Eileen McDonagh

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Eileen
McDonagh, a prisoner at HMP
Styal, on 2 July 2022
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
© Crown copyright, 2024
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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 Eileen McDonagh died on 2 July 2022 having been found hanged in her cell at HMP
Styal. She was 25 years old. I offer my condolences to Ms McDonagh’s family and friends.
While Ms McDonagh presented as a challenging woman to manage and her behaviour
could be impulsive and difficult, there were no indications that she was at increased risk of
suicide in the days and hours before her death.
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 February 2024
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
Summary
Events
1. On 28 March 2022, Ms Eileen McDonagh arrived in HMP Styal charged with assault
occasioning actual bodily harm. She had been at Styal on several previous
occasions.
2. Ms McDonagh had been previously diagnosed with attention deficit hyperactivity
disorder (ADHD). She had not been taking any medication for this condition in the
community.
3. Between April and June, Ms McDonagh was involved in several fights or
altercations with other prisoners, and she broke other prison rules: this had also
been a pattern for her during previous sentences.
4. On the morning of 14 June, Ms McDonagh had a fight with another prisoner. In the
afternoon, she tried to climb over the landing railings and after being taken back to
her cell, she deliberately cut her hand and threatened to pour boiling water over
herself. Staff started Prison Service suicide and self-harm monitoring procedures
(known as ACCT).
5. The ACCT was closed at a review on 15 June. Staff noted that Ms McDonagh had
ADHD for which she was not taking any medication but did not record whether
anything further could or should be done to support her.
6. In the late morning of 2 July, Ms McDonagh had a fight with another prisoner and
staff locked her in her cell. At 2.10pm, while other prisoners were on the exercise
yard, they shouted to staff that they could see Ms McDonagh hanging in her cell. An
officer on the yard reached through the window to cut the ligature and he then
radioed a medical emergency code. Other staff went into the cell and started cardio-
pulmonary resuscitation (CPR).
7. Paramedics arrived at 2.23pm and took charge of Ms McDonagh’s care. At 2.31pm,
the paramedics confirmed that Ms McDonagh had died.
Findings
8. Although Ms McDonagh had some known risk factors for suicide and self-harm, we
found that there were no indications that her risk to self had significantly increased
between the ending of ACCT procedures on 15 June and her death on 2 July.
9. The clinical reviewer concluded that the care Ms McDonagh received at HMP Styal
was not equivalent to what she could have expected to receive in the community.
Ms McDonagh had a diagnosis of ADHD, but she was not seen by a long-term
conditions nurse and there were no entries in her record about when she should
have been reviewed. Also, her mental health needs were not explored after an
ACCT was opened on 14 June.
Prisons and Probation Ombudsman 1
The Investigation Process
10. HMPPS notified us of Ms McDonagh’s death on 3 July 2022.
11. The investigator issued notices to staff and prisoners at HMP Styal informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
12. The investigator visited Styal on 4 July. She obtained copies of relevant extracts
from Ms McDonagh’s prison and medical records.
13. The investigator interviewed 12 members of staff at Styal between December 2022
and April 2023. All of the interviews were conducted by video-link. The investigation
was then transferred to one of her colleagues.
14. NHS England commissioned a clinical reviewer to review Ms McDonagh’s clinical
care at the prison. The investigator and clinical reviewer conducted joint interviews
with clinical staff and with some of the prison staff.
15. We informed HM Coroner for Cheshire of the investigation. She gave us the results
of the post-mortem examination. We have sent her a copy of this report.
16. The Ombudsman’s family liaison officer contacted Ms McDonagh’s mother to
explain the investigation and to ask if she had any matters she wanted us to
consider. Ms McDonagh’s mother said that her daughter had severe mental health
problems and she asked:
• why was her daughter not placed on constant watch after she had been
treated for self-harm injuries on 14 June?
• why was her daughter not placed in a shared cell for support?
17. We have addressed these questions in this report.
18. The initial report was shared with Ms McDonagh’s mother and with HM Prison and
Probation Service (HMPPS). HMPPS pointed out several factual inaccuracies, and
this report has been amended accordingly.
2 Prisons and Probation Ombudsman
Background Information
HMP Styal
19. HMP Styal holds up to 486 women. There is a variety of residential units, with 16
separate houses each holding about 20 women. There is also a mother and baby
unit.
20. Spectrum Community Health runs healthcare services at the prison. Greater
Manchester West Mental Health NHS Foundation Trust provides mental health
services. The prison has 24-hour nursing cover.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Styal was in September and October 2021.
