Frazer Williams

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Independent investigation into
the death of Mr Frazer Williams,
a prisoner at HMP Guys Marsh,
on 7 March 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
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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 Frazer Williams died on 7 March 2022, after he was found hanged in his cell at HMP
Guys Marsh. He was 28 years old. I offer my condolences to his family and friends.
Mr Williams was transferred to Guys Marsh on 14 January 2022. He had a history of self-
harm, emotionally unstable personality disorder (EUPD) and drug-induced psychosis, for
which he was prescribed antipsychotic medication.
Mr Williams was a very challenging prisoner. He refused to engage with staff and spent
much of his time living in a dirty cell that smelt of faeces as he refused to flush his toilet.
Mr Williams was under the care of the mental health team and was managed under
suicide and self-harm monitoring procedures (known as ACCT) throughout his time at
Guys Marsh.
He needed additional support, but staff did not consistently address his risk factors
holistically, and his complex issues warranted better case management. There were
deficiencies in the management of ACCT procedures. Although there is evidence of
discussion about Mr Williams’ issues, I am not satisfied that specific actions were identified
that might have helped to resolve these problems.
In particular, there was a lack of effective care planning to help address Mr Williams’ risk,
and there was a lack of input when his circumstances changed (when Mr Williams was
considered not to have mental capacity in regard to his needs). We found that HM Prison
and Probation Service had no self-neglect guidance in place to help to support prisoners
such as Mr Williams.
Ten days before his death, Mr Williams was assaulted, as a direct result of his dirty living
conditions. I am not satisfied that staff properly assessed the risk or impact this might
have had on him.
Four days before Mr Williams’ death, he was informed that he would soon be transferred
to a secure mental health hospital. I am concerned that his risk of suicide and self-harm
was not assessed in light of this.
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 June 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 20
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Summary
Events
1. In October 2021, Mr Frazer Williams was remanded in custody to HMP Winchester.
On 10 November, he was sentenced to nine months in prison. It was not his first
time in prison. He had a history of self-harm, substance misuse and mental health
problems, including emotionally unstable personality disorder, drug-induced
psychosis, attention deficit hyperactive disorder (ADHD), anxiety and depression.
Mr Williams was supported by the mental health team and prescribed antipsychotic
medication.
2. On 14 January 2022, Mr Williams was transferred to HMP Guys Marsh, where his
behaviour deteriorated. He rarely engaged with staff and did not take care of his
personal hygiene. Mr Williams said that he heard voices and refused to flush his
toilet because he believed that his family would be made to eat the contents. As a
result, he lived in dirty conditions. Prison staff managed him under suicide and self-
harm procedures, known as ACCT, for the majority of his six weeks at Guys Marsh.
3. Mr Williams spent long periods of time in his cell, which smelt of faeces, and did not
always collect his medication. Staff tried to conduct 12 ACCT case reviews. Of
these, Mr Williams only attended two and refused to attend or showed limited
engagement at all others.
4. On 9 February, a consultant psychiatrist concluded that Mr Williams had a psychotic
disorder and started the process to transfer him to a secure mental health hospital.
He noted that Mr Williams did not have mental capacity to make decisions about his
needs. There was no evidence that staff had taken action to improve his living
conditions.
5. On 25 February, Mr Williams was assaulted in his cell by another prisoner because
he had thrown a plastic bag containing his faeces out of his cell window and it had
landed in the cell below.
6. On 3 March, a mental health nurse told Mr Williams that he was to move to a
secure hospital. The date of his transfer (7 March) was withheld from him for
security reasons. After this point, no one assessed Mr Williams’ risk of suicide and
self-harm or considered how the news of this transfer might have affected him.
7. At 3.15am on 7 March, an officer found Mr Williams hanging from the inside of his
cell door. The officer radioed a medical emergency code blue and staff responded
quickly. Staff tried to resuscitate Mr Williams until paramedics arrived and took
over. At 3.48am, they confirmed that he had died.
Findings
Management of Mr Williams’ risk of suicide and self-harm
8. Mr Williams had a number of risk factors when he arrived at Guys Marsh: he had a
history of self-harm, substance misuse, mental health problems and was prescribed
antipsychotic medication. Staff appropriately started ACCT procedures.
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9. We are concerned that staff underestimated Mr Williams’ level of risk. They placed
too much emphasis on his behaviour and did not give sufficient weight to his
underlying risk factors, including recognising that his self-neglect was a form of self-
harm.
10. We found some deficiencies in the prison’s management of the ACCT procedures.
These included a lack of a consistent case co-ordinator, not identifying risks or
setting appropriate care plan actions and not correctly recording the outcomes of
those care plan actions which were identified. Staff failed to assess Mr Williams’
risk after he was informed that he would be transferring to a secure hospital setting.
11. We are concerned there was a lack of leadership and planned action in relation to
unusual or complex cases and the Safety Intervention Meeting (SIM) did not create
a proper management plan to address Mr Williams’ risks.
Mr Williams’ location
12. While Mr Williams’ lived in dirty living conditions, staff did not monitor him more
closely and did not consider moving him to another cell or wing.
Key work
13. Prison staff did not have sufficient meaningful interaction with Mr Williams through
key work sessions.
Clinical care
14. The clinical reviewer found that the clinical care at Guys Marsh was partially
equivalent to that which Mr Williams could expect to receive in the community.
There was a lack of safeguarding oversight in managing Mr Williams’ self-neglect.
No one reviewed Mr Williams after he was told that he would be moving to a mental
health hospital.
Recommendations
• The Governor and Head of Healthcare should ensure that all Reception and First
Night staff have a clear understanding of their responsibilities to identify prisoners at
risk of suicide and self-harm in line with national instructions and in particular, the
need to record, share and consider all relevant information about risk, and start
ACCT procedures when indicated.
• The Governor should ensure that staff manage prisoners at risk of suicide and self-
harm in line with national instructions, including that:
• a case co-ordinator is appointed at the first case review, who should lead all
subsequent case reviews wherever possible;
• case review teams assess risk and set levels of observations based on the
prisoner’s risk;
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• prisoners with challenging needs or significant complexity are referred to the
Safety Intervention Meeting, who identify meaningful action points to address
the key issues;
• ACCT care plans are completed that are specific and meaningful and include all
of the issues identified during the assessment interview and at case reviews;
• urgent case reviews are held when information is received that indicates
increased risk; and
• ACCT entries are completed accurately, legibly and in a timely manner and are
signed and correctly dated.
• The Governor should ensure that when a prisoner’s cell is uninhabitable or
damaged to the extent it impacts on his basic needs, prison staff should:
• move him to another cell as quickly as possible; and
• record the damage, monitor the wellbeing of the prisoner while he remains in the
cell and escalate the situation to managers to resolve promptly.
• The Governor should ensure that there is an effective key worker scheme which
provides meaningful and ongoing support to prisoners.
• The Heads of Healthcare at HMP Winchester and HMP Guys Marsh should ensure
that effective liaison between prisons takes place when prisoners with a history of
severe and enduring mental illness are transferred between the prisons, with the
outcome fully documented in the prisoner’s medical records.
• HM Prisons and Probation Service’s national adult safeguarding lead should
develop a self-neglect strategy and formal guidance to be used in the prison
environment.
• The Head of Healthcare should ensure that any information about secreted
medication is recorded, communicated and considered appropriately.
• The Governor and Head of Healthcare should ensure that a copy of this report is
shared with the staff named in this report and that a senior manager discusses the
Ombudsman’s findings with them.
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The Investigation Process
15. The investigator issued notices to staff and prisoners at HMP Guys Marsh informing
them of the investigation and asking anyone with relevant information to contact
him. Two prisoners contacted the investigator.
16. The investigator obtained copies of relevant extracts from Mr Williams’ prison and
medical records.
17. NHS England commissioned a clinical reviewer to review Mr Williams’ clinical care
at the prison.
18. The investigator and clinical reviewer jointly interviewed nine members of staff and
three prisoners at Guys Marsh between 4 and 17 May 2022.
19. We informed HM Coroner for the County of Dorset of the investigation. She gave
us the results of the post-mortem examination report. We have sent her a copy of
this report.
