Dylan Woodhead

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Independent investigation into
the death of Mr Dylan Woodhead,
a prisoner at HMP/YOI Hindley,
on 8 January 2021
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Dylan Woodhead was found hanged in his cell at HMP Hindley on 8 January 2021. He
was 22 years old. I offer my condolences to his family and friends.
Mr Woodhead had been in custody for three months when he died, and for only ten days
at Hindley. It was his first time in prison. While he had a number of risk factors, prison
staff at HMP Forest Bank, his previous prison, should have considered starting suicide and
self-harm procedures for him when he arrived, he sought minimal support from prison staff
and there were no clear signs to indicate that he intended to take his life, including in the
days before his death.
However, I am concerned that roll checks were not properly completed the night and
morning before Mr Woodhead was found dead in his cell. I cannot say whether this might
have affected the outcome for him.
The post-mortem examination confirmed that Mr Woodhead had used psychoactive
substances (PS) before his death. Although this was not found to have caused his death,
PS is known to affect mental health adversely. I am concerned that Mr Woodhead was
able to obtain PS with apparent ease at Hindley, even though strict restrictions had been
put in place during the COVID-19 lockdown. Hindley needs to continue in its efforts to
reduce the supply of and demand for drugs and ensure that staff can recognise and are
vigilant for signs of PS use.
I am also concerned that healthcare staff tried to resuscitate Mr Woodhead despite the
presence of rigor mortis.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman October 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. In September 2020, Mr Dylan Woodhead was remanded into custody at HMP
Forest Bank, charged with assault, causing actual bodily harm, engaging in
controlling/coercive behaviour towards his ex-partner and the damage of property.
It was his first time in prison. He was transferred to HMP Hindley on 29 December.
2. His Person Escort Record (PER) noted that he had depression and anxiety. He
had a restraining order in place not to contact his ex-partner. A reception nurse
assessed Mr Woodhead’s mental health and noted his history of attempted suicide.
However, he had no current thoughts of suicide or self-harm and there was no
evidence that he had tried to harm himself at Forest Bank. Prison and healthcare
staff did not identify any acute mental health concerns.
3. Mr Woodhead disregarded the restraining order in place and used the prison’s PIN
phone system to contact his ex-partner. He made numerous telephone calls to her
during his time at Hindley. They argued during their telephone conversations on the
evening of 7 January, and Mr Woodhead threatened to take his life.
4. On 8 January 2021, an officer found Mr Woodhead sitting on the floor of his cell,
with a ligature around his neck. The officer radioed a medical emergency code blue
and staff responded quickly. Staff tried to resuscitate Mr Woodhead until
paramedics arrived and took over. They were unable to resuscitate him and
pronounced that he had died.
Findings
Assessment of risk
5. Mr Woodhead had a number of risk factors when he arrived at Forest Bank: it was
his first time in prison, he had been remanded for a serious offence against his ex-
girlfriend, he had a history of attempted suicide and self-harm, he misused alcohol
and had anxiety, depression and substance misuse problems.
6. We are concerned that staff at HMP Forest Bank failed to consider opening ACCT
procedures or record why they had decided it was unnecessary.
7. When he arrived at Hindley, we are satisfied that staff reviewed Mr Woodhead’s risk
information, assessed his risk of suicide and self-harm appropriately and made a
reasonable decision in the absence of hindsight, based on the facts they were
presented with at the time that he was not at immediate risk of suicide or self-harm.
Roll check
8. The officer on night duty failed to properly conduct the evening roll check on 7
January 2021 and the morning roll check on 8 January and therefore did not check
on Mr Woodhead. The officer on day duty also failed to conduct a morning roll
check on 8 January. Although we cannot say whether this might have made a
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difference in Mr Woodhead’s case, early intervention in another emergency may
save a life.
Drug strategy at HMP Hindley
9. Although Hindley has a comprehensive drug strategy, Mr Woodhead was still able
to obtain drugs in the prison. The prison updated its drug strategy in March 2021
but must continue to implement it effectively to reduce supply and demand.
Resuscitation
10. While we recognise that staff wanted to save Mr Woodhead’s life, rigor mortis was
already present when he was found hanged in his cell. Trying to resuscitate
someone who is clearly dead is distressing for staff and undignified for the
deceased. Healthcare staff should therefore not have tried to resuscitate him.
