Emmett Morrison

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Independent investigation into the
death of Mr Emmett Morrison,
A report by the Prisons and Probation Ombudsman
a prisoner at HMP Long Lartin,
on 16 October 20 24
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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Emmett Morrison was found hanging in his cell in the segregation unit at HMP Long
Lartin on 13 October 2024 and died in hospital on 16 October 2024. He was 40 years old. I
offer my condolences to Mr Morrison’s family and friends.
Mr Morrison was the third prisoner to take his own life at Long Lartin in three years.
Mr Morrison had a history of substance misuse, suicide attempts and self-harm. He had
struggled to address his illicit drug use, despite speaking of his desire to do so and
seeking help. He had been found under the influence of drugs 27 times at Long Lartin. Mr
Morrison had also spoken of his struggles with accepting the long sentence he had
received, and this had resulted in self-harm and periods of suicide and self-harm
monitoring (known as ACCT).
In the days before his death, Mr Morrison’s behaviour deteriorated, and he was moved to
the segregation unit. It is not clear why he was behaving out of character, but staff
continued to try to support him. He was subject to ACCT monitoring at the time of his
death, but the investigation found that there was no particular evidence that he was in
crisis or at imminent risk of suicide.
The investigation found that staff supported Mr Morrison in trying to address his illicit drug
use and had been supportive following acts of self-harm.
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 June 2025
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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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 15
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Summary
Events
1. On 2 May 2022, Mr Emmett Morrison was remanded to HMP Swansea charged
with murder. On 22 December, he was sentenced to life imprisonment with a
minimum tariff of 28 years. This was not his first time in prison.
2. Mr Morrison had epilepsy and ADHD and was prescribed medication for his
conditions (although he had stopped taking his ADHD medication before his arrest).
He had a history of attempted suicide, self-harm, substance misuse and had been
sectioned under the Mental Health Act twice for attempting suicide.
3. While at Swansea, Mr Morrison was subject to suicide and self-harm monitoring
(known as ACCT) seven times, after self-harming or making threats to harm
himself. He was also recorded as being under the influence of an illicit substance
once.
4. On 10 May 2023, Mr Morrison transferred to HMP Long Lartin.
5. Between June 2023 and October 2024, Mr Morrison was found to be under the
influence of illicit substances 27 times. Mr Morrison engaged with the substance
misuse team (Inclusion) but continued to struggle with his addiction.
6. During his time at Long Lartin, Mr Morrison was subject to ACCT monitoring five
times, after he had made cuts to his arms. Mr Morrison spoke about his struggle to
come to terms with his sentence.
7. On 10 September 2024, staff started ACCT monitoring after Mr Morrison self-
harmed. During an ACCT review, Mr Morrison said that he felt stressed about
threats he received from other prisoners to bring money into the prison. On 24
September, Mr Morrison was moved to a vulnerable prisoners’ wing, and he told
staff that he felt safer.
8. On 4 October, Mr Morrison was found to be under the influence of an illicit
substance. Over the following days, Mr Morrison’s behaviour deteriorated. He
fought with another prisoner, smashed the fixtures in his cell and assaulted staff.
9. On the morning of 7 October, Mr Morrison self-harmed again by cutting his arm. Mr
Morrison was escorted to the healthcare wing where his injuries were treated. When
he was instructed to return to his wing, he assaulted two officers. He was restrained
and was taken to the segregation unit. His behaviour continued to be difficult to
manage, and he was placed on a four officer unlock. Mr Morrison started a dirty
protest (when a prisoner defecates, urinates, or uses other bodily fluids to soil their
cell).
10. At 3.26pm on 13 October, during a routine ACCT check, an officer found Mr
Morrison with a ligature around his neck. Staff entered the cell at 3.27pm and
radioed a medical emergency code. They started CPR and used a defibrillator. At
3.54pm, Mr Morrison started breathing, but he did not regain consciousness.
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11. At 3.55pm, paramedics arrived and stabilised Mr Morrison. He was taken to hospital
and was placed in an induced coma.
12. At 9.15am on 16 October, a hospital doctor pronounced life extinct.
Findings
13. Mr Morrison had risk factors for suicide including a history of suicide attempts,
substance misuse and mental health difficulties. He was serving a life sentence and
found this very difficult to cope with. He was monitored under ACCT procedures a
number of times at Long Lartin after cutting himself or threatening to self-harm. We
found that the ACCT process was generally managed well. All ACCT reviews were
were multidisciplinary and addressed Mr Morrison’s current risks. However, when
Mr Morrison said that he was being bullied and felt under threat, this information
(while recorded in the ACCT document) was not added to his list of risks and
triggers or included on his care plan.