20. The Ombudsman’s family liaison officer contacted Mr Williams’ mother to explain
the investigation and to ask if she had any matters she wanted us to consider. Mr
Williams’ mother asked the following questions about the circumstances leading to
Mr Williams’ death:
• Was Mr Williams being monitored by suicide and self-harm prevention
procedures?
• Did Mr Williams receive any healthcare or psychological support?
• Did Mr Williams have the mental capacity to make decisions and what
safeguarding interventions were put in place to support him?
• What were the circumstances which led to Mr Williams being referred to a
secure mental health hospital?
We have addressed these questions in this report.
21. Mr Williams’ mother received a copy of the initial report. She did not make any
comments.
22. The initial report was shared with HM Prison and Probation Service (HMPPS).
They identified three factual inaccuracies which have been amended in the final
report. All recommendations were accepted.
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Background Information
HMP Guys Marsh
23. HMP Guys Marsh is a medium security prison that holds up to 491 men. Practice
Plus Group (formerly Care UK) provides primary and secondary mental healthcare
and has commissioned another agency, EDP, to provide integrated substance
misuse services. Healthcare services are available on weekdays and at weekends
from 8.30am to 6.00pm and there is a doctor on duty on Saturday mornings.
HM Inspectorate of Prisons
24. The most recent full inspection of HMP Guys Marsh was in January 2019.
Inspectors reported that the prison had started to make progress after successive
poor inspections. However, they remained concerned about safety and purposeful
activity. Levels of violence, driven by drug use and debt, were higher than at similar
prisons. and the prison had been slow to formulate improvement strategies. New
measures to combat illicit drug use were untested, and several deaths had been
related to the use of illegal psychoactive substances. There remained a problem
with increased self-harm among prisoners. Inspectors found that a significant
amount of work had been done to try to improve the situation and support for those
in crisis seemed good.
25. In October 2019, HMIP carried out an Independent Review of Progress to look at
progress against key recommendations from the earlier inspection. Inspectors
reported that, overall, progress had been disappointing. There had been many
incidents, and some deaths, relating to the use of illicit drugs, debt and intimidation
arising from the trade of drugs. Work to prevent drug use and debt prevention work
was developing well, and the number of positive drug tests had dropped markedly.
A wide range of security measures had been taken to cut the supply of drugs, but
more work was needed in light of continuing poor outcomes. Inspectors found that
the response to the drugs problem was undermined by the fact that intelligence was
not always processed promptly or analysed systematically to identify trends and
patterns, and target searching often did not take place. They recommended that
coordinated action should be taken to make the prison safer, in particular,
developing effective responses to drug misuse and debt.
Independent Monitoring Board
26. 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, covering the year to November 2021, the IMB
reported that the availability of illicit substances continued to be a concern, most
commonly psychoactive substances. There were concerns about the number of
prisoners who had severe mental health issues. Key working was notably absent
over the year and impacted on prisoners’ wellbeing. There was still a reluctance
among staff to wear body-worn cameras.
27. The number of prisoners subject to ACCT monitoring averaged 15 throughout the
year. On routine examination of ACCT documents, the IMB found that there was an
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improvement in entries since more staff had been trained in the ACCT process but
entries with minimal content were seen, especially when officers were stretched by
monitoring multiple prisoners who were subject to ACCT procedures and who had
high observation demands.
Previous deaths at HMP Guys Marsh
28. Mr Williams was the third prisoner to die at Guys Marsh since 1 January 2019, and
the first to have taken his life. Of the previous two deaths, one prisoner died from
natural causes and the other was drug-related. Our report into the death of a
prisoner in July 2021 found that the prisoner did not receive appropriate support
through the key worker scheme.
Assessment, Care in Custody and Teamwork
29. 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. 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. Regular multidisciplinary review meetings involving the prisoner should be
held.
30. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of 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. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011,
Management of prisons at risk of harm to self, to others and from others (Safer
Custody).
Key worker scheme
31. The key worker scheme aims to improve safer custody by engaging with prisoners,
building better relationships between staff and prisoners and helping prisoners
settle into life in prison. It provides that all adult male prisoners will be allocated a
dedicated key worker who will spend an average of 45 minutes a week on key work
activities, including having meaningful conversation which each of their allocated
prisoners.
32. The key worker scheme was suspended across the prison estate on 24 March 2020
due to the COVID-19 pandemic. To ensure that meaningful interaction continued
for priority prisoners, such as those who were at risk of suicide or self-harm, the
Prison Service introduced the Exceptional Delivery Model for key work in May 2020.
This provides that an officer will have a weekly conversation with prisoners
identified as vulnerable.
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Transfers of prisoners to hospital under the Mental Health Act
33. When a prisoner has a mental illness that requires detention in a hospital for
medical treatment, and the prisoner urgently needs that treatment, the prison can
arrange for them to be transferred to a secure hospital under section 47, 48 or 49 of
the Mental Health Act 1983.
Self-neglect
34. Self-neglect is an extreme lack of self-care and is a category of neglect which falls
under the adult safeguarding procedures in the Care Act 2014. It can be challenging
for professionals to work with someone who self-neglects and it requires a complex
and multifaceted approach.
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Key Events
35. On 4 June 2021, Mr Frazer Williams was remanded in custody to HMP Lewes,
charged with having an article with a blade or point in a public place. He was
subsequently sentenced to four months in prison.
36. From July, Mr Williams was monitored under suicide and self-harm prevention
procedures, known as ACCT, and located in the healthcare inpatient unit due to
concerns over his declining mental health. He had a history of poor engagement,
self-harm, substance misuse and self-neglect. Mr Williams had ADHD, emotionally
unstable personality disorder and drug-induced psychosis.
37. On 4 October, Mr Williams was released on licence from Lewes. He was monitored
under ACCT procedures until his release.
HMP Winchester
38. On 7 October, Mr Williams, was recalled to HMP Winchester, charged with
possession of an offensive weapon in a public place.
39. Reception staff recorded that Mr Williams was experiencing the effects of
withdrawal from drugs. He refused the support of the substance misuse team. No
concerns were recorded about his risk of suicide and self-harm. The reception
nurse recorded Mr Williams’ substance misuse history. She noted that he had
anxiety and depression but was mentally stable.
40. The next day, the healthcare team reviewed Mr Williams’ medical record and
completed a medicine reconciliation. They noted that his prescribed medication
included amitriptyline (used to treat depression), naproxen (used to treat pain) and
olanzapine (an antipsychotic). He was not allowed to keep his medication in his cell
and had to collect it in person each day and take it in front of a nurse.
41. On 18 October, a mental health nurse saw Mr Williams in his cell after it was
reported that he was living in dirty conditions. Mr Williams was in bed and declined
to be assessed. The nurse recorded that his cell was full of rubbish and decaying
food and that his personal belongings were on the floor and his cell smelt of urine.
The nurse informed wing staff to monitor Mr Williams and for the mental health
team to complete welfare checks on him.
42. That day, wing staff notified the healthcare and substance misuse teams that Mr
Williams had been observed trying to divert his medication. From a review of his
medical record, it was noted that he had an extensive history of diversion.
43. On 19 October, Mr Williams again declined to be assessed by a mental health
nurse.
44. On 10 November, Mr Williams was sentenced to nine months in prison. (His
release date from prison was 25 March 2022.)
45. On 5 December, healthcare staff noted that Mr Williams had not collected his
medication for two days. A member of the pharmacy team spoke to him. Mr
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Williams said that he was okay but did not feel like taking his medication. Staff
noted that Mr Williams’ medication compliance would be monitored and informed
the mental health team.
46. On 22 December, a consultant forensic psychiatrist assessed Mr Williams who
refused to talk about his mental health but was happy to discuss his medication
(olanzapine). He wanted the dose to be increased, which was agreed. The
psychiatrist noted that Mr Williams displayed no acute signs of psychosis at the time
and would be reviewed in approximately two weeks to check for signs of
deterioration to his mental health. The psychiatrist noted that Mr Williams’ medical
records showed that when he was previously in custody, his mental health and self-
care had simultaneously deteriorated. This included that his cell was in a state of
neglect, with flies in the toilet.