Recommendations
• The Governor and Head of Healthcare at Forest Bank should ensure staff consider
and record all the known risk factors of newly arrived prisoners when determining
their risk of suicide or self-harm, including information from suicide and self-harm
warning forms, person escort records and medical records, and consider ACCT
monitoring in light of those risk factors.
• The Governor should ensure that roll checks are properly carried out.
• The Governor should ensure that staff continue to prioritise implementing Hindley’s
drug strategy, and that they can recognise, are vigilant for and address signs of PS
use.
• The Governor and Head of Healthcare should ensure that staff are given clear
guidance and check their understanding about the circumstances in which
resuscitation is inappropriate in line with the Resuscitation Council Guidelines.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Hindley informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Woodhead’s prison
and medical records.
13. NHS England commissioned a clinical reviewer to review Mr Woodhead’s clinical
care at the prison.
14. The investigator interviewed five members of staff jointly with the clinical reviewer.
The interviews were completed by video and telephone because of the restrictions
imposed due to the COVID-19 pandemic.
15. We suspended our investigation pending the police investigation into the death of
Mr Woodhead, the outcome of which was received on 11 March 2022, 14 months
after his death. The investigation was further delayed by the COVID-19 pandemic.
The police shared information with us to assist our investigation.
16. We informed HM Coroner for Greater Manchester West District of the investigation.
He gave us the results of the post-mortem examination. We have sent him a copy
of this report.
17. We contacted Mr Woodhead’s family to explain the investigation. They wanted to
know the full circumstances leading to Mr Woodhead’s death, including:
• whether Mr Woodhead was monitored under suicide and self-harm prevention
procedures at HMP Hindley;
• why he was in a single cell and how often he was checked;
• whether Mr Woodhead had bipolar disorder and whether he was prescribed any
medication; and
• whether Mr Woodhead was allowed access to a telephone at Hindley.
We have addressed these concerns in this report and in separate correspondence.
18. Mr Woodhead’s family legal representative received a copy of the initial report. The
solicitor representing Mr Woodhead’s family wrote to us raising a number of
questions that do not impact on the factual accuracy of this report. We have
provided clarification by way of separate correspondence to the solicitor.
19. The initial report was shared with HM Prison and Probation Service (HMPPS).
They identified no factual inaccuracies. All recommendations were accepted. Their
action plan is attached as an annex.
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Background Information
HMP Hindley
20. Hindley is a Category C training and resettlement prison near Wigan, holding up to
590 adult male prisoners. Nearly a quarter of the population are under 21 years
old. About half of the prisoners are serving long sentences of at least four years.
Primary healthcare and mental health services are provided by Greater Manchester
Mental Health NHS Foundation Trust.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Hindley was a scrutiny visit in December 2020
to inspect the conditions and treatment of prisoners during the COVID-19
pandemic. Inspectors found that the amount of time that most prisoners spent out
of their cells had increased since the start of the pandemic to two 45-minute
sessions a day when they could shower and exercise outdoors.
22. Inspectors found that the recent reintroduction of mandatory drug tests had yielded
a very high positive rate of 59% in the first month. They noted that Hindley was
taking steps to reduce the supply of drugs but psychosocial support for prisoners
with substance misuse issues was very stretched. Inspectors concluded that the
care of those at risk of suicide and self-harm was reasonable. They found that staff
checked on the wellbeing of all prisoners regularly, and those with high risks or
needs received support through regular key work sessions. They noted that the
uptake of video calls and social visits, when they were able to take place, had been
low. They noted that all prisoners had in-cell telephones for use 24 hours a day,
and this had helped them maintain family contact.
Independent Monitoring Board
23. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 December 2021, the IMB
reported and noted that throughout the year, the prison has been subject to a range
of restricted regimes as management tried to maximise out of cell opportunities
while protecting prisoners and staff from COVID-19 outbreaks. There were ongoing
concerns about prisoners being locked in their cells for 23 out of 24 hours, and on
occasion longer. They noted a concerning increase in the incidents of self-harm.