14. In early October, Mr Morrison’s behaviour deteriorated and those that knew him
said that this seemed out of character. We do not know why his behaviour changed
so dramatically. Mr Morrison was subject to ACCT monitoring when he was found
hanged. The changes in his behaviour and unpredictability were appropriately
considered by staff when deciding on the level of ACCT observations and they
continued to try to support him despite his aggressive and challenging behaviour.
While staff recognised that Mr Morrison was struggling, we do not think that it was
evident that he was in crisis or at very high risk of suicide.
15. Given the number of times Mr Morrison was discovered to be under the influence of
drugs, it is evident that he found it easy to obtain illicit substances. Long Lartin’s
drug strategy is clear and addresses the current trends and access routes for illicit
substances into the prison. Moving prisoners to disrupt cohorts, random testing,
searching of prisoners and staff and reacting to and sharing intelligence are all
being used to try and reduce supply.
16. The clinical reviewer concluded that the care Mr Morrison received at Long Lartin
was of a reasonable standard and equivalent to what he could have expected to
receive in the community.
17. We make no recommendations.
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The Investigation Process
18. HMPPS notified us of Mr Morrison’s death on 16 October 2024.
19. The investigator issued notices to staff and prisoners at HMP Long Lartin informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
20. The investigator visited Long Lartin on 24 October 2024. He obtained copies of
relevant extracts from Mr Morrison’s prison and medical records. He completed
interviews with five members of prison staff.
21. NHS England commissioned a clinical reviewer to review Mr Morrison’s clinical care
at the prison. She and the investigator jointly interviewed five members of
healthcare staff.
22. We informed HM Coroner for Worcestershire of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
23. The Ombudsman’s office contacted Mr Morrison’s family to explain the investigation
and to ask if they had any matters, they wanted us to consider. Mr Morrison’s family
asked whether Mr Morrison had been appropriately monitored under suicide and
self-harm prevention measures and whether he had been bullied.
24. An inquest into Mr Morrison’s death was concluded on 6 February 2026. A jury
concluded:
Mr Morrison died as a result of suspending himself by a ligature from the window of
his prison cell. It is not possible to determine what his intention was at the time he
did this.
25. The jury also stated that:
The admitted failure to consider and include on the ACCT care plan support plans
to try to mitigate Mr Morrison’s risk of suicide and/or self-harm possibly caused or
contributed to his death on 16 October 2024.
Following the ACCT review on 8 October 2024 a further review should have been
arranged sooner than 14 October 2024.
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Background Information
HMP Long Lartin
26. HMP Long Lartin is a high security male prison in the Vale of Evesham,
Worcestershire. All prisoners are accommodated in single cells. Practice Plus
Group provides healthcare services and Midlands Partnership Foundation Trust
provides mental health care.
HM Inspectorate of Prisons
27. The most recent inspection of HMP Long Lartin was in December 2022. Inspectors
reported that levels of self-harm were the highest among similar prisons and that
the rate of self-harm had doubled in the last 12 months and managers had no
strategic plan to reduce self-harm. Inspectors found some good examples of
multidisciplinary work to support the individual care of some prisoners with complex
needs.
28. Inspectors reported that living conditions on the older wings remained inadequate,
and that most residential areas were poorly maintained. There were some serious
heating and hot water failures during the inspection. The remote electronic
unlocking system (Night-San) that allowed access to sanitation on the older wings
had been upgraded and worked more efficiently, but it remained unacceptable that
prisoners did not have free access to a toilet or running water.
29. A split regime was operating, which meant most prisoners were locked up either in
the morning or afternoon. Many prisoners who were not working had just two and a
half hours out of their cells each day plus the time it took to collect their meals.
Vulnerable prisoners’ access to education and work were too restricted.
Independent Monitoring Board
30. 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 December 2023, the IMB
reported that access to mobile phones and drugs, now delivered by illegal drones,
posed a serious risk to safety and control, fuelling the illicit prisoner trading culture,
which led to bullying, debt and increased violence within Long Lartin.
Previous deaths at HMP Long Lartin
31. Mr Morrison was the tenth prisoner to die at Long Lartin since June 2021. Of the
previous deaths, two were self-inflicted, six were from natural causes and one was
drug related. Up to the end of March 2025, there have been five deaths at Long
Lartin since Mr Morrison’s death. Four were from natural causes and one was self-
inflicted.
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Assessment, Care in Custody and Teamwork (ACCT)
32. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
Guidance on ACCT procedures was set out in the Prison Service Instruction (PSI)
64/2011, Management of prisoners at risk of harm to self, to others and from others
(Safer Custody). From January 2025, this was superseded by the Prison Safety
Policy Framework, in which the principles of how an ACCT is managed remain
largely unchanged.
33. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. There should be regular multidisciplinary review meetings involving the
prisoner. As part of the process, a care plan (plan of care, support and intervention)
is put in place. The ACCT should not be closed until all the actions on the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison.