47. On 5 January 2022, a mental health nurse tried to review Mr Williams, who said that
he did not need mental health support.
48. On 14 January, Winchester arranged for Mr Williams to transfer to HMP Guys
Marsh. Healthcare staff recorded in Mr Williams’ medical record that they had
emailed a handover note to the healthcare team at Guys Marsh. The handover
noted that Mr Williams had emotionally unstable personality disorder and drug-
induced psychosis and was prescribed olanzapine. It noted that his engagement
with mental health services was poor.
HMP Guys Marsh
49. Mr Williams arrived at Guys Marsh that afternoon. His Person Escort Record (PER,
a document that provides information about a person's risk and is used as they
move between police custody, court and prison) noted that he had health issues
and was prescribed olanzapine.
50. An officer recorded that Mr Williams had no history of substance misuse or self-
harm and had not previously been monitored under ACCT procedures. She noted
that he was not taking any prescribed medication and had no physical or mental
health problems. This information was incorrect.
51. A nurse conducted a health screen and noted Mr Williams’ mental health diagnoses
and history of substance misuse. Mr Williams said that he had no thoughts of
suicide or self-harm. The nurse referred Mr Williams for a mental health
assessment.
52. Mr Williams was allocated a single cell on the Reverse Cohorting Unit (where
prisoners are usually isolated on arrival in prison under COVID-19 restrictions), due
to his mental health concerns.
53. On 15 January, a member of the substance misuse team visited Mr Williams at his
cell to conduct an assessment. Mr Williams declined to engage. He was given
information about how to minimise the harm from drugs.
54. That day, a mental health nurse and the mental health team leader saw Mr Williams
in his cell and completed a triage assessment. This followed concerns from wing
staff that Mr Williams had refused to engage, had isolated himself in his cell and
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declined his meals and medication. Mr Williams refused to engage with the nurses,
although when the nurse told him that she intended to start ACCT procedures, he
stated that he would kill himself if this happened. She started ACCT procedures,
with monitoring initially set at four observations per hour.
55. As he was being monitored under ACCT procedures, Mr Williams fell under Guys
Marsh’s criteria to have daily wellbeing checks. (A wellbeing check is when an
officer interacts with a prisoner face-to-face to check on his health and wellbeing.)
56. That evening, staff completed a wellbeing check on Mr Williams. They noted that
he still did not engage and had not left his cell or collected his evening medication.
57. On 16 January, Mr Williams refused to attend his ACCT assessment and first case
review. A Supervising Officer (SO), the case co-ordinator, reported that Mr Williams
had started to engage with staff, had left his cell and was seen interacting with other
prisoners. Mr Williams had told staff he had no thoughts of self-harm, had a year
left of his sentence and was making plans for his release from prison. She and a
Custodial Manager (CM) (the ACCT assessor) agreed to reduce Mr Williams ACCT
observations so that they were less intrusive for him. Observations were changed
to one per hour, with staff having two conversations each day with him. His ACCT
case review was rescheduled for 17 January.
58. A nurse saw Mr Williams that evening. Mr Williams said that he had eaten and was
now willing to engage with the mental health team. He asked for his medication to
be reviewed. The nurse noted that another prisoner (a long-term friend of Mr
Williams) had reported that Mr Williams was hearing voices.
59. An officer completed a wellbeing check that evening. She saw Mr Williams coming
out of his cell and talking with his friend. He had also collected his meals and
medication.
60. Another SO was now named as the case co-ordinator and completed an ACCT
case review on 17 January, assisted by the Head of Healthcare. Mr Williams
attended and was supported by his friend. Mr Williams said that he was struggling
but had no thoughts of self-harm. He said that his medication (olanzapine) had an
adverse impact on his mental health. He said that he had difficulty sleeping and
heard voices which distracted him and made him laugh. Mr Williams refused to talk
about his family. His friend told the panel that he believed that Mr Williams’ mental
health issues were due to him misusing drugs. The Head of Healthcare told Mr
Williams that a full medication review would be completed after a psychiatrist had
assessed him. The panel noted that Mr Williams had left his cell more than once
and collected his medication and meals. They noted a slight change in ACCT
observations to one conversation per day but continued with hourly observations.
61. The case co-ordinator recorded three issues in Mr Williams’ ACCT support plan: his
lack of sleep due to his medication not working; for him to see the psychiatrist due
to hearing voices (an appointment had been made for 20 January); and for
consideration to be given to his friend living on the same wing as Mr Williams when
they were moved from the Reverse Cohorting Unit. (Despite further ACCT reviews
noted later in this report, no further support plan actions were recorded.)
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62. On 18 January, an officer completed a wellbeing check. He recorded that Mr
Williams had remained in bed all day (other than to collect his meals) and had not
engaged with staff. Wing staff completed frequent wellbeing checks during the rest
of the month and recorded similar behaviour from Mr Williams each time. He rarely
left his cell, other than to collect meals (which he also sometimes missed) and
engaged little with staff.
63. On 20 January, a consultant psychiatrist assessed Mr Williams in his cell. (Mr
Williams’ friend was also present to support him.) He noted that Mr Williams
presented as distressed and guarded. Mr Williams said that if he flushed the toilet
in his cell, his family would be made to eat the contents (faeces). He also believed
that if he watched television, his family would be tortured. He no longer wanted to
take olanzapine and said that he wanted medication to help him sleep. Mr Williams
denied substance misuse or an intent to harm himself. His friend told the
psychiatrist that he had known Mr Williams for a long time and had not seen him
like this before. The psychiatrist noted that Mr Williams had a possible psychotic
disorder and would need further assessment. He prescribed an alternative
antipsychotic, quetiapine.
64. The next day, the case co-ordinator chaired an ACCT case review. A member of
the substance misuse team, a nurse and Mr Williams’ friend attended. Mr Williams
was initially reluctant to attend but his friend persuaded him to. Mr Williams said
that he heard voices and did not want to be at the case review or be monitored by
ACCT procedures. He said that he “could not be bothered” to collect his new
medication from the medication hatch. The nurse reminded him of the importance
of taking his prescribed medication. Mr Williams refused to discuss why he would
not flush his toilet. Due to his lack of engagement, ACCT monitoring remained in
place, with no change to the level of observations.
65. On 22 January, a nurse reviewed Mr Williams in his cell. Mr Williams was lying in
bed in the dark. She noted that he did not want to speak to her for long. He
expressed his fears of flushing his toilet and said that he had no thoughts of self-
harm. She noted that staff should regularly encourage Mr Williams to engage.
66. On 24 January, Guys Marsh became a COVID outbreak site, and the prison
remained an outbreak site until after Mr Williams died. The outbreak affected staff
attendance, reducing the consistency of available staff on residential wings.
67. That day, Mr Williams moved to Saxon Wing. Contrary to the ACCT support plan
action, his friend was moved to a different wing.
68. On 26 January, a CM, now listed as the ACCT case co-ordinator, tried to conduct
an ACCT case review. Mr Williams refused to attend. The CM rescheduled the
case review for the following day in the hope that Mr Williams would want to
engage. ACCT observations remained unchanged.
69. On 27 January, another CM, listed as the case co-ordinator, chaired an ACCT case
review. A mental health nurse attended, and a previous case co-ordinator provided
a verbal contribution. After much persuasion, Mr Williams agreed to attend.
However, he made no eye contact with the panel, kept his head bowed and the
conversation with him was limited. Mr Williams asked more than once if he could
stop the meeting and return to his cell. He said that he had no thoughts of self-
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harm. The CM noted that Mr Williams “played down his poor mental health” and
stated that he was okay and no longer heard voices. The nurse recorded that the
panel had discussed whether ACCT monitoring needed to continue as Mr Williams
had not harmed himself and had no thoughts to do so. Her recommendation was
that the ACCT should remain open because Mr Williams’ poor engagement meant
his risks could not be properly assessed. She made an urgent appointment for Mr
Williams to see the psychiatrist (on 1 February) as he continued to present with
psychotic symptoms. The CM noted in the ACCT record that Mr Williams
observations had been reduced to one conversation a day (and no observations).