They found that cannabis, psychoactive substances (PS) and 'home brewed'
alcohol (hooch) were the most available illicit substances used by prisoners during
the year. It was thought that many prisoners had illicit mobile phones, used
primarily to keep in contact with family as the cost of using the in-cell phones was
felt to be prohibitively high. There was also concern about the number of prisoners
choosing to self-isolate and remain in their cells. The most common reason given
were the prisoners wanting to avoid trouble as their parole/Category D hearing was
approaching.
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Previous deaths at HMP Hindley
24. Mr Woodhead was the first prisoner to die at Hindley since June 2018.
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Key Events
HMP Forest Bank
25. On 15 September 2020, Mr Dylan Woodhead was remanded to HMP Forest Bank,
charged with assault, causing actual bodily harm, engaging in controlling/ coercive
behaviour towards his ex-partner and the damage of property. It was his first time
in prison.
26. His Person Escort Record (PER), which accompanied him to prison, noted his
history of attempted suicide and self-harm, he was violent, he misused alcohol and
had anxiety and depression. Mr Woodhead had a restraining order in place,
preventing him from contacting his ex-partner. He was seen by the Court’s Liaison
and Diversion (L&D) services (who identify people who have mental health
concerns, learning disabilities, substance misuse or other vulnerabilities when they
first come into contact with the criminal justice system), due to his self-harm history
in the community
27. Prison reception staff interviewed Mr Woodhead when he arrived. His PER and
court documentation, which included comments from the L&D team noted no
specific concerns about his immediate risk.
28. A reception nurse completed Mr Woodhead’s reception health screen. The nurse
reviewed the PER, examined Mr Woodhead and recorded his physical
observations. It was noted that he had a history of substance misuse, anxiety and
depression. Mr Woodhead declined substance misuse support and said that he
had no thoughts of suicide or self-harm. He said that he had previously tried to take
his life (in July 2020) by taking an overdose of 30 paracetamol/co-codamol tablets
due to the stress of possibly receiving a prison sentence. The nurse referred Mr
Woodhead to the mental health team.
29. A mental health nurse completed a mental health assessment. The nurse noted
that Mr Woodhead had no suicidal ideation but that it was his first time in prison. Mr
Woodhead said that at the time that he had taken an overdose, he was depressed.
He said that he had been admitted to hospital and the mental health team had seen
him but he had subsequently failed to attend any of his follow-up appointments. Mr
Woodhead thought that he may have bipolar disorder. The nurse noted that Mr
Woodhead was not taking any medication, and she did not identify any immediate
risks but agreed to discuss Mr Woodhead at the next mental health multidisciplinary
team meeting.
30. On 16 October, a mental health nurse assessed Mr Woodhead by telephone. Mr
Woodhead said that he had no thoughts of suicide or self-harm. He believed that
he had bipolar disorder and asked for a diagnosis. He said that he had a split
personality, low mood, was “easily wound up” and got angry at the slightest thing.
He added that he was upset that he was unable to see his baby daughter due to the
COVID-19 pandemic. The nurse discussed Mr Woodhead’s symptoms with him
and explained that they related more to emotional regulation than a clinical mood
disorder. She assessed that he presented with no psychotic symptoms and
discussed how psychological interventions could help him identify and manage his
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emotions. She agreed to refer Mr Woodhead to a psychological wellbeing
practitioner to support his emotional regulation and anger management.
31. On 4 December, Mr Woodhead attended court by video link and was sentenced to
two and a half years in prison. He also received a five-year restraining order not to
contact his ex-partner.
32. On 22 December, Mr Woodhead was prescribed omeprazole (for indigestion).
33. On the morning of 29 December, a nurse saw Mr Woodhead and completed a
health screen before his impending transfer to HMP Hindley. Mr Woodhead was
assessed as being fit for transfer. The nurse recorded that he had no outstanding
health appointments. It was not recorded that Mr Woodhead was waiting to see a
psychological wellbeing practitioner.
HMP Hindley
34. On 29 December, Mr Woodhead was transferred to HMP Hindley. His PER noted
that he had depression and had committed a domestic violence offence.
35. A prison officer interviewed Mr Woodhead in reception when he arrived. Mr
Woodhead had no thoughts of suicide or self-harm, he had not been monitored by
suicide and self-harm prevention procedures (known as ACCT) and it was his first
prison sentence. Staff offered him emergency PIN credit.