Incentives Policy
34. Each prison has an incentives 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 three levels,
basic, standard and enhanced.
Key work
35. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm, and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners, and helping
people settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available for
an average of 45 minutes per prisoner per week for delivery of the key worker
role, which includes individual time with each prisoner.
36. Within this allocated time, key workers can vary individual sessions to provide a
responsive service, reflecting individual need and stage in the sentence. A key
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worker session can consist of a structured interview or a range of activities such as
attending an ACCT review, meeting family during a visit or engaging in conversation
during an activity to build relationships.
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Key Events
37. On 2 May 2022, Mr Emmett Morrison was remanded to HMP Swansea charged
with murder. On 22 December, he was sentenced to life imprisonment with a
minimum tariff of 28 years. This was not his first time in prison; Mr Morrison had
previously served several short prison sentences mainly for drug-related offences.
38. Mr Morrison had epilepsy and attention deficit hyperactivity disorder (ADHD - a
condition that can cause unusual levels of hyperactivity and impulsive behaviour)
and was prescribed medication for his conditions. He stopped taking his ADHD
medication in the community before his arrest. Mr Morrison also had a history of
attempted suicide, self-harm and substance misuse. In 2011 and 2014, Mr Morrison
was sectioned under the Mental Health Act for attempting suicide.
39. While at Swansea, Mr Morrison was subject to suicide and self-harm monitoring
(known as ACCT) seven times, due to cutting himself and threats of self-harm and
he spent time under constant supervision. Staff noted that he had a history of illicit
drug use, and he was recorded as being under the influence of an illicit substance
once.
40. On 10 May 2023, Mr Morrison transferred to HMP Long Lartin.
41. On his arrival, Mr Morrison completed a full induction and did not raise any
concerns.
42. Mr Morrison had regular contact with his family by telephone and visits; in particular,
he spoke to his mother regularly.
43. During his initial health screen, staff noted from his history at Swansea that Mr
Morrison had epilepsy and received medication for this condition. He was
prescribed methadone (opiate substitution) and received medication for other pre-
existing conditions including antipsychotic medication (Quetiapine) and anxiety
related medication (Clonazepam). Mr Morrison was referred to the mental health
team and substance misuse team.
44. On 17 May, the mental health team saw Mr Morrison for an initial assessment. Mr
Morrison reported having poor appetite, poor sleep and was experiencing
flashbacks related to his offence. He said that his sentence was unfair and that he
had no intention of living in prison for that long. The mental health team observed
that the length of sentence was having a significant impact on his mental well-being
and that he was struggling to come to terms with it. (Mr Morrison appealed against
his sentence, but no decision had been made prior to his death.) Mr Morrison said
that he used illicit substances and self-harmed to manage his frustrations which
allowed him to ‘escape from reality’.
45. The mental health assessment concluded that there was no evidence of any major
mental health issues and no signs of psychosis, but that Mr Morrison had an
Emotionally Unstable Personality Disorder (EUPD – a person has difficulty in
managing the way they think and feel about themselves and others, which impacts
on their ability to cope from day to day) and a long history of substance misuse.
Staff decided that he would benefit from support from the mental health team and
substance misuse team, and he was allocated to both services.
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46. In June, Mr Morrison was found to be under the influence of drugs five times. On 22
June, Mr Morrison was due to have a visit with his mother and brother, but this had
to be cancelled because he was under the influence of an illicit substance.
47. Mr Morrison’s use of illicit substances was discussed at a multi-agency meeting. He
said that his presentation was as a result of the effects of one of his prescribed
medications. Staff agreed that healthcare staff would monitor him and stop his other
medications if he appeared to be under the influence again.
48. On 26 June, Mr Morrison was downgraded to the basic incentives level (meaning
certain privileges, including in-cell television were removed) and staff referred him
to the substance misuse team. Mr Morrison was advised about the risks of using
illicit substances while taking methadone and was informed that this would be
stopped if he continued to take illicit drugs. Healthcare staff created a recovery care
plan to provide Mr Morrison with additional support.
49. On 5 July, a Supervising Officer (SO) held the first keyworker session with Mr
Morrison. The SO recorded they discussed substance misuse, support networks,
sentence planning and any concerns. Mr Morrison said that he was getting on well
on F wing (a standard residential wing) but had found settling in difficult. He said
that he had been using Spice (a synthetic cannabinoid) but had not used it for a
week. He said that he wanted to be more positive and drug free, had a particularly
good support network and received regular visits.
50. That day, Mr Morrison was discussed at the multidisciplinary meeting. It was noted
that his methadone would be stopped if there was evidence of PS (psychoactive
substances, including Spice) use and that the prison would complete a series of
mandatory drug tests.
