasing attitude’. During the afternoon, Ms Canning
apologised for her earlier behaviour.
71. An officer noted that, during the evening, Ms Canning had constantly rung her cell
bell, and that she had tied clothing around her legs as she believed this would stop
her circulation and that she would die. He noted that Ms Canning spoke to the
Samaritans on the telephone. (During her time at Hewell, Ms Canning did not make
any calls other than to the Samaritans.) She also flooded her cell.
72. During the night, the night manager recorded that he spoke to Ms Canning for
around 15 minutes. She told him that talking made her feel better and that she would
loosen the sock she had tied around her leg and go to sleep.
Sunday 23 July
73. At 4.11am, the communication room contacted Officer A. They asked for a welfare
check on Ms Canning as they had received a call from Samaritans saying that she
was going to kill herself. Officer B went to Ms Canning’s cell. He observed a small
amount of water on the floor and that Ms Canning was talking on the phone to
Samaritans. She had socks tied loosely around her leg and arm. Ms Canning told
him that Samaritans said he had to open her cell door and that she needed an
ambulance. He explained that he was not able to open her cell. He informed a CM of
the contact and agreed to continue monitoring Ms Canning as part of the ACCT
process. There was nothing recorded in the ACCT regarding the contact from
Samaritans or if any consideration was given to reviewing the ACCT or increasing
the number of observations.
74. At 4.44am, the CM went to Ms Canning’s cell. He recorded that she wanted him to
enter her cell and remove the sock tied on her arm. He described the sock as being
loose. He told her that he would not open the cell door for security reasons. Ms
Canning told him that if he did not enter the cell, she would tie a ligature around her
neck and jump off the top bunk of her bed to hurt herself. Ms Canning requested to
see a Listener, but he noted that due to her unpredictable and non-compliant
behaviour he would not authorise this to protect the Listener. He advised Ms
Canning to contact Samaritans if she needed to talk. He submitted a referral to the
mental health team and offered to provide Ms Canning with a distraction pack, which
she declined.
75. At around 6.00am, Officer A responded to an emergency cell bell and found Ms
Canning throwing bowls of water under the cell door. This behaviour continued while
she was on the phone to Samaritans. The CM recorded that other prisoners were
shouting at Ms Canning as they had not been able to sleep.
76. The CM submitted an intelligence report detailing that Ms Canning had continuously
misused her cell bell and during the night had tried to manipulate staff into opening
her door for non-emergency purposes. He noted that Ms Canning might be under
threat from other prisoners on the wing, as she had kept them awake with her
disruptive behaviour.
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77. During the morning, an officer recorded that he spoke to Ms Canning about her poor
behaviour since coming to Hewell. She told him that she wanted to move to
Houseblock 5. He explained to Ms Canning that she was being placed on the basic
IEP regime (the lowest level of the three-tier system designed to reward and
encourage good behaviour in prisons which reduces access to things like in cell
television, the prison shop and visits).
78. Another officer noted that Ms Canning had rung her cell bell most of the morning,
that it was ‘a nuisance’ and that every time he spoke with her she verbally abused
him. He noted that Ms Canning was too scared to leave her cell, because other
prisoners were angry as she had kept them awake. She did not therefore collect her
medication or any food.
79. Ms Canning continued to press her cell bell over the lunchtime period, and when
officers answered the bell she accused them of harassing her.
80. In the afternoon, Ms Canning moved to Houseblock 5 (the vulnerable prisoners’
unit). An officer and a CM escorted Ms Canning to her new (single) cell. At around
2.00pm, Ms Canning rang her cell bell. An officer responded, and she told him that
she respected women but not men. He asked another officer and a CM to go with
him to speak to Ms Canning to explain the use of the emergency cell bell. When the
officer spoke to Ms Canning about the misuse of the cell bell, she became
aggressive and spat in his face. He used force to restrain Ms Canning and applied
handcuffs. Ms Canning quickly calmed down and, on the arrival of the CM, the cuffs
were removed. Ms Canning was charged with a prison disciplinary offence.
81. Ms Canning later apologised to the officer for her behaviour and said she understood
why she had been restrained, but that staff had been too rough with her. A prison
paramedic assessed Ms Canning, noting mild bruising to her nose and wrists, but
that no further medical attention was required.
82. During the afternoon Ms Canning left her cell to collect her medication and dinner.
An officer noted that Ms Canning had agreed to a fresh start the following day.
Nothing was noted in the ACCT in relation to the evening observations and
conversations.
Monday 24 July
83. During the night, an officer recorded that Ms Canning saw a Listener and that she
warned her on multiple occasions about misusing her cell bell. The officer also noted
that, because of her behaviour, Ms Canning had received threats from other
prisoners.