In contrast, the nurse recorded that his observations were to remain hourly. (Staff
applied the CM’s monitoring instruction.) Mr Williams’ next ACCT review was
scheduled for 1 February, if he had had his appointment with the psychiatrist, and
otherwise it would be completed on 2 February.
70. Over the next few days, Mr Williams behaviour remained unchanged.
71. On 31 January, Mr Williams broke the fire detector in his cell, which activated the
fire alarm several times in the evening. Mr Williams was relocated overnight onto
Anglia Wing, so that a member of the maintenance team could fix the fire detector
in the morning.
72. On 1 February, a CM completed an ACCT case review. An officer and a nurse also
attended. Mr Williams declined to engage in the meeting, although stated that he
had not harmed himself and did not want to be monitored under ACCT procedures.
He had not left his cell on Anglia Wing since his temporary move. The CM told Mr
Williams that his cell had now been repaired and that he would return to Saxon
Wing soon. Mr Williams’ response was that he had no intention to return to his
former cell. He then refused to engage further with the panel. The nurse noted that
Mr Williams looked unkempt, refused to answer any of the CM’s questions and kept
shaking his head. He did not respond when asked if he had any thoughts or
intention to harm himself or end his life. The CM increased Mr Williams’ ACCT
observation level to two conversations a day (with no observations).
73. Mr Williams was sent back to his cell on Saxon Wing that afternoon. Staff reported
no concerns about him.
74. Shortly afterwards, the psychiatrist assessed Mr Williams at his cell. He observed
that Mr Williams looked dishevelled and that his room smelt due to him not flushing
the toilet. Mr Williams refused to engage in any conversation and just shook or
nodded his head when asked any questions. Mr Williams’ medical records noted
that he had refused to take his quetiapine on four occasions since 20 January. The
psychiatrist believed that Mr Williams may have a psychotic disorder and noted that
he would review him in a week.
75. On 2 February, a multidisciplinary mental healthcare meeting discussed Mr
Williams. Attendees included the psychiatrist and two nurses. It was agreed that
when the psychiatrist returned from his forthcoming annual leave, the team would
discuss whether Mr Williams should be assessed for hospital admission under the
Mental Health Act (MHA). A nurse was assigned as his case worker.
76. That day, staff opened a food refusal log after Mr Williams declined to eat.
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77. Over the coming days, there was no change in Mr Williams’ behaviour. He
occasionally collected food from the servery and also purchased food through his
canteen orders. The food refusal log was therefore closed on 7 February.
78. On 8 February, a CM tried to complete an ACCT case review. A nurse assisted him
and an officer contributed verbally. When the CM and the nurse went to collect Mr
Williams, he was in bed in the dark, with the bed sheet pulled over his head. He
declined to engage or leave his cell, which had an “extremely offensive” smell of
faeces due to the toilet not being flushed. The nurse noted that staff were
struggling to work in such conditions and that it was difficult to assess Mr Williams’
risk of suicide and self-harm. She sent an urgent email to the senior healthcare
manager and to the covering psychiatrist (the other psychiatrist was on leave) to
seek an urgent review. The CM noted that Mr Williams’ observations would remain
at two conversations a day.
79. The CM told us at interview that the smell from Mr Williams’ cell was abhorrent and
that staff had taken to flushing his toilet themselves during the daily fabric checks of
his cell. Other prisoners on the wing had also apparently tried to encourage Mr
Williams to clean his cell. We found no consistent recorded information to support
this.
80. On 9 February, Mr Williams’ case was referred to the Safety Intervention Meeting
(SIM), a weekly multidisciplinary meeting which discussed prisoners with complex
needs in order to create care plans to support them. The SIM minutes noted that
an emergency referral had been made for Mr Williams to see a psychiatrist. No
other information was recorded.
81. That day, the duty consultant psychiatrist assessed Mr Williams. A nurse and Mr
Williams’ friend were also present. The psychiatrist noted that Mr Williams’
presentation was unkempt and that he was withdrawn and extremely guarded when
he tried to discuss his self-care/hygiene and toilet issues. He concluded that Mr
Williams had a psychotic disorder and would benefit from further assessment in a
mental health hospital. He made a first recommendation for a transfer to hospital
under section 47 of the MHA and explained this to Mr Williams. Mr Williams
responded, “I’m not mad, I don’t want to go anywhere”. The psychiatrist recorded
that Mr Williams was vulnerable and noted his level of self-neglect and poor
engagement. He noted that Mr Williams had a poor insight into his mental health
and did not have mental capacity to make decisions about his needs. He also
increased Mr Williams’ quetiapine dose.
82. That evening, an officer completed a wellbeing check. She noted that Mr Williams
had not engaged in any conversation with staff that day. He had collected his
lunch, evening meal and canteen, and left his cell during association time (when
prisoners socialise with each other).
83. On 10 February, an officer completed a key work session. Mr Williams did not
engage in conversation although occasionally responded with ‘yes’ or ‘no’. The
officer noted that he appeared to be socialising more with other prisoners, collecting
his food and that he now had a television.
84. Later, a nurse created Mr Williams’ mental health care plan. It noted that Mr
Williams continued to present with psychotic symptoms and fixed delusional beliefs
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about flushing his toilet. He also had intermittent compliance with his antipsychotic
medication, a deteriorating mental state and poor self-care. While he had a long
history of substance misuse, there was no evidence that he had recently used illicit
substances at Guys Marsh. The plan remained to continue with the
recommendations required for section 47 of the MHA and for Mr Williams to be
transferred to a secure mental health hospital. In the meantime, staff were to
monitor him for any change in behaviour.
85. That day, a prison GP completed a second recommendation for section 47 of the
MHA. She noted Mr Williams’ poor mental health and engagement and concluded
that he did not have mental capacity to make decisions about his health and
wellbeing.
86. A member of the substance misuse team tried twice to call Mr Williams’ in-cell
telephone. Mr Williams did not answer so a self-referral form was sent to him to
complete and report any issues.
87. On 15 February, a CM, listed as the ACCT case co-ordinator, and a nurse tried to
complete an ACCT case review. Mr Williams refused to engage with the staff or
leave his cell. The CM noted that his cell “reeked so much of excrement” that he
almost vomited. He noted that he disliked that he had to work in such conditions
and believed it compromised his health and safety. The nurse noted that Mr
Williams remained in bed, with his head under the blanket and his light on. His cell
had a “very malodorous smell of urine” and was unkempt. The nurse noted that two
section 47 recommendations had been made, and that Mr Williams was waiting to
be assessed by the local psychiatric hospital (Ravenswood Unit). His ACCT
observations remained the same.
88. That afternoon, the nurse noted that it had been difficult to assess Mr Williams
because of his lack of engagement. Mr Williams failed to acknowledge the need for
a risk assessment and would not give staff permission to contact his family. She
recorded that he lacked capacity and insight into his mental health. She also
recorded that prison staff remained concerned that Mr Williams continued to live in
an unpleasant environment and to neglect his personal self-care. She commented
that prison staff had to clean Mr Williams’ cell due to the offensive odour. We have
been unable to find any evidence in Mr Williams’ prison records to confirm when or
how many times staff helped to clean his cell.
89. Later that afternoon, an administering nurse reported to the nurse who had
attended the ACCT that Mr Williams had been caught secreting his medication the
previous day.
90. On 16 February, a SO, listed as the case co-ordinator, and a nurse attended Mr
Williams’ cell to conduct an ACCT case review. Mr Williams was in bed and
refused to engage. The SO noted that the cell had a stench of human waste from
the toilet and rubbish was strewn over the floor. He queried whether ACCT
monitoring was appropriate as Mr Williams had not harmed himself and said that he
had no intention to do so. The nurse said that Mr Williams had a history of serious
self-harm, and, in view of his current mental health state, it would be prudent for
some form of monitoring to continue. The SO asked for Mr Williams’ case be
referred to the morning SIM. He recommended that Mr Williams’ lack of
engagement and the concerns about his mental health meant that a higher
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multidisciplinary approach needed to be considered. The observation level
remained the same.
91. The SIM meeting which took place later that day acknowledged that Mr Williams
had been referred due to his “bizarre behaviour” and that he was waiting for a
psychiatric appointment. There is no record that any other action or action plan was
considered.