51. On 6, 9 and 12 July, Mr Morrison was again found under the influence of drugs. Mr
Morrison made references to harming himself and staff started suicide and self-
harm monitoring. During his ACCT reviews, Mr Morrison said that he was struggling
to come to terms with his conviction and length of sentence and felt hopeless. He
said that he was close to his family, particularly his mother and family ties were a
support for him. It was also noted that Mr Morrison was receiving peer support from
fellow prisoners on the wing. He said that he had been in debt previously, but this
was now sorted, and he had no concerns.
52. Also on 12 July, a psychiatrist saw Mr Morrison. Mr Morrison reported hearing
voices telling him to hurt himself and others, and he said that he did not know if he
could carry on until the end of his sentence. Mr Morrison said that he had been
looking for ways to kill himself in his cell. The psychiatrist concluded that Mr
Morrison had symptomatic EUPD and possible depression. The psychiatrist
decided that Mr Morrison should continue with his antipsychotic medication and be
supported through the ACCT process.
53. That day, Mr Morrison was discussed at a multi-agency meeting. Prison staff
confirmed that they had swabbed his cell which was positive for heroin.
54. At a subsequent ACCT review, Mr Morrison said that he was having ‘an off day’ but
he did not wish to take his own life. He said that he had now moved to D wing (a
standard residential wing), felt more settled and hoped to gain employment. Staff
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agreed that as a precaution and to provide time to settle, the ACCT would remain
open.
55. Over the weeks that followed, Mr Morrison continued to use illicit substances which
resulted in staff calling several medical emergency code blues (used to indicate that
someone is not breathing or having difficulty breathing, and which instructs the
control room to call an ambulance). He continued to be supported by the substance
misuse team, the mental health team and through ACCT monitoring.
56. On 18 August, Mr Morrison was relocated to the healthcare unit on the advice of
medical staff, due to the number of code blues and under the influence (UTI) calls
he was generating. Mr Morrison remained in the healthcare unit until 25 October,
and while he was there, there were no incidents of illicit drug use. The ACCT
remained open until 19 October.
57. On 25 October, Mr Morrison was relocated to Perrie Blue wing, Incentivised
Substance Free Living (ISFL) accommodation. ISFLs are dedicated wings for
prisoners who want to live in a drug-free environment.
58. Between 9 November and 28 December, Mr Morrison was found under the
influence of drugs six times. On 13 December, during a cell search, officers found
Spice, and, on 19 December, he was placed on a frequent drug testing programme
(FTP) as he had been placed on report twice for using Spice. The FTP would
require Mr Morrison to provide one negative mandatory drug test within the next
three months in order to leave the testing programme.
59. In January 2024, staff reported that Mr Morrison tried to pass prescribed medication
to another prisoner. Between February and April, he was found under the influence
of drugs four times and was also placed on report for taking methadone that was
prescribed to another prisoner. Mr Morrison was referred to the safeguarding team
and continued to be discussed at the multi-agency meetings regularly.
60. On 24 May, Mr Morrison self-harmed by making superficial cuts to his arms. He was
also under the influence of drugs. Staff opened an ACCT and checked him every
half an hour. At his ACCT reviews, Mr Morrison spoke about not seeing his mother
again outside of a prison, but also said that he had a visit planned which was seen
as a positive. Mr Morrison said that he had no current thoughts of suicide or self-
harm and asked for the ACCT to be closed. Staff decided to keep the ACCT open,
and it remained open until 10 June.
61. In July, Mr Morrison was found to be under the influence of an illicit substance, and
during a routine cell search, he was found in possession of five litres of fermenting
liquid (hooch). On 17 July, an officer met with Mr Morrison to complete a keyworker
session. Mr Morrison said that he was fully aware that he had breached his ISFL
compact. He said that he did not use spice but used cannabis. The officer noted
that an ISFL case review was arranged for 22 July, and Mr Morrison’s recent
behaviours would be discussed. The officer noted that Mr Morrison was now
prescribed 10mg of Subutex (an opiate substitute medication) daily, and was no
longer on methadone, which he said was working better for him.
62. Due to his on-going drug misuse, Mr Morrison was deselected from the ISFL on 22
July. Staff planned to move him to Perrie Red wing (a standard residential wing). Mr
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Morrison did not react well to the news and he self-harmed twice by cutting his arm.
He said that he could not go to Perrie Red wing because he was in debt to other
prisoners but would not name those he was in debt to. Staff started ACCT
monitoring.
63. On 23 July, an officer from the safer custody team spoke with Mr Morrison about his
recent self-harm. Mr Morrison said that he had used a razor but had since disposed
of it. He said that he had been deselected from ISFL due to his use of spice and
said that the recent drugs he had used had not been Spice, but he did not say what
they were. Mr Morrison told the officer that he was going to write a ‘goodbye’ note to
his mother as he did not want her worrying about him anymore. The officer also
discussed with Mr Morrison his claims that he owed money for drugs and mobile
telephones, but he refused to provide names of the prisoners he was in debt to.