84. At around 6.30am, Ms Canning asked an officer if she could see a paramedic as she
said she had passed out on the floor of the cell. There is no evidence that anyone
from healthcare was informed.
85. During the day, staff noted that Ms Canning appeared to be in a good mood, raised
no concerns and collected her medication and lunch.
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Tuesday 25 July
86. During the night, an Operational Support Grade (OSG) noted that Ms Canning had
not slept, had constantly rung her cell bell and had seen a Listener for around an
hour. She said she told Ms Canning that pressing her cell bell constantly during the
night and disrupting the wing would not help her to move off the basic IEP regime.
Ms Canning said that she did not care.
87. In the morning, a worker from Inclusion attempted to meet Ms Canning for a mental
health assessment. Ms Canning was attending her adjudication hearing for spitting
at an officer, so the appointment did not go ahead. It was rebooked for 8 August.
88. During the adjudication hearing, Ms Canning apologised for spitting and did not
dispute the evidence put to her. The adjudication was proven, but the case was
adjourned for (unrecorded) further information. (Ms Canning died before the hearing
was concluded.)
89. In the afternoon, an officer noted that Ms Canning had asked to see someone from
the mental health team. She also asked about being on the basic regime and not
having access to a television. Later, he noted that Ms Canning had been distressed
due to a wing lockdown (for an unrelated matter), and again asked to speak with
someone from mental health. He informed Ms Canning that she had an appointment
booked for 8 August.
90. In the evening, an officer noted that Ms Canning had been settled. During the night,
the OSG recorded that Ms Canning rang her cell bell for non-emergency reasons.
She told the OSG she was ringing the bell for attention as she was a poor coper and
did not like being locked in her cell. Ms Canning met Listeners at around 2.45am.
The OSG had several conversations with Ms Canning and encouraged her not to
misuse her cell bell as other prisoners would get frustrated. Ms Canning said she did
not care and continued to misuse her cell bell throughout the night.
Wednesday 26 July
91. An officer noted that Ms Canning had rung her cell bell for most of the night, which
had woken other prisoners. He also recorded that she had tied part of a jumper
around her wrist out of frustration.
92. Another officer noted that Ms Canning had had a settled morning and had interacted
well, collected her food, and raised no issues. Staff spoke to her again about
misusing her emergency cell bell.
93. Later in the morning, Ms Canning complained of rib pain and attended healthcare. A
nurse assessed her. Ms Canning told the nurse that she had been restrained several
days earlier. The nurse noted no bruising and told Ms Canning to ask for pain killers,
if required, from the medication hatch.
94. Ms Canning attended a transgender review board, which was chaired by the Head of
Security. The Equalities Manager, the Safety Hub Manager and the keyworker also
attended. It was noted that Ms Canning did not have a gender recognition certificate,
but that she identified as a woman. Ms Canning said she might like to transition in
the future but had no firm plans. The board recorded that Ms Canning did not have a
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formal diagnosis of gender dysphoria. Ms Canning said she had little support outside
of prison.
95. Ms Canning told the board that she had undiagnosed attention deficit hyperactivity
disorder (ADHD), post-traumatic stress disorder (PTSD), obsessive compulsive
disorder (OCD) and depression. The board noted that they were ‘not sure’ of these
diagnoses and that Ms Canning was to be seen by the mental health team on 8
August.
96. The Head of Security asked Ms Canning about her recent behaviour and that she
was disrupting other prisoners by disturbing their sleep. Ms Canning said she felt
safe and supported on Houseblock 5 and agreed that she would have a better
relationship with other prisoners if she did not disturb them. Ms Canning
acknowledged that she needed to be more considerate. The board noted that Ms
Canning was on the basic regime and so did not have a television. They agreed that
Ms Calloway would arrange for distraction packs, such as painting by numbers, to be
provided to Ms Canning and she was told that she could apply for prison work.
Arrangements were also made for Ms Canning to have access to a list of products
available to female prisoners and that this would be arranged in time for her next
order from the prison shop.
97. The keyworker later recorded that Ms Canning had had a ‘really good afternoon’,
that she had been provided with fresh clothes, mopped her cell, been provided with
a new in-cell phone (she had smashed hers during the night) and that a member of
staff had supervised her while she shaved. Ms Canning also attended the library.
She told the keyworker that she felt much better, appreciated what staff had done to
support her and would try harder not to misuse her cell bell. Nothing was noted in
the ACCT in relation to the evening observations and conversations.
98. Cell bell records show that Ms Canning did not use her cell bell between 10.00pm,
when she asked for a toilet roll, and 7.12am on 27 July. An OSG noted that Ms
Canning raised no concerns overnight.