36. A Phoenix substance misuse officer saw Mr Woodhead as part of his induction. Mr
Woodhead said that he had not used illicit substances in prison and declined the
structured psychosocial support offered to him.
37. A member of the chaplaincy team spoke to Mr Woodhead in reception. He raised
no concerns.
38. A nurse completed Mr Woodhead’s initial and secondary health screens. She had
no concerns about him.
39. She referred him to the prison GP who continued his omeprazole prescription for
indigestion. Mr Woodhead told the nurse that he had a history of cocaine misuse.
She completed an alcohol screen for him and assessed that he was not a
hazardous drinker and did not need support for this. The nurse also assessed Mr
Woodhead’s mental health. She noted his history of attempted suicide and that he
had taken an overdose in July 2020. He had not tried to harm himself in prison and
had not seen a doctor in the past few months. Mr Woodhead said that he had no
thoughts of suicide or self-harm. She noted that he presented as relaxed and said
that he was happy to be at Hindley. She noted that he would not be allowed to
keep and administer his omeprazole due to his overdose history.
40. After he completed his reception screen, Mr Woodhead was moved to a single cell
on the induction unit. All the cells have in-cell PIN phones.
41. An officer completed Mr Woodhead’s first night interview and assessed his risk of
suicide and self-harm. She had no concerns about him. Mr Woodhead said that
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he was happy to be at Hindley because it was easier for his family to visit him. He
said that he was unable to see his daughter because of his offence.
42. Shortly after the officer had completed Mr Woodhead’s first night interview, he rang
his emergency cell bell and asked for cloth to clean his cell and toilet rolls which an
officer gave him.
43. On 30 December, an officer completed an induction follow-up interview with Mr
Woodhead. She noted that he raised no concerns.
44. On 3 January 2021, staff noted that when staff refused to give Mr Woodhead
emergency telephone PIN credit because he had not applied for it on the
appropriate day, he repeatedly threatened to damage his cell. No further
information was recorded about this.
45. That day, Mr Woodhead’s father left a telephone message for the safer custody
team. He was concerned that he had not heard from Mr Woodhead for nearly a
week. An officer from the safer custody team picked up the message that afternoon
and visited Mr Woodhead to pass on his father’s concerns.
46. The officer said that Mr Woodhead was in “good spirits” and joked with him. Mr
Woodhead said that he had had problems getting phone credit but this had been
rectified. He asked the officer to call his father on his behalf and reassure him that
he was “fine”. Mr Woodhead said that he would try and call his father the following
week. The officer could not make contact with Mr Woodhead’s father so left a
telephone message for him.
47. On 6 January, prison staff completed a public protection risk assessment, and
decided to monitor Mr Woodhead’s PIN phone and mail.
Events on Thursday 7 January
48. On the morning of 7 January, it was noted in prison intelligence reports that a
prisoner had reported to wing staff that another prisoner on the wing had illicitly
used his cellmate’s PIN phone credit, and that he wanted these phone numbers
removed from his account. The prisoner did not name the other prisoner.
49. Later that morning, immediately after staff unlocked Mr Woodhead from his cell, he
walked over to another cell, where two prisoners lived and started threatening them
through their cell door. Both prisoners returned the abuse before staff removed Mr
Woodhead. Mr Woodhead had threatened to “cave their heads in” if they opened
their door. One of the prisoners threatened to “flatten” Mr Woodhead if they were
out of their cells at the same time. Staff assumed that Mr Woodhead had been the
prisoner who had used one of the prisoner’s PIN phone credit. When the security
team subsequently checked the prisoner’s request to remove phone numbers from
his PIN account, the two sets of phone numbers he had selected had the surname
“Woodhead”. Wing staff were told to monitor the three prisoners.
50. At 12.41pm, Mr Woodhead used his PIN phone and called a mobile telephone
number, identified from prison records as belonging to his sister. However, his ex-
partner answered. Mr Woodhead told her that he had had an argument with two
prisoners that morning about PIN phone credit and had threatened them.
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51. At 12.49pm, Mr Woodhead phoned his father and said that he had a phone but was
waiting for a SIM card for it.