Inspectors noted that incidents of violence at Styal had increased significantly since
the previous inspection in 2018, although most of the incidents were not serious
and reflected a build-up of frustration. Inspectors found that violent incidents were
investigated well, and management of perpetrators and victims was good.
Inspectors found that the quality of ACCT records was not good enough and care
plans were particularly poor and did not fully reflect the women’s concerns or
triggers. Inspectors found that an experienced clinical manager led health services
well. However, inspectors noted that despite strenuous efforts to recruit registered
nurses, the service remained reliant on agency staff and the nursing team was
occasionally stretched.
Independent Monitoring Board
22. 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 April 2022, the IMB reported that
incidents of self-harm had reduced significantly since the previous reporting year,
although Styal remained concerned about an increase in self-harm among
prisoners with learning difficulties. The IMB noted that prisoner-on-prisoner assaults
at Styal were the highest in the female estate. The IMB reported that relationships
between staff and prisoners generally remained positive with many staff showing
skill and compassion in dealing with prisoners in crisis.
Previous deaths at HMP Styal
23. Ms McDonagh was the fourth prisoner to die at Styal since May 2019. Of the
previous deaths, one was self-inflicted and two were from natural causes. We also
investigated a stillbirth.
24. In our investigation into the self-inflicted death of a prisoner at Styal in December
2020, we found that staff failed to take account of all the known risk factors when
considering whether to start ACCT procedures and we made a recommendation.
The prison responded to the recommendation and said that the Safety department
at Styal had re-launched their Safety Strategy which placed emphasis on the
national guidelines used to support those at risk of self-harm or suicide. The prison
Prisons and Probation Ombudsman 3
planned to run weekly coaching drop-in sessions for ACCT Case Coordinators to
enhance their skills and provide ACCT briefings in morning operational meetings.
Assessment, Care in Custody and Teamwork
25. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses for supporting and monitoring prisoners assessed as at risk
of suicide and self-harm. The purpose of the ACCT process is to try to determine
the level of risk posed, the steps that might be taken to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Levels of supervision and
interactions are set according to the perceived risk of harm. There should be regular
multidisciplinary case reviews involving the prisoner. Checks made on prisoners
should be at irregular intervals to prevent the prisoner anticipating when they will
occur. Part of the ACCT process involves assessing immediate needs and drawing
up a care plan to identify the prisoner’s most urgent issues and how they will be
met. Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011.
4 Prisons and Probation Ombudsman
Key Events
26. On 28 March 2022, Ms Eileen McDonagh was remanded to HMP Styal charged
with assault occasioning actual bodily harm. Ms McDonagh had been at Styal on
several previous occasions and had last been released one month before.
27. A nurse saw Ms McDonagh for a reception health screen. Ms McDonagh said that
she smoked crack cocaine daily, and had a history of self-harm, but had no current
thoughts of suicide or self-harm. The nurse noted that Ms McDonagh had a history
of poor mental health and had been diagnosed with attention deficit hyperactivity
disorder (ADHD). She also noted that Ms McDonagh was chatty, laughing, engaged
well and maintained eye contact. Ms McDonagh was not able to pass urine for a
drug test.
28. Ms McDonagh’s prison security record shows that she had an extensive history of
fighting with other prisoners, threatening staff and climbing onto or over the landing
railings. Ms McDonagh was assessed as unsuitable to share a cell.
29. On 29 March, Ms McDonagh provided a urine sample that was positive for cocaine
and cannabis. A nurse noted that Ms McDonagh had been given appointments for a
learning disability blood test and review at the learning disability long-term
conditions clinic (part of an approach recognising that people with learning
disabilities often have poorer health than the general population and, therefore, to
identify possible health problems that the patient might not have reported). The
appointments did not go ahead as planned prior to Ms McDonagh’s death.
30. That day, a nurse visited Ms McDonagh to complete a mental health assessment,
but she said that she had no concerns and did not want to be seen. The investigator
was told that the assessment would have included an assessment of her
neurodiversity needs and whether she needed help from the learning disability
nurse (neurodiversity refers to how different people behave and react differently
from one another). In keeping with standard practice, Ms McDonagh was offered an
assessment the following day which she again declined; as a result, she did not
receive any input from the learning disability nurse. Any internal staff or external
agencies can refer a prisoner for a mental health assessment at any time, but no
such referrals were made.
31. On 30 March, Ms McDonagh saw a substance misuse worker and had several
appointments with the substance misuse team in the following months.
32. On 14 April, Ms McDonagh was placed on report following a fight with another
prisoner. A disciplinary hearing was arranged for the following day.