Thursday 27 July
99. During the morning, an officer noted that Ms Canning was in good spirits, had
spoken to the Probation Service via videolink, and returned in a good mood. She told
him the meeting had gone well.
100. During the afternoon the officer noted that Ms Canning had been ‘good’ all afternoon
and they discussed what behaviour had led to her being placed on the basic regime.
101. At 2.45pm, the acting SO chaired Ms Canning’s ACCT review. A nurse also attended
with Ms Canning. The SO noted that at first Ms Canning presented negatively. She
said that earlier she had had a bad call with her solicitor who had told her that she
might receive a custodial sentence, which Ms Canning said she was not expecting.
The SO noted that Ms Canning was next due to appear in court on 4 August and he
would schedule an ACCT review on 3 August, to assess Ms Canning’s mood.
102. Ms Canning told the SO that she had thoughts of self-harm but did not intend to take
her own life, as she did not want to hurt herself. The SO recorded that Ms Canning
made use of the Samaritans for support, talked to officers and was being supported
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by the substance misuse team and transgender board. The SO told Ms Canning that
staff would look to return her television on Monday 31 July, dependant on her
behaviour over the weekend.
103. The nurse recorded that Ms Canning asked for support for her alcohol use and was
told that someone had been allocated to see her but had been unable to meet with
her as she was attending her adjudication at the time. She noted that Ms Canning
had said she had thoughts of self-harm, but when this was explored further, she
reported that she no longer had these thoughts as talking about it had helped her.
She noted that the review agreed that Ms Canning would find meaningful
conversations more beneficial than observations. Observations remained at one
every two hours during patrol state and meaningful conversations in the morning and
afternoon.
104. In the evening, the keyworker noted that Ms Canning had been settled and had only
rung her cell bell once.
105. At 8.30pm, an OSG recorded that Ms Canning had flooded her cell and was trying to
put water in the cell electrics using her kettle. Staff temporarily switched off the
electricity to the cell.
106. At 9.20pm, Ms Canning masturbated in front of staff and the OSG charged her with a
prison disciplinary offence (the adjudication hearing was scheduled for 31 July). Ms
Canning refused to put her clothes on. During the rest of the night, staff noted that
Ms Canning constantly misused her cell bell and was threatening and abusive to
staff. She said that she was doing it because she felt frustrated and was having
nightmares. Staff also recorded that Ms Canning was loosely tying clothing around
her neck and legs. The OSG observed that Ms Canning was breathing, talking, and
moving as normal and there was no restriction to her airway. There is no evidence
that the level of ACCT observations was reviewed.
107. Other prisoners on the wing shouted at Ms Canning to stop pressing the bell as they
wanted to sleep.
Friday 28 July
108. During the morning, an officer recorded in Ms Canning’s prison record that she had
tried to speak with her, but that Ms Canning did not want to engage. She issued her
with a negative entry as she had misused her emergency cell bell overnight.
109. At around 1.40pm the officer went to Ms Canning’s cell and discovered her with two
cleaning cloths tied around her legs, which she said would stop her circulation. Staff
removed the cloths, and Ms Canning spoke to Samaritans.
110. Ms Canning was discussed as a complex case during the Safety Intervention
Meeting. (SIM – a meeting to discuss managing risks to prisoners and the prison. It
should be attended by heads of function, including safer custody, representatives
from the offender management unit (OMU), and healthcare managers.) The Head of
Safety and Equalities chaired the meeting, which was attended by two safety
representatives, the Head of OMU, a member from OMU and a CM. There was no
representative from healthcare present.
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111. The Head of OMU told the SIM that she had previously managed Ms Canning in the
community and that her behaviour in prison was similar. The safety hub manager
noted that Ms Canning was impulsive and due to a shortage of Listeners on
Houseblock 5, she was reliant on talking to Samaritans. Ms Canning had recently
requested distraction materials, and she had been given some painting by numbers,
which she enjoyed, but was on basic level of IEP. The CM told the SIM that Ms
Canning continued to use her cell bell to get staff’s attention and because she said
she enjoyed talking.
112. Ms Canning had said that she hoped to be released from court. The Head of Safety
& Equalities asked for staff to note Ms Canning’s court date and to complete an
immediate ACCT review should she not be released. During the meeting it was also
noted that Ms Canning might benefit from being seen by the neuro-diversity
manager.
113. Staff completed eleven ACCT observations between 2.50pm, and 11.00pm.
(Although Ms Canning was not required to be observed this frequently, staff
appeared to record ACCT observations at around the same time that they answered
cell bells.)
114. At around 7.30pm, an officer noted in Ms Canning’s ACCT that her behaviour was
poor and that there was water on the floor of her cell.