64. On 29 July, a SO held an ACCT review. She recorded that Mr Morrison appeared
well and better than at the previous reviews. He engaged well and showed interest
in getting back onto the ISFL. Mr Morrison had maintained family ties and had not
self-harmed since the ACCT was opened. Mr Morrison said that he had no current
thoughts of suicide or self-harm. She recorded that she did not feel closing the
ACCT was suitable, and those present agreed that observations could be lowered
to one check every hour. On 15 August, the ACCT was closed.
65. On 10 September, Mr Morrison self-harmed by cutting and staff re-opened the
ACCT document. During an ACCT review held the next day, Mr Morrison said that
he felt stressed about threats he was receiving from other prisoners to bring money
into the prison. Mr Morrison said that he felt he would need to defend himself or get
assaulted. He said that he was not in a lot of debt, and he could easily pay it off.
The review recorded that efforts would be made to try and find an alternative
location; observations would remain at three checks per hour to support his mental
state and he would receive on-going support from staff. These issues were not
added to the ACCT document to reflect his potential risks and triggers.
66. On 12 September, an officer spoke with Mr Morrison. Mr Morrison said that he and
his mother were under threat due to debt and that he was concerned for their lives.
He would not provide the names of the prisoners who were threatening them. Mr
Morrison told the officer that the wing staff were aware. Wing staff referred Mr
Morrison for Situational Vulnerable Prisoner (SVP) status which meant he could be
moved to a separate unit. (Situational vulnerable prisoner status is granted to
prisoners at Long Lartin who are vulnerable due to debt or other similar factors,
rather than due to the nature of their offence.)
67. Despite his concerns with debt, which was likely as a result of his illicit drug use, Mr
Morrison continued to use drugs, and was found under the influence on 13, 14 and
18 September.
68. On 19 September, Mr Morrison attended a recovery support meeting with the Drug
Strategy Lead and the Lead Substance Misuse Nurse. The support meeting was
held following several code blues and repeated reports of Mr Morrison being UTI.
The Drug Strategy Lead recorded that Mr Morrison was open about his struggles,
and he disclosed that he was being used as the wing guinea pig (first to try any new
batch of drugs, to test the strength) and was being bullied by a prisoner (Mr
Morrison named the prisoner). Mr Morrison said that he had spiralling debt which
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was now affecting his mother via people linked to the prisoner outside of the prison.
Mr Morrison said that people were trying to get his mother to pay his debt, as the
families were from the same area. He said that the stress was causing him to use
drugs. Mr Morrison said that he was concerned that if he was not moved by the
following afternoon, which was canteen day (when prisoners received their orders
from the prison shop), he would be hurt as he could not pay his debt. He would not
say who else was involved. As a precaution against any drug interactions, Mr
Morrison’s regular medications were stopped.
69. The Drug Strategy Lead recorded that he discussed the ISFL with Mr Morrison; he
told Mr Morrison that he would support his return in time and that he would support
him in accessing the substance misuse team and mutual aid groups in the interim.
He recorded that he felt there was a considerable threat to Mr Morrison based on
what he had told him, and he requested that the SVP application was expedited. He
noted that Mr Morrison had threatened to climb onto the safety netting separating
the landings in order to be moved to the segregation unit.
70. On 23 September, Mr Morrison refused to attend his ACCT review because he was
self-isolating. Staff went to speak with him at his cell, but Mr Morrison was not keen
to speak while other prisoners were on the landings. As a result, observations
remained at three checks per hour.
71. On 24 September, Mr Morrison was moved to Alpha wing (vulnerable prisoner
wing). A SO chaired an ACCT review, which was attended by the chaplaincy team
and the substance misuse team. It was recorded that Mr Morrison engaged well
and answered all questions. Mr Morrison said that he felt better now that he had
been moved. Mr Morrison told the review that he had telephoned his mother the
previous day, but the telephone had cut off due to no credit. The chaplaincy team
agreed to call his mother and inform her that he was ok and that he had moved
location. Mr Morrison was keen for his observations to be lowered to hourly, but the
review team explained that while he was feeling better, he had self-harmed the
previous day, so observations would be set at twice hourly until the next review,
which was scheduled for 1 October.
72. A prison chaplain contacted Mr Morrison’s mother and told her that Mr Morrison
was all right. She gave Mr Morrison’s mother the prisoners at risk phone number (a
dedicated number for friends and family to log concerns about prisoners at Long
Lartin) to call if she was ever concerned about his well-being.