33. At the disciplinary hearing on the morning of 15 April, Ms McDonagh was found
guilty of fighting, and she received a suspended punishment of seven days cellular
confinement. That afternoon, Ms McDonagh climbed onto the landing railings
because she had not received her canteen order (canteen is the prison shop where
prisoners can buy various items such as confectionary). After around ten minutes,
Ms McDonagh climbed down, and staff placed her on report and moved her to the
segregation unit (where prisoners are kept apart from other prisoners) pending a
disciplinary hearing.
Prisons and Probation Ombudsman 5
34. At a disciplinary hearing the following day, Ms McDonagh was found guilty of
deliberately endangering her safety and her suspended punishment of seven days
cellular confinement was activated. Ms McDonagh had been assessed by a mental
health nurse as fit to be segregated when she first arrived, but her records indicated
that a healthcare practitioner only visited her twice in the following days.
(Segregation can increase the risk of suicide or self-harm because it isolates the
prisoner and reduces their access to the normal regime and can have a negative
impact on their mental health. As a result, a nurse must complete a safety algorithm
to indicate if there are any medical reasons why an individual should not be
segregated, a duty Governor will then countersign it. Prisoners in segregation
should be visited every day by a healthcare practitioner.)
35. Ms McDonagh returned to a standard unit on 21 April.
36. On 26 April, Ms McDonagh hit another prisoner with a hair dryer. As a result, staff
suspended her from association (social time) for seven days.
37. On 29 April, an officer mistakenly unlocked Ms McDonagh’s cell so that she could
attend association. When staff asked her to return to her cell, she climbed onto the
landing railings. Staff managed to talk her down and she was taken back to her cell.
A Supervising Officer (SO) was one of the staff who spoke to Ms McDonagh. She
told the investigator that Ms McDonagh would often climb onto the railings as she
knew this would give her some time in the segregation unit.
38. On 21 May, Ms McDonagh had a fight with another prisoner (a different prisoner).
39. On 2 June, Ms McDonagh went to the medication hatch to collect paracetamol that
had been prescribed for a headache. When staff asked her for her identification
card, she became aggressive as she did not have her card with her. Officers
intervened and took her back to her cell.
40. On the morning of 14 June, Ms McDonagh was again involved in an altercation with
another prisoner (a different prisoner to the previous three). An officer helped
separate the two women. He told the investigator that he had had a good
relationship with Ms McDonagh but said, “she could go from zero to 100 miles an
hour in a millisecond” and often had confrontations with other prisoners. He said
that the incident that morning had been a confrontation rather than a fight and after
they were separated, the two women were locked in their cells.
41. Shortly afterwards, the officer escorted a nurse to Ms McDonagh’s cell to check for
any injuries. When he unlocked her door, Ms McDonagh left her cell, started
walking down the landing and then attempted to climb onto the railings. He and a
colleague escorted Ms McDonagh back to her cell.
42. Around 15 minutes later, Ms McDonagh pressed her cell bell and when the officer
responded, she showed him that she had cut her hand. She also threatened to pour
boiling water on herself. He called a nurse, who noted a moderate cut to Ms
McDonagh’s left hand, which she cleaned and dressed in gauze. Staff started
Prison Service suicide and self-harm monitoring procedures (known as ACCT).
Staff moved Ms McDonagh to a cell on a different landing to separate her and the
other prisoner.
6 Prisons and Probation Ombudsman
43. An offender supervisor saw Ms McDonagh on the morning of 15 June for an ACCT
assessment interview. Ms McDonagh said that since the age of eight she had used
self-harm to relieve frustration and had harmed herself the previous day following
her fight with the other prisoner. She said that she had no present thoughts of
suicide or self-harm and that she would speak to staff if she needed support.
44. An SO chaired an ACCT review with Ms McDonagh shortly afterwards. An officer
and a mental health nurse also attended the review. The SO noted that Ms
McDonagh engaged well, and she reiterated that she had no thoughts of suicide or
self-harm. He noted that Ms McDonagh was positive, presented well and explained
that she had a good relationship with her mother, which was a protective factor for
her.
45. The SO noted that Ms McDonagh discussed ADHD medication with the nurse, but
the nurse’s record contains no reference to this. Instead, he noted that Ms
McDonagh presented in a bright mood and was in a stable mental state. Ms
McDonagh said that she harmed herself in reaction to her fight with the other
prisoner, had cut herself to help her cope and had not intended to end her life. The
SO noted that all parties were content for the ACCT to be closed. Ms McDonagh’s
ACCT had no care plan actions.