115. At around 8.15pm, two OSGs started their night shift. They were responsible for
Houseblocks 5 and 6. (OSG A was working her first set of nights. OSG B was more
experienced having previously been a prison officer.) They were told by their
colleagues that Ms Canning was not wearing trousers, had her penis out, and had
threatened to make their night difficult.
116. Ms Canning repeatedly misused her emergency cell bell. Between 8.26pm and
11.09pm, she used it 26 times. The night staff answered most within a minute or two,
and the longest to answer took five minutes. (Either OSGs sometimes answered the
cell bells individually, and sometimes they went together.) Each time Ms Canning
swore at them, and other prisoners began to get frustrated as their sleep was being
disturbed. At 9.30pm, when OSG B answered the cell bell, she noted that Ms
Canning was standing at her window with her legs open holding her penis. The OSG
reminded her that her behaviour was inappropriate. Ms Canning said she was fed up
and wanted sleeping tablets as she was worried about her sentencing hearing.
117. At around 10.30pm, OSG B said that Ms Canning continued to be verbally abusive
to staff and continued to make sexually inappropriate comments. Around the same
time, there was an unrelated medical emergency on Houseblock 5 which the
operational manager for the night duty responded to. While he was on the
houseblock he heard banging from Ms Canning’s cell. The OSG told the manager
that Ms Canning had been disruptive since the start of her shift and was constantly
misusing her cell bell. He spoke to Ms Canning through the cell door. She did not
engage in conversation and swore at him to go away. He told the OSG to record all
poor behaviour in the observation book and charge Ms Canning with a disciplinary
offence for exposing herself. He sent an email to The Head of Safety & Equalities,
describing Ms Canning’s behaviour as disruptive and asked whether a move to the
Oak Unit should be considered. (Oak Unit is a small unit for prisoners who have
severe mental health issues or complex social, emotional, and psychological needs.)
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Saturday 29 July
118. The investigator watched CCTV footage and body worn video camera (BWVC)
footage from 29 July. She also obtained information from West Midlands Ambulance
Service. Neither of the OSGs were wearing a BWVC, which meant Ms Canning’s
behaviour during the night was not captured. The following account has been taken
from all sources.
119. Between 12.30am and 3.39am, Ms Canning pressed her emergency cell bell 34
times. The night staff answered most within a minute or two, and the longest to
answer took five minutes. OSG B completed ACCT observations at 12.00am,
1.10am, 2.10am and 3.40am.
120. OSG B said that Ms Canning would often ring the cell bell as she and OSG A walked
away and would then try and hide in the cell by lying flat on the top bunk of her bed,
crouching in the corner, sitting behind the door, or down the side of the toilet. Ms
Canning pretended to be hurt and asked for an ambulance or said she could not
cope with the door being closed. OSG A said they knew these claims of being hurt
were not genuine, as they stood outside the door for long periods listening and
observing her behaviour. They explained to her that they were not able to open the
cell door as the prison was in night state. CCTV footage confirms that they both
attended the cell frequently and can be seen waiting outside the cell for periods of
time.
121. At around 2.10am, Ms Canning used her kettle to pour water into the electrical
sockets in the cell and the night staff saw her place her wet fingers on the socket.
OSG B switched off the electricity to Ms Canning’s cell for her safety, but she did not
inform the night operational manager. Ms Canning then started to push water under
the cell door onto the landing. Other prisoners who could hear what was happening
continued to shout at her as they could not sleep. Ms Canning became angry and
smashed her phone onto the floor and swore at staff to go away. OSG B said she
continued trying to calm her.
122. Later, OSG B found Ms Canning with clothing loosely tied around her neck and a
green cloth wrapped around her leg. (The time of this and some of the later events is
not recorded and given the number of times that the night staff went to Ms Canning’s
cell it is not apparent from CCTV footage when exactly these particular events
occurred.) She said there was no restriction to Ms Canning’s breathing. They talked
about her past, including Ms Canning’s difficult childhood. Ms Canning refused to
remove the clothing from around her neck, telling the OSG she liked the attention.
123. When OSG B answered the next cell bell, Ms Canning was sat on her side with the
telephone cable around her neck and leg. The OSG asked her to remove it, but she
refused. The OSG said that she could see the cable was tied loosely and there was
no restriction to Ms Canning’s airway. Ms Canning asked again for her door to be
opened, but the OSG said that this was not possible.
124. OSG B said that when Ms Canning pressed her cell bell again she had removed the
cable from around her neck, but still had it tied around her leg. She said she wanted
to cut off the circulation in her leg. When she encouraged her to remove the cable,
Ms Canning swore at her and told her to go away.