73. A further ACCT review was completed on 30 September. Mr Morrison appeared to
be stressed and frustrated about something and when asked what was wrong, he
became very vocal, blaming healthcare staff for stopping his medications that kept
him pain and stress free. He said that he had not used drugs in the past ten days
and would take a drug test to prove it. Although angry, Mr Morrison said that he
understood the reasons for his medication being stopped, due to the dangers of
interactions between prescribed and non-prescribed drugs. Mr Morrison also spoke
about his frustration at not being on the ISFL so he could get completely drug free.
74. When asked about other issues, Mr Morrison said that he did not have any and all
his frustration was around his healthcare. He said that he had thoughts of
destroying his cell in order to move to the segregation unit. When asked why, Mr
Morrison said that he would be isolated from other people which would keep him
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calm, he would be unable to have access to drugs which would help him detox
without pressure from others, and he would sit in the segregation unit until he was
given a transfer to another prison. The review panel advised Mr Morrison to
continue on the correct path in showing that he wanted to remain drug free. Mr
Morrison said that he had no thoughts of suicide or self-harm, but he still felt
unstable. Observations were set at one check every hour.
75. On 4 October, staff found Mr Morrison under the influence of an illicit substance and
placed him in his cell. The next day, staff witnessed Mr Morrison fighting with
another prisoner, although staff questioned whether Mr Morrison might have been
the victim of an assault. Mr Morrison denied this and both prisoners admitted to
fighting.
76. Throughout the day on 6 October, Mr Morrison smashed the fixtures and fittings in
his cell, and this continued into the evening. He gave no reason for his actions, but
staff described it as a sudden change in his behaviour.
77. Mr Morrison’s poor behaviour continued. He persistently pressed his emergency
cell bell, smashed furniture in his cell and was generally disruptive. Staff tried to
remove the broken items from his cell, but Mr Morrison would not comply. When
staff entered the cell to remove the items, Mr Morrison was verbally aggressive and
made aggressive moves towards the staff which resulted in him being restrained.
Healthcare staff assessed him and confirmed that he had no injuries.
78. At 9.20am on 7 October, a SO went to Mr Morrison’s cell to collect him for his
medication. Mr Morrison had covered his observation panel, but the SO was able to
move the obstruction slightly from the top of the door and discovered that Mr
Morrison had made significant cuts to both his wrists. Healthcare staff were present
as they had intended to discuss medication with Mr Morrison. Healthcare staff
decided that the injuries did not require an ambulance or outside medical treatment,
but Mr Morrison was escorted to the healthcare unit for treatment. At 10.30am, after
being treated, Mr Morrison was asked to return to A wing. He then assaulted two
officers by punching them in the face. He was restrained and temporarily placed in
a vacant cell on the healthcare unit. Nursing staff recorded that that Mr Morrison
had no reported injuries as a result of being restrained.
79. Later that afternoon, Mr Morrison was moved to the segregation unit, pending a
disciplinary hearing for the assaults. No force was used to relocate him. Staff held
an ACCT review and Mr Morrison was recorded as displaying unsettled behaviour
and he could not say whether he would self-harm or not. His observations were
increased to four checks per hour and a review was scheduled for 8 October. A
prison manager completed a defensible decision log for locating Mr Morrison in the
segregation unit while subject to ACCT monitoring and recorded that the decision
was due to Mr Morrison’s assault on two members of staff, that it was a controlled
environment and would allow for a period of stability.
80. On 9 October, Mr Morrison assaulted another member of staff when they opened
his door to check on him, as he had covered his observation panel. As a result, and
for the safety of staff, four staff had to be present when Mr Morrison’s door was
unlocked. Over the next few days, Mr Morrison’s behaviour continued to be
confrontational and disruptive. Segregation reviews and ACCT reviews were
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completed in his absence due to his refusal to comply with staff instructions and his
aggressive behaviour. Levels of observations remained the same.
81. During segregation reviews, Mr Morrison’s return to the ISFL or the healthcare unit
was discussed, but until he could comply, neither was realistic. A member of the
substance misuse team, who had worked with Mr Morrison and knew him well, tried
to speak with him at his door and understand the change in his behaviour, but he
told her to ‘F off.’ She said that Mr Morrison’s behaviour was out of character, and
she did not feel it could be solely attributed to his illicit drug use.
82. On 10 October, Mr Morrison started a ‘dirty protest’. (A dirty protest is when a
prisoner defecates, urinates or uses other bodily fluids to soil their cell.) Mr Morrison
gave no reason for the escalation in his poor behaviour but refused to clean his cell
and himself when requested. His dirty protest continued.
Events of 13 October
83. The following account has been taken from documentary evidence provided by
Long Lartin, CCTV and Body Worn Video Camera (BWVC) footage, medical
records and transcripts of interviews with staff.