92. On 17 and 18 February, staff noted that Mr Williams had spent a lot of time out of
his cell interacting with other prisoners and had collected his meals.
93. On 18 February, a CM, listed as case co-ordinator, and a nurse tried to conduct an
ACCT case review. When they arrived at Mr Williams’ cell, he again refused to
engage. He lay in bed in the dark. The staff recorded that they were unable to
assess Mr Williams’ risk and presentation due to his non-engagement. They
recorded that there were suspicions that Mr Williams may be secreting his
medication.
94. On 20 February, an officer completed a key work session. The officer noted that he
felt that he was slowly getting more of a response from Mr Williams as opposed to
his normal “no” or monosyllabic responses he gave other wing staff.
95. The next day, prison records noted that Mr Williams had a broken sink in his cell.
Mr Williams spent most of the morning in his cell due to the COVID regime. He did
not collect his lunch or engage with staff, but he collected his medication.
96. On 23 February, the psychiatrist tried to review Mr Williams, but he refused to
engage. He noted that Mr Williams’ cell remained in a poor state, and that he was
experiencing a psychotic disorder that could not be adequately treated in a prison
setting.
97. That evening, an officer noted that Mr Williams had been “pretty chatty” with staff
during the day, had collected his medication and meals and was seen on the
landing during association.
98. On 24 February, a CM and a nurse tried to conduct an ACCT case review. Mr
Williams refused to engage with them. The CM noted that considerations were
underway for Mr Williams to be transferred to a psychiatric hospital. He scheduled
the next review for 28 February.
99. On 25 February, the maintenance repair team attended Mr Williams’ cell to fix the
broken sink pipe. The repair team noted that they were unable to conduct the work
as the cell was “too dirty” to work in and needed to be bio-cleaned (cleaned to
remove harmful bacteria) before the work could be completed.
100. Later that morning, Mr Williams had a fight in his cell with Prisoner A. Staff
intervened quickly and separated both prisoners, who were given disciplinary
warnings. The prisoner told us that he had confronted Mr Williams because he had
thrown faeces out of his cell window and it had entered his cell, which was directly
below Mr Williams’ cell. No ACCT review took place to assess Mr Williams’ risk
after this incident.
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101. A nurse and a consultant psychiatrist from Ravenswood Unit (a secure mental
health unit) arrived on the wing shortly after Mr Williams’ fight with Prisoner A, to
complete an assessment. When they attended his cell, Mr Williams refused to
engage. He said that he was okay, that he did not want to talk and asked staff to go
away and close his cell door. The nurse recorded that Mr Williams appeared very
unkempt, his cell was in an unhygienic state and had an offensive smell. She noted
her concern that other prisoners on the wing had targeted Mr Williams by saying
offensive things about the smell from his cell. At interview, she told us that
prisoners had also put incense sticks outside Mr Williams’ cell door and burnt them
to stop the smell. Having raised her concerns with a wing manager, she told us that
she was informed that consideration was being given to moving Mr Williams to a
different wing. We found no evidence in prison records to suggest what, if any
action, was considered.
102. Following the assessment, the psychiatrist told the nurse that he would contact her
once he knew of an available bed space at Ravenswood Unit.
103. The next day, Mr Williams’ disciplinary hearing (for fighting) was adjourned. That
evening, an officer completed a wellbeing check. She noted that Mr Williams and
Prisoner A had apologised to each other for the fight. Mr Williams had not collected
his lunch but had collected his medication. She noted that his cell was still “a
mess”.
104. Prisoner A told us that he became friends with Mr Williams. He said that they would
often smoke psychoactive substances (PS) together and get “stoned”. He said that
Mr Williams did not talk a lot. He was aware that Mr Williams had mental health
problems and encouraged him to collect his dinner. He was also aware that Mr
Williams was selling his medication for nicotine caps. Another prisoner told us that
he believed Mr Williams was struggling with his mental health and that staff and
prisoners gave him less attention because of the smell from his cell and called him
names.
105. On 27 February, an officer noted in her wellbeing check that Mr Williams’ cell smelt
very foul. His engagement with staff was still very limited and he remained in his
cell for most of the day. Mr Williams was scheduled to have an ACCT case review
on 28 February. There is no record that this took place.
106. On 1 March, a CM tried to conduct an ACCT case review. An officer assisted and a
nurse from the mental health team contributed verbally. Mr Williams refused to
engage with the staff.
107. That day, a warrant was received for Mr Williams to be transferred to hospital under
section 47 of the MHA. Healthcare staff were told that a bed space was available
for Mr Williams to transfer to Ravenswood Unit on Thursday 3 March. During
interviews, however, we were told that on that day, the prison could not facilitate
any transport vehicles to take Mr Williams. In response, the hospital indicated they
could not accept Mr Williams on Friday 4 March, as they had reduced staffing levels
over the weekend. It was then agreed and confirmed that Mr Williams would be
transferred to Ravenswood Unit on Monday 7 March, accompanied by a nurse.
108. An officer completed a wellbeing check that evening (1 March). He noted Mr
Williams had left his cell during the day but remained uncommunicative with staff.
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109. On 2 March, a CM chaired the SIM. The panel discussed Mr Williams’ need for
ACCT support. It was agreed that it would remain open and noted that Mr Williams’
transfer to a psychiatric hospital had been delayed to 7 March.
110. On 3 March, a nurse saw Mr Williams. She explained to him that he would be
moving to a secure psychiatric hospital for further assessment. She added that she
could not advise him when this would be due to security reasons. Mr Williams said
that the move was “not happening” and he would not go. While trying to explain the
process to him, she said that Mr Williams got up and walked out of the meeting
room. She told us that Mr Williams’ presentation appeared no different after
hearing the news.
111. The nurse recorded in Mr Williams medical record that she was unable to assess
his risk associated with the news of his transfer to hospital. She asked staff to
monitor him for any change in his presentation and to increase his observations if
necessary. She told us that she also recorded her concerns in Mr Williams’ ACCT
document and informed wing staff. The ACCT documents contained no information
about an ACCT review that day or about the events that occurred when Mr Williams
was informed of his transfer.
112. After this, healthcare staff only saw Mr Williams when he collected his medication
between 3 and 5 March.
113. On 4 March, an officer conducted a wellbeing check of Mr Williams and noted no
real change. Mr Williams collected his food and medication during the day and
generally kept to himself.
114. On 6 March, Mr Williams did not attend for his medication.
Events of 6-7 March 2022
115. CCTV footage shows that Mr Williams collected his lunch and left his cell for short
periods on three occasions. While he had little interaction with staff, he spoke to
some prisoners.
116. Two prisoners told us that they saw two unknown prisoners enter Mr Williams cell
while he was not in his cell and flush his toilet. They speculated that this happened
because the other prisoners were unhappy with the smell from Mr Williams’ cell.
117. At 8.38pm, CCTV footage shows that an Operational Support Grade (OSG) A
completed a roll check, which consisted of her looking through Mr Williams’ cell
door observation panel. At interview, she told us that Mr Williams’ observation
panel was open and the main cell light was on. Mr Williams was on his bed and
appeared to be asleep. As she had noticed on previous occasions, Mr Williams’
cell was very untidy. She left his observation panel open, as she found it.
118. At 9.35pm, OSG A patrolled the wing landing. She told us that she heard nothing
untoward as she walked past Mr Williams’ cell.
119. At 3.12am on 7 March, OSG A completed an ACCT check on another prisoner,
whose cell was on the opposite side of the landing to Mr Williams’ cell. As she did
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this, she noticed a silhouette through Mr Williams’ observation panel. The cell light
was still on. She went to check.
120. When OSG A arrived at the cell, she saw Mr Williams standing with his back to the
cell door, slightly left of the observation panel. She thought that, based on his
height, his feet appeared to be on the floor. Mr Williams’ chin was resting on his
chest. Mr Williams did not respond when she called his name. She noticed what
looked like a ligature around Mr Williams’ neck, although she told us that it was so
tight that it was almost obscure. She was unable to see what the ligature was
attached to. She radioed a medical emergency code blue. The control room log
recorded that this occurred at 3.15am and that they called an ambulance
immediately.