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125. At around 4.00am, OSG B answered Ms Canning’s cell bell. Ms Canning swore at
her and told her to go away. She said she stood outside for around ten minutes and
could hear Ms Canning moving around and could hear that there was water on the
floor. She said she then left Ms Canning’s cell to complete ACCT observations on
other prisoners.
126. At around 4.28am, both OSGs went to check on Ms Canning, as she had been quiet
for around 15 minutes. CCTV shows that OSG B used her torch to look in the cell.
She saw Ms Canning lying on the floor by the side of the toilet. She knocked on the
door but got no response. She said that she believed that Ms Canning was
pretending to be injured as she had done earlier in the night. She radioed the night
operational manager and asked him to attend. (She did not say that they could see
anything tied around Ms Canning’s neck.)
127. A 4.35am, the operational manager arrived on the houseblock and switched the
electricity back on. He looked into Ms Canning’s cell and, when he received no
response, he opened the door. He discovered Ms Canning was not breathing with
the telephone cable and a jumper wrapped around her neck. He radioed a code blue
medical emergency (used when a prisoner is unconscious or has breathing
difficulties) and the control room operator called an ambulance immediately. He cut
the cable around Ms Canning’s neck and started cardiopulmonary resuscitation
(CPR). He said that both the cable and a jumper were loosely tied around Ms
Canning’s neck.
128. At 4.37am, the officers applied a defibrillator, which advised there was no shockable
rhythm and to continue chest compressions.
129. At around 4.44am, the emergency response nurse and an HCA arrived. The nurse
struggled to find the correct attachments for the oxygen cylinder, but resuscitation
efforts continued. At 4.53am, an oxygen mask was placed on Ms Canning. At
5.15am, paramedics arrived and took over. At 5.33am, they confirmed that Ms
Canning had died.
Contact with Ms Canning’s family
130. Hewell appointed a family liaison officer and a deputy. On the morning of 29 July,
they travelled to Ms Canning’s husband’s home to break the news of her death.
They offered their condolences and ongoing support. In line with Prison Service
instructions, the prison contributed towards the costs of Ms Canning’s funeral, which
was held on 29 August.
Support for prisoners and staff
131. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans to
provide confidential peer-support) to identify prisoners most affected by the death.
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132. Postvention procedures were not fully implemented. After Ms Canning’s death, the
duty governor held a debrief for prison staff involved in the emergency response.
The staff care team and trauma risk management (TRiM) were also made available
to them. Healthcare staff did not attend a debrief and described that they did not feel
supported.
133. The prison posted notices informing prisoners of Ms Canning’s death and offering
support. Staff reviewed all prisoners assessed as at risk of suicide and self-harm in
case they had been adversely affected by Ms Canning’s death.
Post-mortem report
134. The post-mortem report concluded that Ms Canning’s death was due to hanging.
Toxicology results showed only prescribed medication at levels consistent with the
prescribed dosage.
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Findings
Assessment of risk of suicide and self-harm
135. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm to
self, to others and from others (Safer Custody), contains requirements for staff using
ACCT procedures. Staff are required to use ACCT when they identify that a prisoner
is at risk of suicide and self-harm, based on identified risk factors and triggers. The
PSI says that ACCT case reviews should be multidisciplinary where possible, that a
support plan should be completed at the first review, and that it must reflect the
prisoner’s needs, level of risk and the triggers of their distress. Support actions must
be tailored to meet the individual needs of the prisoner, be aimed at reducing the
prisoner’s risk to themselves and be time-bound.
136. Ms Canning was monitored using ACCT procedures from 15 July, when she arrived
at Hewell, until her death on 29 July.
137. It is clear that Ms Canning presented considerable management challenges in her
fortnight at Hewell. She had a history of mental ill health and substance misuse. She
was transgender. She had a history of self-harm in the community and in previous
prison sentences, including by methods with a high chance of lethality, such as self-
strangulation. She had said that she would kill herself if she was remanded to prison
in relation to her most recent charges.
138. Additionally, she repeatedly and inappropriately used her cell bell, damaged items in
her cell, was rude and inappropriate with staff and disturbed prisoners around her to
the extent that she made herself more vulnerable to assault. Undoubtedly, a great
deal of limited staff resource went into the day to day management of her behaviour.
Staff noted that Ms Canning responded well to staff attention and benefited from
discussing her concerns with staff.
139. In the context of her challenging and resource-intensive presentation, we found that
the ACCT procedures did not provide the overarching strategy, clear for all staff to
follow, to support Ms Canning’s various needs, challenges and vulnerabilities.
Support actions
140. PSI 64/2011 states that during case reviews, the case review team must set and
review support actions to mitigate risk. Support actions were agreed during the first
two case reviews but were not updated at subsequent reviews. There was no
support action specifically relating to Ms Canning’s mental health, despite a history
of stress and anxiety being identified during the ACCT assessment. Support actions
could also have been set to address Ms Canning’s frequent use of cell bells and
concerns she raised about her medication and its impact on her sleep, and her
impending court appearance.