52. At 2.30pm, 2.49pm, 3.52pm and 4.43pm, Mr Woodhead phoned his ex-partner.
They had a general conversation about his family and his release date. His ex-
partner then told him that his phone credit would run out if he kept calling her. Mr
Woodhead said that he was bored.
53. Mr Woodhead phoned his grandmother at 5.14pm. They talked about money and
his bank account.
54. At 5.17pm, CCTV footage shows that staff completed a roll check and raised no
concerns about Mr Woodhead.
55. Mr Woodhead called his ex-partner four times between 5.23pm and 6.42pm. They
talked about money. Mr Woodhead said that he had tried to ring her twice and
accused her of ignoring him. They talked about his ex-partner sending him a parcel
and whether she loved him. Mr Woodhead said that he would kill her if she found
someone else. Their conversation about their relationship became heated and they
swore at each other. Before the phone call ended, Mr Woodhead said that he
would call her at 9.00pm as he did not have enough credit. His ex-partner told him
to stop wasting his phone credit.
56. Mr Woodhead phoned his father at 6.44pm and his grandmother at 6.49pm. Both
conversations were about money and Mr Woodhead’s bank account. Mr
Woodhead agreed to call his grandmother the next day.
57. CCTV footage at 6.57pm shows that Operational Support Grade (OSG) completed
a roll check. She checked that all the cell doors on the wing were locked but did not
look through the observation panels to check on prisoners.
58. At 7.06pm, Mr Woodhead phoned his partner. He asked her to apologise to a
prisoner for him for the morning’s events. Mr Woodhead said that she should
transfer £10 to the prisoner.
59. Mr Woodhead made a number of short phone calls to his ex-partner at 7.20pm,
7.26pm, 7.29pm and 7.33pm. They talked about money and the transferring of
money into bank accounts. His ex-partner questioned why he had phoned her
again as it was not 9.00pm. Their conversation became heated and his ex-partner
ended the call. Mr Woodhead then called his ex-partner again. They shouted and
swore at each other about not being able to log into each other’s bank accounts and
money issues. His partner said that she was sick of Mr Woodhead always blaming
everyone else for his problems. Mr Woodhead said that he would kill himself if she
ended the call. His ex-partner told him to do it. Mr Woodhead responded and said,
“I’m fucking paying you back.” His ex-partner replied, “You do this every month.”
Mr Woodhead again told her that he would pay her back. His ex-partner said it was
not about that but how he made her feel.
60. In the next phone call at 7.29pm, Mr Woodhead said that he would pay his ex-
partner back every penny of the money he owed her. They argued and shouted
about trust and money. He asked his ex-partner if he should call her later. She told
him that he should do what he wanted to do.
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61. When Mr Woodhead called his ex-partner at 7.33pm, he screamed at her and told
her not to put the phone down on him again. He told her that she could take her
money and then she would not have to speak to him again as she obviously could
not “fucking stand” him. He said that he would ring her on Monday and if she did
not want to speak to him, she could block the number. Mr Woodhead is then heard
shouting (as if to someone else near or outside his cell), “shut your fucking mouth”.
His conversation then resumed with his ex-partner and he told her how to log in to
his bank account. He told her to take all the money and that he would tell everyone
else that he had spent it. Mr Woodhead then said his phone credit was going. He
told his ex-partner that once she logged into the account, she would see where his
money had gone and would “kick off” (be upset).
Events of 8 January
62. CCTV footage shows that at 2.57am, the OSG walked along the landing and
opened cell door observation panels but did not look through them. The OSG then
failed to conduct the morning roll check between 5.00am and 6.00am, despite
signing the roll check sheet and wing observation book at 5.50am to state that she
did.
63. The OSG completed a handover to an officer before her duty finished at around
6.00am. At 6.17am, CCTV footage shows that the officer did not conduct the
morning roll check after he arrived for his shift. While he checked that cell doors
were locked, he did not check on the occupants.
64. Just before 8.00am, staff started unlocking some prisoners.
65. In her police statement, an officer stated that she had just finished the medication
round and was walking towards Mr Woodhead’s cell to unlock him. As she
approached his cell door, she saw a piece of paper pushed out under his cell door.