121. OSG A continued to try and gain a response from Mr Williams. CCTV footage
shows that OSG B responded to the emergency alarm and arrived at Mr Williams’
cell within a minute. Mr Williams still had not responded. OSG B looked through
the observation panel and noticed a green cord running up the back of Mr
Williams's neck and up to the top left corner of the cell door. He unlocked the cell
door and found that Mr Williams' body was wedged behind it, making it difficult to
open. A CM, followed by officers, arrived to assist and helped OSG B to push the
door slightly open so that he could squeeze through. OSG B cut the ligature from
behind the door and Mr Williams fell onto his bed. This allowed staff entry to the
cell.
122. OSG B placed Mr Williams on the floor and removed the ligature from around his
neck. Mr Williams showed no signs of life and was cold. The CM started
cardiopulmonary resuscitation (CPR). In the meantime, OSG A collected the
defibrillator from the office, which advised that CPR should continue. An officer also
collected the red medical emergency bag (containing oxygen and other monitoring
equipment). Staff continued CPR efforts.
123. Paramedics arrived at 3.30am and took over Mr Williams’ care. At 3.48am, they
confirmed that he had died.
Information received after Mr Williams’ death
124. In his statement, an officer who also responded to the emergency, said he saw
what looked like PS paraphernalia on a shelf in Mr Williams’ cell. He said that the
cell had a pungent smell, and the sink was hanging off the wall.
125. After Mr Williams’ death, a number of prisoners came forward with information to
suggest that Mr Williams was being bullied and “tortured” because of the state of his
cell. They alleged that some prisoners, fed up with the smell of his cell, had entered
his cell and flushed his toilet the day before his death. Another prisoner reported
that Mr Williams was being bullied for his medication.
Contact with Mr Williams’ family
126. After Mr Williams died, it was noted that he had not identified any next of kin. Staff
located his mother’s contact details from the probation database.
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127. The family liaison officer and the Governor visited Mr Williams’ mother to inform her
and Mr Williams’ sister of his death. Mr Williams’ family said that they were not
aware that he had been transferred from Winchester to Guys Marsh.
128. The prison provided ongoing support and contributed towards the costs of Mr
Williams’ funeral in line with national instructions.
Support for prisoners and staff
129. The Head of Safety debriefed the prison staff involved in the emergency response.
All staff were offered the support of the prison’s care team. The Governor posted
notices informing other prisoners of Mr Williams’ death and offering support in case
they had been adversely affected.
Post-mortem report
130. A post-mortem examination identified Mr Williams’ cause of death as ligature
suspension. Post-mortem toxicology tests found quetiapine and olanzapine present
in Mr Williams’ system. No other drugs or illicit substances were detected. The
amount of quetiapine present was at a subtherapeutic level and therefore may have
been consistent with non-recent use.
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Findings
Management of Mr Williams’ risk of suicide and self-harm
131. Prison Service Instruction (PSI) 64/2011 on safer custody contains guidance and
mandatory instructions on managing prisoners at risk of suicide and self-harm. We
are satisfied that prison and healthcare staff appropriately started ACCT procedures
on 15 January 2022.
132. Managing Mr Williams was challenging for prison staff, and he had several factors
that increased his risk of suicide and self-harm. He was diagnosed with ADHD,
emotionally unstable personality disorder and drug-induced psychosis (for which he
was prescribed antipsychotic medication). Mr Williams had a history of poor
engagement, self-harm, substance misuse and self-neglect. His behaviour was
very challenging and made it difficult for staff to manage him due to his lack of
engagement, lack of personal hygiene and unhygienic living conditions. Mr
Williams’ behaviour prompted multiple referrals to the mental health team.
133. Some positive, supportive actions were taken, and it was apparent from our
interviews that staff were aware of the issues surrounding Mr Williams’ care.
However, there were some aspects of ACCT procedures that might have been
improved. In particular, we are concerned that staff underestimated Mr Williams’
risk of suicide and self-harm and did not give enough thought to addressing and
resolving his risk factors. We identified a number of concerns about the
management of ACCT procedures.
Reception
134. When Mr Williams arrived at Guys Marsh, his PER noted he had health issues and
was prescribed antipsychotic medication. His electronic prison record identified a
history of self-harm and that he had been monitored by ACCT procedures in prison
more than once. Despite this, reception staff recorded that Mr Williams had no
risks. We are concerned that staff did not properly review and consider his risk
factors as they should have and consider whether starting ACCT procedures was
appropriate.
Management of ACCT procedures
135. During his time at Guys Marsh, staff conducted 12 ACCT case reviews, including
those in which Mr Williams refused to participate or his engagement was limited.
An additional case review scheduled to take place on 28 February did not happen
and no reason was recorded for this. All of the reviews were multidisciplinary and
had input from the mental health team.
Appointment of a case co-ordinator
136. PSI 64/2011 instructs that ACCT reviews are led by a consistent ACCT case co-
ordinator, appointed at the first case review. A SO was initially named as case co-
ordinator on the front cover of the ACCT document but did not participate in this role
thereafter. Indeed, Mr Williams had nine different case co-ordinators for 12 ACCT
reviews. HM Prison and Probation Service (HMPPS) guidance states that it is good
practice to consider which case co-ordinator is best placed to oversee the ACCT
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procedures as the individual may feel more comfortable with engaging with the
process if a member of staff they know and trust is co-ordinating them. The lack of
a clear case co-ordinator meant there was little managerial ownership of Mr
Williams’ case, and it is likely that this contributed to the lack of care planning.
Assessing the risk of suicide and self-harm
137. Mr Williams’ lack of engagement meant that it was difficult for staff to assess his
risk. However, we are concerned that some aspects of his behaviour were not
given sufficient weight or recognised as factors that increased his risk.
138. On 8 February, staff made an urgent referral for Mr Williams to see the psychiatrist,
where it was assessed that he had poor insight into his mental health and did not
have mental capacity to make decisions about his needs and increased his
antipsychotic medication. This might have indicated that his risk level had
heightened and there is no evidence that a change to the level of observations was
considered at the case review held that day. There is also no evidence that the
case review team considered what additional support could be provided.
139. PSI 64/2011 instructs that an urgent case review should take place as soon as
possible if risk is likely to have increased between planned case reviews. It gives
examples of when this might happen, including when information is received to
suggest increased risks.
140. We found that no ACCT case review took place after Mr Williams was assaulted by
another prisoner (on 25 February), to assess and review his risk and the impact that
this altercation might have had on him. There was no evidence that the assault was
considered or discussed at Mr Williams’ next case review, several days later.
141. On 3 March, Mr Williams was told that he was to be transferred to a secure
psychiatric hospital. He was adamant that he did not want to make this move. Mr
Williams did not have an ACCT case review after this and there is no evidence that
anyone considered the impact this may have on his risk of suicide and self-harm.
142. At the same time, Mr Williams’ poor living conditions were not recognised in the
ACCT support plan. There is no evidence that staff considered that Mr Williams’
neglect for his personal hygiene and the cleanliness of his cell may be an additional
risk factor. Indeed, on more than one occasion, staff appeared to question the use
of ACCT monitoring to support Mr Williams, indicating that they did not recognise
that he was harming himself through poor self-care and living in poor conditions.
Our Fatal Incidents Learning Lessons Bulletin, published in August 2014, identified
that challenging behaviour can mask vulnerability and that managing the risk of
suicide and self-harm, treating mental ill health and managing behaviour needs to
be better integrated to ensure a balanced, holistic and consistent approach.
143. PSI 64/2011 identifies that some prisoners supported through ACCT procedures
may have particularly challenging needs or a significant level of complexity. It says
that such prisoners should be referred to the SIM. PSI 64/2011 gives two specific
instances where prisoners must be referred to the SIM (neither of which applied to
Mr Williams) but says that it is largely up to ACCT case review teams to decide
whether a case requires a referral for discussion at a SIM.