141. We note that, over the two weeks, different staff from different disciplines proposed
other support actions that did or might have helped Ms Canning. This included the
suggestion that she might be suitable for Oak Unit, the provision of distraction
activities to compensate for her not having a television in her cell and the suggestion
that she might benefit from referral to the neurodiversity nurse. These were the
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holistic and creative suggestions that an effective and well-managed multi-
disciplinary ACCT process should have come up with.
Assessing risk and setting ACCT observations
142. Case review teams are required to set appropriate levels of observations and
conversations. PSI 64/2011 also says that an urgent case review should take place
as soon as possible if risk is likely to have increased, including when there is a
change in behaviour that causes concern.
143. When ACCT procedures were begun in reception on 15 July, the CM set observation
levels at once every two hours. At each following case review, the frequency of
observations was never more frequent than that despite fluctuations in her mood,
statements and behaviours (although we note that, at times, staff were essentially
checking on Ms Canning more frequently than required, for example when
responding to her persistent use of the cell bell). We did not find sufficient evidence
that observations were set at appropriate levels or demonstrated a considered
assessment of Ms Canning’s risk. While staff felt that Ms Canning would benefit
more from conversations (which, as we note later, did not always take place) these
should be conducted alongside, rather than instead of, observations.
144. We found little evidence in the ACCT documentation that staff reviewed Ms
Canning’s risk factors or considered signs that her risk might be escalating or
changing (such as anxiety about her impending court appearance). Other than on 20
July, there was no urgent case review when Ms Canning engaged in self-harming
behaviour or other behaviour that might indicate increased risk.
Completing observations and conversations
145. PSI 64/2011 instructs that ACCT observations and conversations must be carried
out in line with levels set by case review teams. It states that conversations, and
written summaries of these, must be meaningful.
146. While we saw evidence that various staff had spent time trying to respond to Ms
Canning’s needs, address her challenging behaviour and provide reassurance, her
ACCT record contained little evidence that meaningful conversations were carried
out in line with the level set. On some days the only entries were brief comments on
her behaviour or engagement with the regime. Meaningful conversations are
important for all prisoners monitored under ACCT procedures, but were particularly
so for Ms Canning, who had indicated that talking to staff helped to reduce her risk.
147. Observations were often at routine and at predictable times or not recorded at all.
Supervisor checks, which should quality assure the ACCT document and verify that
expected observations and conversations have been carried out, were not always
completed.
Conclusion
148. Ms Canning was difficult to manage. There was a clear need for robust and
supportive leadership from senior managers to junior staff on how best to safely
manage Ms Canning’s risk to herself and to others. There was no consistent strategy
for staff to follow which meant that the staff response to her challenging behaviour
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was inconsistent, and sometimes punitive, which left them and Ms Canning
vulnerable.
149. We found that the overall ACCT management was not sufficiently robust. HMIP and
the IMB, in their most recent reports, also identified areas for improvement in ACCT
procedures. We make the following recommendation:
The Governor should review the quality and compliance with policy of ACCT
management in the previous 12 months, identify any improvements required,
and devise a plan to deliver those improvements.
Healthcare input into risk management
150. The clinical reviewer found that there was a missed opportunity to engage Ms
Canning in conversation about her future risk of suicide and self-harm when she met
a support worker on 20 July, after a ligature attempt that morning. There was no
evidence that Ms Canning was asked about having any current thoughts of harming
herself. There was another missed opportunity on 21 July, when Ms Canning met
with HCA Poolman and said that staff had cut a ligature from her that morning. While
there is no other evidence that these events occurred as Ms Canning described, the
HCA indicated that this would be escalated to the duty response nurse, but there is
no evidence in her medical record that Ms Canning was discussed or if there was a
plan about her care and support seeking behaviours.
Management of Ms Canning on 28/29 July
151. Both OSGs acted with compassion and professionalism towards Ms Canning on the
night that she died, in difficult circumstances. They were subject to verbal abuse
from her for much of the night, and other provocative behaviour, some of which was
sexually explicit. They continued to respond quickly to her many cell bells. When Ms
Canning became quiet, they might easily have assumed that she had now settled for
the night. Instead, they checked her and identified the emergency earlier than might
otherwise have been the case.