The officer opened Mr Woodhead’s cell observation panel and saw him sitting on
the floor, with a ligature made from a bed sheet tied around his neck at the end of
the bed. Mr Woodhead’s face was blotchy and purple/grey in colour and his tongue
was protruding slightly from his mouth. The officer saw a second officer nearby and
asked him to call a code blue, indicating a life-threatening situation. The control
room log recorded that this occurred at 8.07am and an ambulance was called at
8.09pm.
66. In the meantime, the officer tried to open Mr Woodhead’s cell door. She found that
his feet were obstructing the door and she had to use her shoulder to push it open.
The second officer joined her and they entered the cell. In his police statement, the
second officer said that Mr Woodhead’s skin was grey and his blood was pooling in
certain parts of his body.
67. The second officer tried to cut the ligature with his fish knife (cut-down tool) but it
was too thick. An officer arrived and helped the officer to support Mr Woodhead’s
body while an officer removed the ligature.
68. The officer checked Mr Woodhead for signs of life. He had no pulse and his skin
was cold and very hard. He started cardiopulmonary resuscitation (CPR) but then
noticed that Mr Woodhead’s body was stiff so he had to push him flat. An officer
helped with CPR efforts.
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69. A nurse arrived at Mr Woodhead’s cell at 8.08am, with a medical emergency bag.
She took over CPR attempts.
70. A second nurse arrived at 8.10am, with personal protective equipment for staff to
wear. She helped the nurse who noted in Mr Woodhead’s medical record that he
had no pulse and was not breathing. His skin was mottled and his pupils were fixed
and dilated. The nurses attached a defibrillator to Mr Woodhead but it advised no
shock.
71. The nurse told us that Mr Woodhead’s skin on his feet, stomach, hands and
partially on his calves was mottled and discoloured. She said that his lips appeared
blue and rigor mortis was present. She was unable to insert an oral airway because
his jaw was clenched so they inserted a nasal airway to administer oxygen. The
nurses completed approximately six cycles of CPR before paramedics arrived at
8.21am. They pronounced his death at 8.23am.
Information discovered after Mr Woodhead’s death
72. After Mr Woodhead’s death, staff found a suicide note in his cell, addressed to his
parents, ex-partner, daughter and family. In it, he said that he was “sorry that he
did this, don’t blame anyone other than me I’ve been nothing but a complete failure
to you all [sic]”. He also said that he loved his daughter very much. Staff found a
short note, addressed to a prisoner. It said, “Sorry about using your credit, I’ll get
[my ex-partner] to transfer you £10 and I’ll sort you some NEMO…”. (It is not clear
what ‘NEMO’ referred to but it is possibly an anti-inflammatory drug used for pain
relief.)
73. A wing officer submitted a security intelligence report at around 9.00am to say that
while conducting welfare checks, four prisoners who lived on Mr Woodhead’s
landing, said that they had heard him arguing with his partner on the phone at
around 10.00pm the previous night and that Mr Woodhead had told his partner that
he would kill himself if she broke up with him. The security team checked Mr
Woodhead’s PIN phone activity and noted that he did not make any calls from his
in-cell phone at this time.
Contact with Mr Woodhead’s family
74. After Mr Woodhead died, staff identified his father as his next of kin. The prison
appointed a member of the chaplaincy team, as the prison’s family liaison officer
(FLO). The FLO and the Deputy Governor visited Mr Woodhead’s father shortly
before 11.00am and broke the news of Mr Woodhead’s death. Mr Woodhead’s
father contacted Mr Woodhead’s mother and informed her of his death.
75. Mr Woodhead’s funeral took place on 29 January. The prison contributed towards
the cost of Mr Woodhead’s funeral in line with national instructions.
Support for prisoners and staff
76. After Mr Woodhead’s death, a Custodial Manager (CM) debriefed the staff involved
in the emergency response to ensure that they had the opportunity to discuss any
issues arising, and to offer support. The staff care team also offered support. The
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prison posted notices informing other prisoners about Mr Woodhead’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 Woodhead’s death.
Post-mortem report
77. The post-mortem report concluded that Mr Woodhead died from hanging.
Toxicology results showed that he had taken psychoactive substances (PS)
sometime before his death.