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144. Mr Williams was appropriately referred to the SIM on 9 February. However, we
found that the SIM minutes simply recorded that Mr Williams was to see a
psychiatrist with a view to moving to a secure psychiatric hospital. They did not
create any action points to address his self-neglect and dirty living conditions, lack
of engagement and other issues. While hospital admission was clearly important, in
the interim, a meaningful care plan might have helped address Mr Williams’ issues
to improve his quality of life and reduce his vulnerability.
Setting ACCT observations
145. PSI 64/2011 instructs that ACCT case review teams must set appropriate levels of
observations and conversations, which need to be tailored to reflect the assessed
risk and needs of the prisoner. Mr Williams’ ACCT observations were initially set at
hourly. On 27 January, they were reduced to one conversation per day and, on 1
February, increased to two conversations a day. They remained at this level for the
remainder of Mr Williams’ life.
146. We are concerned that Mr Williams’ observations were reduced so significantly
while he still presented with several risk factors, including ongoing mental health
problems, isolating behaviour, and minimal engagement with staff. Furthermore, at
this same time, the outcome of an urgent planned appointment with the psychiatrist
was unknown, which should have at least given staff more reason for concern about
his mental health and possibly raised his risk. While we cannot know if maintaining
an increased level of ACCT observations at the case review on 27 January would
have affected the eventual outcome for Mr Williams, it would have provided an
additional level of monitoring and support for someone whose risk was not easy to
assess.
147. We also note that a CM and a nurse both recorded contradictory information about
the level of observations that Mr Williams was subject to at the ACCT case review
on 27 January.
148. As noted, no one considered whether Mr Williams’ risk of suicide and self-harm had
increased when he was told that he was to be transferred to a secure hospital. This
might also have led to an increase in ACCT observations.
ACCT care plan
149. PSI 64/2011 states that support actions must be set at the first case review to
mitigate and lower risk for all prisoners subject to ACCT monitoring. These should
be completed as part of a care plan in the ACCT document, identifying action points
required to reduce risk, who is responsible for completing these actions points and
when they should be completed. They should be reviewed at each subsequent
case review, with additional support actions added as required.
150. Staff did not include some important issues in Mr Williams’ care plan. While a care
plan was started at Mr Williams’ case review on 17 January, it was not further
completed or updated. It therefore contained no additional support actions. It did
not reference Mr Williams’ complex needs that were not therefore addressed in his
ACCT care plan. This included his deteriorating mental health, the unhygienic
conditions he lived in, any measures put in place to keep him safe from violence or
the outcome of any of the urgent referrals to the psychiatrists or identified support
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measures. The care plan might also have been used to identify how Mr Williams
might have been able to receive support from his long-term friend once they moved
to different locations.
151. These were major omissions. As well as being a mandatory requirement, the care
plan is a key tool in planning how to address a prisoner’s issues and it is hard to
see how prison staff could have made any coherent plan for Mr Williams without
being able to identify, progress and manage his risks effectively.
ACCT quality
152. PSI 64/2011 states that staff must follow the level of conversations stated on the
ACCT document and must record these immediately or as soon as is practical. It
states that conversations with prisoners should be meaningful, and that staff must
be aware of what is in a prisoner’s care plan to understand the context of any
conversation. It also notes that the written summaries should be meaningful and
sufficiently detailed to convey the key details of what was discussed.
153. From the ACCT document provided to the investigator, we found that the
administration and qualitative content of the ACCT document was poor. As well as
the lack of a properly completed care plan, the ACCT ongoing record was only
partially completed. We noted a number of blank spaces which should have been
completed with staff summaries detailing conversation updates with Mr Williams,
noting his behaviour and presentation. Some entries that were completed were not
signed, dated or time-stamped. Some ACCT reviews were signed with the wrong
date and noted incorrect planned review dates.
154. We consider that the management of the ACCT was inadequate in terms of
addressing Mr Williams’ risk and that his risk of suicide and self-harm should have
been better managed. We make the following recommendations:
The Governor and Head of Healthcare should ensure that all Reception and
First Night staff have a clear understanding of their responsibilities to identify
prisoners at risk of suicide and self-harm in line with national instructions
and in particular, the need to record, share and consider all relevant
information about risk, and start ACCT procedures when indicated.
The Governor should ensure that staff manage prisoners at risk of suicide
and self-harm in line with national instructions, including that:
• a case co-ordinator is appointed at the first case review, who should lead
all subsequent case reviews wherever possible;
• case review teams assess risk and set levels of observations based on the
prisoner’s risk;
• prisoners with challenging needs or significant complexity are referred to
the Safety Intervention Meeting, who identify meaningful action points to
address the key issues;
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• ACCT care plans are completed that are specific and meaningful and
include all of the issues identified during the assessment interview and at
case reviews;
• urgent case reviews are held when information is received that indicates
increased risk; and
• ACCT entries are completed accurately, legibly and in a timely manner and
are signed and correctly dated.
Mr Williams’ environment and location
155. Mr Williams’ living conditions affected those who lived and worked around him and
led to him being bullied (verbally and physically) because of his behaviour. A CM
described the smell in Mr Williams’ cell as so bad that it made him want to vomit
and said that it was a health and safety issue. We were also told that prisoners
placed incense sticks outside Mr Williams’ cell to diffuse the smell.
156. A nurse said that she had advised prison staff to move Mr Williams because of
these conditions and believed he was vulnerable to abuse from others. There was
little recognition in the ACCT document or elsewhere of how staff planned to
manage this and the impact Mr Williams’ living conditions might have on him, other
prisoners or staff.
157. Moving Mr Williams to a different location within the prison may have averted
friction from other prisoners and staff from the incidents we have described.
However, it seems unlikely that it would have changed his behaviour given that
there was no change when he was moved to Saxon Wing. That said, we found no
evidence that prison staff discussed in any detail or considered moving Mr Williams
to a different location. A CM told us that the only other location available would
have been the Segregation Unit. However, they considered that living on this unit
would further isolate him because of the already restricted regime and it was
therefore not deemed suitable. We agree with this. Prison research into the mental
health of prisoners held in solitary confinement indicates that, for most prisoners,
there is a negative effect on their mental wellbeing and that in some cases, the
effects can be serious. Such a move might therefore have exacerbated Mr
Williams’ already declining mental health.
158. However, we are concerned that there was no plan to try to improve Mr Williams’
living conditions, especially as it was considered that he lacked the mental insight
into his care needs. We appreciate that addressing the condition of the cell with Mr
Williams would have been difficult due to his poor engagement. However, it
appeared that staff became complacent and accepting of the conditions he lived in,
rather than proactively trying to improve the environment.
159. We saw no evidence that staff had tried to assess the impact of, for example,
relocating Mr Williams to a different cell temporarily so that his cell could be bio-
cleaned, and his toilet flushed. We noted that the prison maintenance team had
refused to work in Mr Williams’ cell to fix a broken sink until it was bio-cleaned.
There was no consideration given to cleaning of Mr Williams’ cell when he was
moved temporarily overnight due to a defective fire detector. We make the
following recommendation:
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The Governor should ensure that when a prisoner’s cell is uninhabitable or
damaged to the extent it impacts on his basic needs, prison staff should:
• move him to another cell as quickly as possible; and
• record the damage, monitor the wellbeing of the prisoner while he remains
in the cell, and escalate the situation to managers to resolve promptly.
Key worker scheme and wellbeing checks
160. Under the Offender Management in Custody model, each prison officer is a named
key worker for five or six prisoners and should be allocated an average of 45
minutes per week to spend on key work duties with each prisoner, including having
regular meaningful conversations. In March 2020, HMPPS suspended key work
due to the COVID-19 pandemic. On 12 May 2020, key work was reintroduced but
delivered in a more limited way in line with an Exceptional Delivery Model, where
priority prisoners received key work.
161. Mr Williams was monitored under ACCT procedures for most of his time at Guys
Marsh, which meant that he was a priority prisoner for key work sessions and
regular wellbeing checks. Despite this and his complex mental health needs, he
only received two key work sessions on 10 and 20 February.
162. We acknowledge that Guys Marsh had become a COVID-19 outbreak site during
parts of January and February 2022. This impacted on staff attendance, reduced
the consistency of available staff on residential wings and affected their ability to
conduct weekly key work sessions. We also appreciate that the delivery of key
work was accompanied by the use of wellbeing checks, which Mr Williams received
most days.