152. Management of challenging behaviour during the night is particularly difficult given
the strictures on opening cells and the fewer staff on duty. The night operational
manager said that staffing levels had been impacted by other significant events that
night (a prisoner was taken out to hospital and another prisoner was monitored on
constant supervision requiring staff to be positioned outside his cell at all times). He
said that he did not assess that Ms Canning’s behaviour was problematic enough to
justify sending over the only spare officer to support the OSGs or consider moving
Ms Canning to a different location. He did not consider increasing ACCT
observations because he said he knew staff were checking on Ms Canning
frequently in response to the emergency cell bells. He did not consider that Ms
Canning’s risk of suicide or self-harm had increased because she continued to use
her cell bell.
153. However, other than his conversation with the OSGs (one of whom was
experienced, the other of whom was on her first set of night duties) at the beginning
of the evening, the night operational manager did not visit the houseblock again until
Ms Canning was found unresponsive. We consider that he could have provided the
OSGs with any better support and guidance on how best to manage Ms Canning
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overnight. We make no recommendation, but the Governor may wish to consider
whether there is any learning.
Clinical care
154. The clinical reviewer found that the care Ms Canning received was not equivalent to
that she would expect to receive in the community. The clinical reviewer made a
number of recommendations that are not directly relevant to Ms Canning’s death but
should be actioned by the Head of Healthcare.
Mental health
155. When Ms Canning arrived at Hewell she was already experiencing poor mental
health. She told staff that she was concerned that she may receive a custodial
sentence, and that she believed her relationship had broken down, which further
impacted on her anxiety and increased her risk of suicide and self-harm. Ms Canning
was referred on reception for a mental health assessment and was triaged the next
day. This identified that Ms Canning should be assessed by the mental health and
substance misuse team (Inclusion) because of her complex needs. We note that a
representative from Inclusion attended ACCT reviews, but no formal mental health
assessment was carried out.
156. Inclusion tried to see Ms Canning on 25 July (one day over the seven-day target for
referrals), but she was at an adjudication hearing. The appointment was rebooked,
but the new appointment was not for two weeks.
157. The clinical reviewer found that there should have been a more proactive response
to providing Ms Canning with mental health support. She concluded that this lack of
recognition and consideration of Ms Canning’s risks at the point of arranging a new
appointment fell below the standard reasonably expected. The clinical reviewer also
found that it would have been appropriate to consider a referral to Oak Unit sooner.
158. We also found no evidence that Ms Canning was considered for the Targeted Care
Pathway (TCP) at Hewell, which has two mental health nurses available, seven days
a week. The TCP is for people who have been deemed to require increased mental
health support due to their needs and are seen for daily reviews. The mental health
team manager explained that prisoners referred to the TCP required an increased
level of mental health input that the core mental health services are unable to
provide. The clinical reviewer concluded that it was difficult to say whether Ms
Canning should have been under the care of the TCP, because while core mental
health services may have supported her sufficiently, she was not assessed by
Inclusion as she should have been.
159. We make the following recommendation:
The Head of Healthcare should ensure that prisoners who present with
persistent and challenging behaviours are assessed according to their level
of risk and need, with consideration given to their most suitable location.
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Emergency Response
160. PSI 03/2013, Medical Emergency Response Codes, sets out the actions that staff
should take in a medical emergency. It contains mandatory instructions for
Governors to have a protocol to provide guidance on efficiently communicating the
nature of a medical emergency, ensuring staff take the relevant equipment to the
incident and that there are no delays in calling an ambulance. It stipulates that if an
emergency code is called over the radio, an ambulance must be called immediately.
161. PSI 24/2011, Management and Security at Nights, contains instructions for staff on
entering cells at night. When the OSGs discovered Ms Canning unresponsive on the
floor of her cell, they did not immediately enter because of her behaviour earlier that
night. They did not see the ligature until the door was opened. We found the decision
not to enter the cell immediately to be reasonable.
162. Staff called a medical emergency code at 4.35am. Although Houseblock 5 is only
around 400 meters away from the healthcare centre, it took the response nurses
around nine minutes to arrive. The night operational manager said that he sent
another message over the radio to advise healthcare staff that CPR was in progress
as he thought they were taking too long to respond. A healthcare manager told us
that she asked the response nurse and HCA why it took that length of time to reach
Ms Canning’s cell, but neither could account for this.
163. Ms Canning had flooded her cell, but staff did not consider moving her to the
landing, which was dry, before attaching the defibrillator. This would also have given
them more space to perform CPR.
164. When healthcare staff arrived, it took around nine minutes before oxygen was given
to Ms Canning, a total of 18 minutes after the emergency was first radioed. BWVC
footage shows that the communication between prison and healthcare staff was
limited and there were delays finding the correct breathing mask. (The HCA told us
that she was unsure what she was looking for.) The clinical reviewer was not able to
conclude if these delays would have impacted Ms Canning’s chances of survival, but
that prioritising good quality chest compressions and use of a defibrillator were
essential to the chances of survival. We make the following recommendation:
The Head of Healthcare should ensure that all emergency response staff
attend medical emergency codes immediately.