46. That day, Ms McDonagh had a disciplinary hearing to consider the circumstances
surrounding her fight on 14 June. A prison manager chaired the hearing. Ms
McDonagh was found guilty, and a note made that she had been found guilty of a
similar offence in April. Staff moved Ms McDonagh to the segregation unit for seven
days cellular confinement.
47. On 20 June, a prison manager recognised that a defensible decision log had not
been completed for Ms McDonagh: defensible decision logs are completed for
prisoners who are moved to the segregation unit and who are presently being
supported by ACCT procedures or had had an ACCT closed in the recent past. The
manager noted that Ms McDonagh was a person with a pattern of violent behaviour
who often behaved in a way to try to secure a move to the segregation unit for a
period of “time out.” In a section of the form on options for alternative locations, the
manager noted that Ms McDonagh was unsuitable for the Valentina unit as that was
a unit for vulnerable prisoners. The manager concluded that as Ms McDonagh was
due to return to a standard unit the following day, there appeared little need to move
her that day.
48. On 21 June, Ms McDonagh left the segregation unit and was moved to second floor
cell on X wing. The following day, Ms McDonagh moved to a ground floor cell on X
wing.
Events of 2 July
49. In the late morning of 2 July, Ms McDonagh was unlocked for lunch, and she then
began fighting with another prisoner: again, a different prisoner to all the previous
ones. An officer and a colleague separated them and locked them in their cells. He
delivered Ms McDonagh’s lunch to her cell.
50. The officer told the investigator that he knew Ms McDonagh quite well. He said that
she was always involved in conflicts with other prisoners but was generally okay
Prisons and Probation Ombudsman 7
with staff. He said that when he gave Ms McDonagh her lunch tray, she was her
usual self and was talking normally.
51. A nurse checked Ms McDonagh at around 12.00pm and noted that she had slight
bruising on her face and slight bruising on one of her fingers. Ms McDonagh
reported no other injuries.
52. At just after 2.00pm, prisoners were unlocked for exercise, but Ms McDonagh and
the other prisoner were kept locked in their cells. An officer said that he let the
women onto the exercise yard and just as he was about to relock the yard gate, he
heard women screaming that Ms McDonagh was hanging (her cell window looked
out onto the exercise yard). He ran to Ms McDonagh’s cell window and radioed for
staff assistance. While standing on the yard, he reached through Ms McDonagh’s
window, cut the ligature and lowered her to the floor. He then radioed a medical
emergency code blue (to indicate a prisoner is unconscious or having breathing
difficulties). The code blue call was made at 2.12pm and control room staff called
an emergency ambulance.
53. Two officers responded to the officer’s call for assistance, and they went into the
cell. One officer cut the remaining piece of ligature from Ms McDonagh’s neck, and
the officers moved her to the centre of the room and started CPR.
54. A nurse told the investigator that she was treating a prisoner on the second landing
of X wing when she heard the code blue and responded immediately. She said that
while waiting for a colleague to collect the emergency bag, she held Ms
McDonagh’s head up to keep her airway clear. She noted that Ms McDonagh was
cold to the touch, and she had no signs of life. Ms McDonagh was checked with a
defibrillator which instructed that no shock could be given, and that CPR should
continue.
55. Ambulance paramedics arrived at 2.23pm and took charge of Ms McDonagh’s care.
At 2.31pm, the paramedics declared that further efforts to resuscitate Ms
McDonagh should cease and confirmed that Ms McDonagh had died.
Contact with Ms McDonagh’s family
56. A prison manager and a family liaison officer went to the family home accompanied
by one of the prison chaplains. They arrived at 8.15pm and broke the news to Ms
McDonagh’s mother and two of her siblings.
57. The prison contributed to cost of Ms McDonagh’s funeral in line with national
instructions.
Support for prisoners and staff
58. A prison manager debriefed the staff involved in the emergency response to ensure
they had the opportunity to discuss any issues arising, and to offer support. The
staff care team also offered support.
8 Prisons and Probation Ombudsman
59. The prison posted notices informing other prisoners of Ms McDonagh’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 Ms McDonagh’s death.
Post-mortem report
60. The post-mortem report gave Ms McDonagh’s cause of death as hanging. A
toxicology report found a low concentration of gamma-hydroxybutyrate (GHB), but
the concentration was consistent with natural body processes and was not deemed
by the pathologist to be indicative of use of the drug prior to death.
Prisons and Probation Ombudsman 9
Findings
Assessment of risk
61. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that staff must follow where a prisoner is at risk of suicide and self-harm.