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Findings
Risk assessment on arrival at HMP Forest Bank
78. Prison Service Instruction (PSI) 64/2011 on safer custody and PSI 07/2015 on early
days in custody list risk factors and potential triggers for suicide and self-harm. The
PSIs requires that staff appropriately manage newly arrived prisoners who are at
risk of suicide and self-harm. It requires that reception staff examine the PER and
any other available documentation to assess a prisoner’s risk of suicide, self-harm
or harm to or from others.
79. Mr Woodhead had a number of risk factors when he arrived at Forest Bank in
September 2020: it was his first time in custody, he had been remanded into
custody for a serious offence against his ex-girlfriend, he had a history of attempted
suicide and self-harm, he misused alcohol and had anxiety, depression and
substance misuse problems.
80. In these circumstances and contrary to national instructions, we are surprised that
neither prison nor healthcare staff challenged critical risk information from Mr
Woodhead’s PER and other related documents and considered opening ACCT
procedures or recording why they decided it was unnecessary. However, Mr
Woodhead appears to have settled at Forest Bank after this, so if he had been
monitored under ACCT procedures, it is likely that monitoring would soon have
ended. Although this did not contribute directly to Mr Woodhead’s death four
months later, it was a missed opportunity to understand his risks and triggers. We
make the following recommendations:
The Governor and Head of Healthcare at Forest Bank should ensure staff
consider and record all the known risk factors of newly arrived prisoners
when determining their risk of suicide or self-harm, including information
from suicide and self-harm warning forms, person escort records and medical
records, and consider ACCT monitoring in light of those risk factors.
Risk assessment on arrival at HMP Hindley
81. PSI 07/2015 on early days in custody is clear that staff should assess all newly
arrived prisoners and share, review and act on information, including person escort
records, where necessary. The National Institute for Health and Care Excellence
(NICE) guidelines state that initial health screens in reception should ensure
continuity of care for people transferring from one custodial setting (including
courts) to another by accessing relevant information from the patient clinical record,
PER, cell-sharing risk assessments, medication prescriptions and outstanding
medical appointments.
82. In addition to Mr Woodhead’s significant risk factors, when he arrived Hindley on 29
December, he had also been recently sentenced.
83. We note that prison and healthcare staff assessed him in reception and determined
that his risk of suicide and self-harm was low, he had no current thoughts of self-
harm and he did not need ACCT monitoring. His initial reception screen raised no
particular concerns about Mr Woodhead’s mental health.
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84. While Mr Woodhead had taken an overdose in the community in July 2020, this was
in response to a social situation that had caused him stress and appeared to have
been an isolated incident. Mr Woodhead spent over three months at Forest Bank
and there is no evidence that he had tried to harm himself during that time. After he
transferred to Hindley, staff had no concerns about Mr Woodhead. Staff followed
up on concerns raised by Mr Woodhead’s father on 3 January 2021, and a safer
custody officer spoke to Mr Woodhead and checked on him. Mr Woodhead
expressed no concerns and explained that he had not contacted his father because
he had not had enough PIN credit. Although we recognise that Mr Woodhead had
a number of significant risk factors, they had not changed since he was at Forest
Bank and he had not tried to harm himself or expressed any thoughts of suicide or
self-harm during his time in custody.
85. Although it was a finely balanced decision, we consider that without the benefit of
hindsight, prison staff’s assessment of Mr Woodhead at Hindley was reasonable.
We do not consider that prison staff could reasonably have predicted that Mr
Woodhead was at imminent risk of suicide when he arrived.
Roll checks
86. The primary purpose of a roll check is to confirm that all prisoners are present.
However, roll checks are also an opportunity to check on the wellbeing of prisoners
and to identify any obvious signs that a prisoner may be ill or dead. Hindley’s roll
check procedures state that night duty staff should complete full roll checks at
7.45pm and 6.30am in the morning. The day duty staff are required to conduct a
full roll check on handover from the night duty staff in the morning.