84. On 13 October, staff decided that Mr Morrison would be moved from his cell on the
upper landing, to a clean cell on the ground floor. The investigator was told that this
decision was made due to Mr Morrison throwing urine from his window onto cells
below and attempting to throw urine or other fluids through the gap in his door as
staff passed by. At 3.10pm, officers escorted Mr Morrison to the cell on the ground
floor and no force was used.
85. At 3.26pm, an officer checked on Mr Morrison as part of the routine ACCT check
and on looking into the cell via the observation panel, saw Mr Morrison standing at
the back of the cell with a ligature around his neck, made from his t-shirt attached to
the window. The officer told the investigator that he alerted his colleagues and
nursing staff who were on the unit. Because Mr Morrison was still subject to a four
officer unlock, he considered he should wait for colleagues to be close by before
entering the cell. At 3.27pm, he entered the cell and then radioed a medical
emergency code blue which triggered staff in the control room to request an
emergency ambulance.
86. Staff cut the ligature from Mr Morrison’s neck and initially placed Mr Morrison on his
bed to check for a pulse and breathing. They established that he was not breathing,
and, under the direction of nursing staff, Mr Morrison was placed onto the floor and
staff started cardiopulmonary resuscitation. Resuscitation continued with a
defibrillator attached to Mr Morrison to check for any shockable heart rhythm. At
3.54pm, Mr Morrison began breathing, but he did not regain consciousness.
87. At 3.55pm and 4.07pm, two ambulances arrived at Long Lartin, followed by an air
ambulance with a doctor at 4.09pm. The paramedics and air ambulance staff took
over Mr Morrison’s care. He was stabilised and taken in an ambulance to hospital at
4.52pm.
88. On his arrival at hospital, Mr Morrison was admitted to the critical care unit and was
placed in an induced coma.
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89. At 9.15am on 16 October, a hospital doctor pronounced life extinct.
Contact with Mr Morrison’s family.
90. At 5.40pm on 13 October, a prison manager telephoned Mr Morrison’s mother and
informed her that her son had been taken to hospital and was in a critical condition.
The prison appointed a family liaison officer, and she also spoke to Mr Morrison’s
mother. She arranged to meet the family at the hospital and remained in contact
with them following Mr Morrison’s death.
91. The prison contributed to funeral expenses in line with national policy.
92. Mr Morrisons family raised concerns about the behaviour of prison staff while Mr
Morrison was at hospital. The investigator shared the family’s concerns with the
prison and an internal investigation has been commissioned. A subsequent
photograph of a bruise on Mr Morrison’s arm was shared by his mother. She asked
whether our investigation could ascertain how Mr Morrison came by the bruise. Our
investigation has not been unable to identify the cause of the bruise.
Support for prisoners and staff.
93. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner 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.
94. After Mr Morrison was taken to hospital, a prison manager carried out a debrief with
all staff involved in the initial response in the segregation unit to ensure they had the
opportunity to discuss any issues arising, and to offer support. The staff care team
also offered support.
95. Following Mr Morrison’s death, the prison manager arranged further support for all
staff including those who had been with Mr Morrison at hospital. The prison followed
postvention procedures in ensuring that staff and prisoners were offered support.
Post-mortem report
96. The post-mortem report gave Mr Morrison’s cause of death as hypoxic-ischaemic
encephalopathy caused by hanging. No illicit drugs were found in his body.
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Findings
Management of ACCT
97. PSI 64/2011 and subsequently the Prison Safety Policy Framework require all staff
who have contact with prisoners to be aware of the triggers and risk factors that
might increase the risk of suicide. Mr Morrison had a history of attempted suicide
and self-harm, substance misuse, a history of poor mental health and had been
given a life sentence which he was struggling to come to terms with.
98. Mr Morrison previously threatened self-harm as he was unable to cope with his
sentence and often self-harmed by way of cutting. He sometimes spoke about
suicide or thinking he would not be able to complete his sentence. He was subject
to ACCT monitoring on five separate occasions at Long Lartin, with the most recent
started on 10 September. Broadly, we consider that the ACCT process provided Mr
Morrison with personalised support. ACCT reviews were carried out in line with
policy, were multidisciplinary and addressed Mr Morrison’s current risk. All
observations were recorded and those evidenced by CCTV were carried out within
the defined timescales. The frequency of checks was increased and decreased in
line with Mr Morrison’s perceived level of risk.
99. However, during a review on 11 September, Mr Morrison spoke of being bullied and
under threat, and said this was a driver for his most recent self-harm. This
information, although recorded as part of the case review, was not added to his list
of potential risks and triggers and was not listed as an issue on the care plan. We
note however that, due to his concerns, Mr Morrison was relocated to another wing,
where during a later case review, he said that he felt safer and more settled. We
bring this to the Governor’s attention.
100. In the days before his death, Mr Morrison’s behaviour deteriorated significantly. He
was aggressive to staff, would not comply with instructions, smashed his cell and
was moved to the segregation unit. Staff who knew him described his behaviour as
out of character. It is not clear what caused Mr Morrison’s behaviour to change so
dramatically.