It lists a range of factors that might increase a prisoner’s risk of suicide and self-
harm. Ms McDonagh had several risk factors including a history of deliberate self-
harm, impulsivity, and propensity to violence. In addition, Ms McDonagh had a
diagnosis of ADHD but was not in receipt of medication or receiving any other
treatment or support.
62. Staff started ACCT procedures for Ms McDonagh on 14 June after she cut herself
and threatened to pour boiling water over herself following a fight with another
prisoner. Ms McDonagh had been involved in several incidents of inappropriate
behaviour in her brief time in Styal, and this was consistent with her behaviour
during previous sentences: it is clear that Ms McDonagh would react inappropriately
and without thought when frustrated. The SO who chaired the ACCT review on 15
June, noted that Ms McDonagh and a nurse discussed ADHD medication, but there
is no such discussion referenced in the nurse’s notes, and we note that Ms
McDonagh was not in receipt of any medication for ADHD and nor would there
appear to have been any formal assessment of this condition during her time at
Styal.
63. The ACCT was closed on 15 June and there were no further indications that Ms
McDonagh was at heightened risk in the two weeks between the closure of the
ACCT and her death. We do not consider that there was ever any clear indication
that Ms McDonagh was at risk of suicide or that the ACCT needed to be reopened.
Use of segregation
64. Prison Service Order 1700, Segregation, sets out the process that should be
followed when a prisoner is segregated. The PSO says that:
“Those prisoners who are the most ‘difficult’ are often the most vulnerable …
Staff are undoubtedly faced with difficult decisions as to where to hold some
prisoners and frequently care for prisoners in segregation units when all other
options have been exhausted. However, there have been cases where
prisoners have been held in segregation units and the justifications for doing so
have not been convincing. There have been cases where alternative options to
segregation have not been adequately explored.”
65. As already noted, it is clear that Ms McDonagh had long-established behavioural
problems and was frequently in conflict with other prisoners. It also seems clear that
she would sometimes deliberately act in a way to manufacture a period of time in
segregation. It is unclear, however, whether staff made sufficient efforts to consider
and explore alternative options on where she could be housed while maintaining
good order and discipline. As Ms McDonagh did not die in segregation, we do not
make a recommendation, but the Governor might wish to consider how best to
10 Prisons and Probation Ombudsman
manage prisoners who are frequently in conflict with other prisoners and with the
prison regime.
Clinical care
66. The clinical reviewer concluded that Ms McDonagh’s physical and mental health
care at Styal was not of a reasonable standard and was not equivalent to what she
could have expected to receive in the community. The clinical reviewer noted that
Ms McDonagh had a diagnosis of ADHD, but she was not seen by a long-term
conditions nurse and there were no entries in her record about when she should
have been reviewed. The clinical reviewer considered that if Ms McDonagh had
been seen, it is possible that she might have been prescribed medication which
might have helped with her impulsive behaviour that was evident throughout her
time at Styal. We note that Ms McDonagh declined a mental health assessment
(also a gateway to assessment by the learning disability nurse) on 29 and 30 March
on her initial arrival into Styal, as she was entitled to do so, but there is no evidence
that staff referred her to the mental health team thereafter.
67. The clinical reviewer considered that there should have been further exploration of
Ms McDonagh’s mental health needs after the ACCT was opened on 14 June. The
clinical reviewer noted that there was limited recording by healthcare staff while Ms
McDonagh was in the segregation unit. The clinical reviewer also noted that Ms
McDonagh reported a significant crack cocaine habit when she arrived at Styal but
was only monitored through the night of 28 and 29 March. The clinical reviewer has
recommended that the Head of Healthcare should implement substance misuse
monitoring for prisoners who arrive with crack cocaine misuse problems.
68. The clinical reviewer has made a number of other recommendations which we do
not repeat in this report, but which the Head of Healthcare will wish to address.
Governor to note
69. The Governor will be aware that no defensible decision log was completed for Ms
McDonagh when she was moved to the segregation unit on 15 June, just hours
after her ACCT had been closed. We understand that the duty governor that day
was unaware that an ACCT had just been closed but another duty governor
identified the omission on 20 June. We understand that a process has been put in
place to prevent such a recurrence and the Governor will wish to ensure that the
new process is robust.
70. The Governor will also be aware from an internal early learning review that an
ACCT post closure review was not completed for Ms McDonagh as should have
been the case.
Inquest
71. An inquest into Ms McDonagh’s death concluded on 21 August 2024 that her
medical cause of death was hanging as a result of misadventure.
Prisons and Probation Ombudsman 11
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