87. The OSG signed a formal document to confirm that she had completed the roll
check on the evening of 7 January and the morning of 8 January. An officer had
also signed a formal document to confirm that he had completed the roll check on
the morning of 8 January. However, CCTV footage shows that neither officer had
completed the roll check properly. Falsifying documents is a serious disciplinary
matter and Hindley subsequently suspended the OSG and an officer from duty and
they are subject to disciplinary proceedings. While we cannot know whether the
outcome for Mr Woodhead might have been different if the OSG and the officer had
conducted their respective roll checks correctly, it may be critical in another
emergency. We therefore make the following recommendation:
The Governor should ensure that roll checks are properly carried out.
88. We are pleased that after Mr Woodhead’s death, Hindley introduced ‘normality’
checks in addition to the routine four roll checks completed by staff each day. This
instructed night duty staff to check on each cell twice (between 10.00pm and
3.00am with checks at least 3 hours apart) to ensure that there is nothing “out of the
ordinary”. This check offers prisoners two opportunities to speak to staff at night.
Drug strategy at HMP Hindley
89. It is troubling that Mr Woodhead was able to access PS, particularly during the
COVID-19 lockdown when severe restrictions had been put in place on prisoner
and visitor movement.
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90. There was a national instruction from HM Prison and Probation Service in April
2019 that all prisons should review their drug strategy. HM Inspectorate of Prisons
expressed concern about the easy availability of drugs at Hindley in December
2020, and Hindley has since made strenuous efforts to ensure support for prisoners
with substance misuse and to reduce the supply and demand for illicit substances.
They also revised their Drug Strategy in March 2021, installed a new CCTV camera
system across the site and introduced a full body scanner and Rapiscan substance
detector equipment. While these are positive measures and work in this area
should continue to be prioritised, we remain concerned that Mr Woodhead was able
to access PS. We therefore make the following recommendation:
The Governor should ensure that staff continue to prioritise implementing
Hindley’s drug strategy, and that they can recognise, are vigilant for and
address signs of PS use.
Clinical care
91. The clinical reviewer noted that overall, the healthcare that Mr Woodhead received
was of a good standard and was equivalent to that which he could have expected to
receive in the wider community. She noted that his physical and mental health
needs were appropriately assessed on arrival at Hindley and his history of overdose
and substance misuse issues were noted.
Mental healthcare
92. Healthcare staff completed a mental health screen when Mr Woodhead arrived at
Hindley. They found that he had no diagnosed mental illnesses and was not
exhibiting signs or symptoms of mental illness, including depression or anxiety.
While at Forest Bank, psychological interventions were identified as being able to
help Mr Woodhead’s emotional regulation and anger management, but healthcare
staff assessed that there was no indication that he needed prescribed medication
for his mental ill health. As there was no known change in Mr Woodhead’s mental
health during his brief time at Hindley, the clinical reviewer considered that Mr
Woodhead’s mental health was appropriately assessed.
Resuscitation
93. While we understand why staff wanted to try to resuscitate Mr Woodhead, starting
CPR in these circumstances was not in line with the national guidelines on when it
is appropriate to do so.
94. The Resuscitation Council (UK) guidelines state that staff should consider whether
CPR efforts would be successful and in the patient’s best interests. It states that,
“Resuscitation is inappropriate and should not be provided when there is clear
evidence that it will be futile.” The guidelines define examples of futility as including
the presence of rigor mortis. In Mr Woodhead’s case, both prison and healthcare
staff noted that rigor mortis was present and that he had and mottled skin so CPR
was not likely to be successful as these are clear signs of death.
95. The Head of Healthcare told us that if officers had started CPR, healthcare staff
would continue rather than making the decision to stop. A nurse also confirmed this
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approach. She told us that if a nurse had been the first on scene, they would have
assessed the situation and decided not to start CPR. She said that there have
subsequently been discussions with staff about when not to start CPR.
96. While we understand the wish to attempt and continue resuscitation until death has
been formally recognised, staff should not carry out CPR in these circumstances.
We make the following recommendation:
The Governor and Head of Healthcare should ensure that staff are given clear
guidance and check their understanding about the circumstances in which
resuscitation is inappropriate in line with the Resuscitation Council
Guidelines.
Inquest
97. The Coroner’s inquest held on 18 January 2024 determined the medical cause of
death to be hanging. The jury returned a narrative conclusion, stating that Mr
Woodhead died as a result of suicide and noted that this was an intentional act of
self-suspension by use of an improvised ligature.
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