163. However, the key work meeting can have a far greater input into building a
relationship with a prisoner, especially one with engagement and mental health
issues like Mr Williams and this should have been prioritised as an important part of
his support plan. Mr Williams’ key worker stated that he had started to build a
rapport with him. Their meetings, however, were not consistent enough to build a
trusting relationship. The regular, supportive contact between prisoners and their
key workers is likely to be a significant protective factor and an important source of
information to those managing and caring for such prisoners. We make the
following recommendation:
The Governor should ensure that there is an effective key worker scheme
which provides meaningful and ongoing support to prisoners.
Clinical care
164. The clinical reviewer found that the clinical care Mr Williams received at Guys
Marsh was of the standard reasonably expected, and was partially equivalent to
that which he could have expected to receive in the community.
165. While there were examples of good practice on the part of the mental health team,
notably the speed of Mr Williams’ referral for an assessment under the Mental
Health Act, the clinical reviewer highlighted areas in which the clinical care could
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have been improved. This centred specifically around the management of his self-
neglect from a safeguarding perspective, and a lack of input when Mr Williams’
circumstances changed (when he was told he would be moving to a mental health
hospital).
Handover from HMP Winchester to HMP Guys Marsh
166. We were told that a nurse at Winchester emailed the mental health team at Guys
Marsh to provide a handover about Mr Williams’ care before his transfer. We have
not seen this email but were told that it provided an impression of Mr Williams’
mental health and confirmed his prescribed medication. We have been unable to
identify what action was taken at Guys Marsh on receipt of the email. What was
evidenced, however, was a handover note recorded on Mr Williams’ medical record
which stated that he had emotionally unstable personality disorder and drug-
induced psychosis, was prescribed antipsychotic medication and that his
engagement with the mental health services was poor.
167. Prison Service Order (PSO 3050) on the continuity of healthcare for prisoners
states that prisoners with more complex health needs may need detailed care
planning with the receiving healthcare team in advance of a transfer. We are
concerned that the handover between prisons was poor before Mr Williams’ transfer
and that the note made in his medical record did not have the level of impact
expected for someone with his history and diagnoses. We share the clinical
reviewer’s concerns that it would have been good practice for a formal handover, at
least in the form of a phone call, to have taken place, especially as the transfer may
well have exacerbated his risks. We make the following recommendation:
The Heads of Healthcare at HMP Winchester and HMP Guys Marsh should
ensure that effective liaison between prisons takes place when prisoners with
a history of severe and enduring mental illness are transferred between
prisons, with the outcome fully documented in the prisoner’s medical
records.
Mental capacity, safeguarding and self-neglect
168. Mr Williams had a history of self-neglect when his mental health deteriorated, and
this was identified early on in his time at Guys Marsh. Both prison and healthcare
staff had reported his poor self-care and poor living conditions. However, this did
not translate into staff raising the issue of self-neglect as a specific safeguarding
concern. The SIM forum appeared not to recognise or consider that Mr Williams’
self-neglect was fundamentally also a safeguarding matter.
169. Within a prison setting, the overall responsibility for safeguarding adults falls to
prison staff. At Guys Marsh, the responsibility for safeguarding is with the Offender
Management Unit but there is also a healthcare safeguarding lead who works as a
Health and Wellbeing Co-ordinator, and who also attends the SIM. All healthcare
staff have a responsibility to report safeguarding concerns to the prison.
170. We found that Guys Marsh had no self-neglect strategy in place. While there are a
number of guidance materials available to prison and healthcare staff at Guys
Marsh, including HMPPS’ policy on safeguarding adults and children (2020), PSI
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16/2015 on adult safeguarding in prison, and Practice Plus Group’s safeguarding
policy’ (October 2020), they lacked details about how to support people who neglect
themselves. The clinical reviewer noted that Mr Williams’ case exposed a gap that
needed to be addressed and identified that a self-neglect strategy/policy should
include:
• the interdisciplinary support available from prison and healthcare services to the
approach of supporting a prisoner who neglects himself;
• a collaborative personalised support plan on how to manage self-neglect in
prison settings;
• identification of a lead person to build a trusting relationship with the prisoner
and understand what they would like as an outcome;
• a risk assessment, with frequent review and monitoring of the risks;
• a positive risk-taking approach to managing self-neglect risks and understanding
that risks will reduce slowly;
• the interface with the Mental Capacity Act (2005), including when best interest
decisions should be made; and
• specific training for staff to understand that self-neglect is a safeguarding
category and approaches that help support the prisoner who is neglecting
himself.
171. Almost all of the elements described above were identified in Mr Williams’ case and
should be contained in a self-neglect healthcare strategy. The clinical reviewer
notes that supporting people who neglect themselves is challenging, and they often
find it hard to engage with others, as was evident with Mr Williams. The need to
build relationships is even more important and we have already highlighted the
value of Mr Williams’ trusted friend and his key worker in building trusting
relationships to change behaviour. We agree with the clinical reviewer that a
strategy should have been developed to address Mr Williams’ self-neglect.
172. We also note that Mr Williams’ mental capacity was assessed not to have capacity
to make decisions about his health, wellbeing and self-neglect risks. However, the
clinical reviewer noted that while it was good practice that Mr Williams’ capacity was
assessed, staff did not have a meaningful discussion about how best to support him
in the areas in which he did not have the mental capacity to make decisions. It was
not clear if information about Mr Williams’ mental capacity needs were shared with
prison staff as there is no reference in his ACCT document or prison records. We
make the following recommendation:
HM Prisons and Probation Service’s national adult safeguarding lead should
develop a self-neglect strategy and formal guidance to be used in the prison
environment.
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Hospital transfers
173. The process of assessing Mr Williams under section 47 of the Mental Health Act,
and the subsequent process of transferring him to a hospital setting, was done
quickly and efficiently. However, we share the concerns of the clinical reviewer that
when a nurse informed Mr Williams (on 3 March) that he would be moving to a
secure hospital setting, no plans were made to review or monitor him. As well as
the impending change in Mr Williams’ circumstances, his reaction to the news
meant that timely follow-up was important. The nurse told us that she advised
prison staff to monitor Mr Williams and noted this in his ACCT document. We did
not see any record in the ACCT document of this. There should also have been a
more formal mental health interim plan to review Mr Williams. We make the
following recommendation:
The Head of Healthcare should ensure that there is a formal care plan in place
when a prisoner is waiting for transfer to a mental health hospital bed.
Prescribed medication
174. It is unclear how compliant Mr Williams was with his prescribed medication
(quetiapine). According to the medication administration records, he did not attend
for his medication on one occasion in February 2022 and again, the day before he
died on 6 March 2022. This would not have triggered an omitted medication
process (which would only have been initiated after three consecutive omitted
doses).
175. The post-mortem toxicology reports noted that, while quetiapine was present in Mr
Williams’ system, it was of a sub-therapeutic level, which suggests that he was not
taking his medication regularly. While healthcare staff had suspicions that Mr
Williams was secreting medication, it was not clear what action was taken about
this as the documentary evidence is poor. The Head of Healthcare told us that
even though Mr Williams may have been secreting some of his medication, as it
was a critical medication for his mental health, it would have still been given to him
on a balance of risks. After Mr Williams’ death, another prisoner told us that Mr
Williams was being bullied for his medication and that he also traded his prescribed
medication for other medications or PS. We found no evidence to suggest that
prison or healthcare staff were aware of this before Mr Williams’ death.
The Head of Healthcare should ensure that any information about secreted
medication is recorded, communicated and considered appropriately.
Learning lessons
176. We have identified a number of concerns in this report. We consider that it is
important that staff learn from our findings. We recommend:
The Governor and Head of Healthcare should ensure that a copy of this report
is shared with the staff named in this report and that a senior manager
discusses the Ombudsman’s findings with them.
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Inquest
177. An inquest was concluded on 17 May 2024, that the cause of Mr Williams’ death
was ligature suspension. The coroner found that Mr Williams died by suicide in
circumstances where there was inadequate assessment and monitoring of his risks
of self-harm and suicide prior to his death.
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