101. Mr Morrison was subject to ACCT monitoring while segregated and was checked
four times an hour. Staff considered his behaviour to be risky (particularly so to
staff) but his self-harming behaviour had not escalated and he had not revealed any
suicidal thoughts. We consider that staff had taken reasonable steps to support Mr
Morrison but that they had no particular reason to consider him in crisis or at
imminent risk of suicide.
Mr Morrison’s illicit substance use
102. Mr Morrison had a long history of substance misuse which continued in prison. He
was frequently found to be under the influence of drugs and admitted to using a
variety of drugs at Long Lartin. Mr Morrison’s drug use led to him to fall into debt
and be fearful for his safety.
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103. The illicit economy within prison is known to be a driver for debt and violence. The
Prison Service published a framework for governors on debt as part of the safety
toolkit.
104. We consider that staff tried hard to support Mr Morrison and keep him safe. The
recovery meeting Mr Morrison attended with the drug strategy lead and lead
substance misuse nurse provided a good opportunity for staff to fully explore Mr
Morrison’s complex substance misuse issues and identify effective support
measures. Staff identified that Mr Morrison was at particular risk of violence and
threat and expedited his move to the vulnerable prisoners’ unit. Despite Mr Morrison
having previously failed to remain drug free on the ISFL, staff told him that they
would support him returning there in due course.
Actions to tackle illicit drug use at Long Lartin
105. Mr Morrison was able to obtain illicit drugs with apparent ease at Long Lartin. He
struggled to remain drug free, despite voicing his desire to do so. Mr Morrison had
the opportunity to reside on the ISFL wing, but he was removed from that wing
because he breached his compact by continuing to use drugs.
106. The Drug Strategy Lead at Long Lartin told the investigation that the prison was
working with the security department to identify ways to restrict supply but also
ways of reducing the demand of drugs. He said that the Incentivised Substance
Free Living (ISFL) unit offered incentives to prisoners to refrain from using drugs
and therefore enabled recovery. In relation to the ingress of illicit drugs, he said that
drones posed the greatest security threat to Long Lartin.
107. The Drug Strategy Lead said that moving prisoners to disrupt cohorts, random
testing, searching of prisoners and staff and reacting to and sharing intelligence are
all used to try and reduce supply. He also said that being aware of the scale of the
issue, the prison had recently introduced and trained staff in the use of naloxone
(which can reverse the effects of an opioid overdose). In addition, Long Lartin
published guidance to staff about identifying those who might be under the
influence of illicit drugs and the actions that should be taken.
Clinical care
108. The clinical reviewer concluded that the care Mr Morrison received at Long Lartin
was of a reasonable standard and equivalent to what he could have expected to
receive in the community.
109. The clinical reviewer noted that Mr Morrison was clearly a very troubled individual
who had struggled for many years to manage his substance misuse issues. She
noted that Mr Morrison frequently reported that he self-medicated using a range of
substances to escape from reality. The clinical reviewer noted that Mr Morrison
presented as chaotic and impulsive, which the healthcare team, and others, tried to
support in the best way they could, within a particularly challenging environment,
using all the resources they had available to them.
110. Substance misuse services, both clinical and psychosocial, made efforts to help Mr
Morrison, and utilised safer prescribing to manage the risks related to Mr Morrison’s
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substance misuse against his clinical prescribing needs. Mr Morrison was
appropriately offered opiate substitute treatment along with psychosocial education
and support with recovery, to support and reinforce harm reduction.
111. The clinical reviewer said that despite the initial delay during the emergency
response of nursing staff being able to access and assess Mr Morrison, which was
outside the healthcare team’s control, all efforts were made to resuscitate Mr
Morrison. The team were well skilled and used all equipment and other resources
available to them in their efforts.
Governor to note.
Emergency response
112. Mr Morrison was subject to a four officer unlock due to his previous violent
behaviour toward staff. When the officer checked on Mr Morrison and saw him
hanged, he alerted his colleagues and nursing staff, but did not immediately enter
the cell. When interviewed, the officer said that he was aware that Mr Morrison was
a four officer unlock and as such he took the decision to wait for his colleagues to
be with him at the cell before entering. Fortunately, his colleagues were not far
away, and it was around one minute from finding Mr Morrison to staff entering the
cell. However, this could have been much longer had they not been so close. We
accept that staff will carry out a dynamic risk assessment, using prior knowledge of
the prisoner’s behaviour and other factors such as presentation and whether a
shared cell before entering. However, Mr Morrison was in a single cell, could clearly
be seen with a ligature around his neck and was unresponsive. When these facts
were put to the officer during interview, he agreed that the response could have
been quicker. We bring this to the Governor’s attention.
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