165. The HCA confirmed that she was Immediate Life Support (ILS) trained yet did not
take an active role in the resuscitation efforts. The clinical reviewer found that prison
staff provided good CPR, but the overall quality of the CPR by healthcare staff was
poor.
166. We escalated the concerns regarding the quality of the CPR to a healthcare
manager. We asked her to review the footage and respond. We were informed that
PPG, Hewell’s healthcare provider, were also going to review the emergency
response and gave assurances that they will provide the appropriate additional
support identified to healthcare staff involved and to all staff who are required to
respond to an emergency. Given the response, we do not make a recommendation.
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Body Worn Video Cameras
167. PSI 04/2017, Body Worn Video Cameras (BWVC), requires prison staff to use
BWVCs during any reportable incident, including medical emergencies. It requires
staff to start recording at the earliest opportunity, to maximise the material captured
by the camera. BWVC’s are an important source of evidence for PPO investigations,
and wider learning for prisons following an incident.
168. Body worn video cameras were not worn by all staff, including the OSGs working on
Houseblock 5 where Ms Canning lived. Therefore, events during the evening where
she was being verbally abusive to staff, or acting inappropriately, were not captured,
nor was the staff response. The HMPPS Early Learning Review after Ms Canning’s
death identified that that night staff should wear BWVC and record reportable
incidents. In light of this, we do not make a recommendation, but the Governor will
want to take appropriate action.
Governor to Note
Induction Unit
169. Hewell has a mixed induction unit, housing both standard prisoners and those
deemed to be vulnerable, whether that is due to the nature of their offence or
because they are deemed at risk for other reasons in the general population. We
have identified in previous investigations that vulnerable prisoners have been subject
to abuse when located with non-vulnerable prisoners but are not able to move to the
vulnerable prisoner unit due to the lack of space. The Governor will wish to consider
the learning from this case.
Head of Healthcare to Note
Alcohol detoxification management
170. When Ms Canning arrived at Hewell, she was prescribed an alcohol detoxification
regime. Despite being on an alcohol withdrawal regime, Ms Canning was not
assessed by a member of the substance misuse team on her arrival. While
withdrawal observations were conducted on the day she arrived, no further clinical
observations were completed. The clinical reviewer made a recommendation about
this that the Head of Healthcare will wish to consider.
Suicide and self-harm awareness (ACCT) training
171. During the investigation we found that not all healthcare staff had received suicide
and self-harm awareness (ACCT) training. This is mandatory training for all staff in
contact with prisoners.
Prescribed medication
172. Ms Canning was prescribed diazepam, which was dispensed between 4.00pm and
5.00pm. She said that she would fall asleep quickly after taking the medication, but
then be awake during the night. In the community, Ms Canning took her medication
at around 10.00pm. The typical regime at Hewell is for medication to be dispensed at
around 6.00pm (5.15pm at weekends). It was not clear why Ms Canning was given
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her medication earlier, but it may have been because staff had to sequence when
prisoners were unlocked for medication, taking into account her vulnerable status.
The Head of Healthcare will wish to consider how medications that affect sleep are
dispensed to prisoners.
Healthcare attendance at the Safety Intervention meeting
173. Ms Canning was identified as a complex case and discussed at the SIM on 28 July.
However, there was no representative from healthcare at the meeting. We were told
that the Interim Head of Healthcare and Team Leaders would attend the SIM, if
resource allowed them to go. If healthcare staff had attended the SIM, it would have
been an opportunity to identify that Ms Canning required timely mental health
support.
174. On 11 September 2023, a Mental Health Team Leader was appointed, who attends
the weekly SIM.
Postvention support
175. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans to
provide confidential peer-support) to identify prisoners most affected by the death.
176. We found that the postvention approach was not followed. Prison staff said they felt
well supported. However, healthcare staff who attended the medical emergency said
that they did not attend a debrief and were not supported afterwards. It is unclear
why they were unable to attend a debrief, but this is an important step in ensuring
that staff are signposted to relevant support services. The Head of Healthcare will
want to consider this.
PPO investigation
177. The HCA is a member of agency staff who does not work permanently at Hewell. We
contacted her during the investigation, but she did not respond to emails inviting her
to be interviewed and the Head of Healthcare could not provide any further contact
details. We encourage the Head of Healthcare to ensure that they have full contact
details for all staff, including agency staff, who had significant contact with a prisoner
that has died, to assist with any investigations.
Inquest
178. The inquest into Ms Canning’s death concluded in April 2025. The inquest found
that Ms Canning’s death was misadventure - asphyxiation and use of ligature.
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