Gary Bell

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Gary Bell,
a prisoner at HMP Holme House,
on 28 December 2019
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 Gary Bell died in hospital on 28 December 2019, after being found hanging in his cell at
HMP Holme House on 25 December. He was 44 years old. I offer my condolences to Mr
Bell’s family and friends.
Mr Bell was subject to suicide and self-harm prevention procedures (known as ACCT) on
several occasions at Holme House. He suffered severe pain in his right leg, following an
old knee injury, and after his leg was amputated in October 2019, he continued to
complain that he was in pain, as well as struggling mentally with having lost his leg.
Staff started the last period of ACCT monitoring on 17 December, after Mr Bell cut his arm
with a razor blade and told them that his pain was not being managed. On 21 December,
staff found him hanging in his cell. Staff cut him down and he remained conscious. Staff
increased his observations to four an hour. The next day, staff assessed that his risk had
reduced and lowered his observations to two an hour. On 24 December, staff lowered his
observations again, to hourly.
The investigation found that overall, staff managed the ACCT procedures well. While it
may appear that staff reduced observations too soon, I am satisfied that they assessed Mr
Bell appropriately and that it was not unreasonable for them to consider that his risk had
reduced. However, as many prisoners find Christmas difficult, it may have been wiser to
have continued observing him twice an hour until after Christmas Day.
I am concerned that the agreed frequency of observations was not always recorded on the
ACCT paperwork and observations were not always carried out at the agreed frequency.
The clinical reviewer found that Mr Bell received good support from the mental health team
when he was in crisis. She found that healthcare staff prescribed appropriate pain relief,
but she considered that they should also have considered referral for specialist pain
management advice. She also noted that Mr Bell did not receive any physiotherapy after
his amputation as he should have done.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman November 2020
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. In January 2018, Mr Gary Bell was sentenced to five and a half years imprisonment
for arson. He was moved to HMP Holme House on 1 February.
2. Mr Bell had recurrent leg infections because of an old knee injury and on 30
October 2019, he had his leg amputated above the knee. He returned to Holme
House the next day.
3. On 25 November, staff started suicide and self-harm prevention procedures (known
as ACCT) after Mr Bell cut his arm and told staff that his pain was not being
managed and that he was struggling mentally with the loss of his leg. Staff stopped
ACCT procedures on 6 December but restarted them when Mr Bell cut his arm
again on 17 December.
4. On 21 December, Mr Bell was found hanging in his cell. He was still conscious and
did not require hospital treatment. Staff increased observations to four an hour.
However, during an ACCT case review on 22 December, it was agreed the
observations should be reduced to two an hour. On 24 December, staff reduced
observations again, to hourly.
5. At 12.30pm on 25 December, Mr Bell was found hanging in his cell. Staff cut him
down and started cardiopulmonary resuscitation (CPR), which was continued by
ambulance paramedics. The paramedics managed to restore a pulse and took Mr
Bell to hospital where he was placed in an induced coma.
6. Mr Bell did not regain consciousness and died in hospital on 28 December.
Findings
7. We found that overall, staff managed the ACCT procedures well. Most ACCT
reviews were multidisciplinary and appropriate caremap actions were identified. We
note that observations were reduced from four an hour to one an hour between 21
and 24 December. We consider that staff assessed Mr Bell appropriately and that it
was not unreasonable for them to consider that his risk had reduced. However, as
many prisoners find Christmas difficult, we consider that it may have been wiser to
have maintained Mr Bell on two observations an hour until after Christmas Day.
8. We are concerned that the agreed frequency of observations was not always
recorded in the ACCT documentation and some observations were not carried out
at the agreed frequency.
9. The clinical reviewer found that Mr Bell received a good and prompt response from
the mental health team when he was in crisis. She concluded that overall, Mr Bell’s
health care needs were well managed. She found that there was effective
prescribing of pain relief medication to Mr Bell. However, she considered that it
would have been helpful for the prison to have considered referring Mr Bell for
specialist pain management advice. Also, Mr Bell had no physiotherapy or
occupational therapy input after his amputation, as he should have done.
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10. We are concerned that not all staff felt adequately supported following Mr Bell’s
death.
Recommendations
• The Governor should ensure that staff:
• record the agreed frequency of ACCT observations on the front of the ACCT
document and in the case review notes;
• carry out observations at the correct frequency; and
• vary times of ACCT checks, while remaining within set observation periods, to
avoid prisoners being able to predict when they will be checked.
• The Head of Healthcare should ensure that prisoners with complex pain
management needs have access to a local specialist pain service.
• The Head of Healthcare should ensure that prisoners have access to appropriate
therapy services, such as physiotherapy and occupational therapy, following major
surgery.
• The Governor should ensure that local systems and arrangements are in place for
effective post-incident care for staff who are exposed to distressing or traumatic
events during their duties.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Holme House
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Bell’s prison and
medical records.
13. NHS England commissioned an independent clinical reviewer to review Mr Bell’s
clinical care at the prison. The investigator and the clinical reviewer jointly
interviewed 11 members of staff on 6 and 7 February 2020. The clinical reviewer
also interviewed two prison GPs by telephone and spoke to the Mental Health
Locality Manager again. The investigator asked a prison officer questions by email
and made notes of her interview with a supervising officer.
14. We informed HM Coroner for Teesside of the investigation. Mr Bell’s post-mortem
examination and toxicology report were not available at the time of issuing this
report. We have sent the coroner a copy of this report.
15. One of the Ombudsman’s family liaison officers contacted Mr Bell’s family to explain
the investigation and to ask if they had any matters they wanted the investigation to
consider. Mr Bell’s family asked:
• Whether Mr Bell was being bullied.
• How his mental health was managed after his leg was amputated.
• When the prison started checking on Mr Bell, and how frequently.
We have addressed these issues in the report.
16. We shared our initial report with HM Prison and Probation Service (HMPPS). They
raised no factual inaccuracies.
17. We provided Mr Bell’s next of kin with a copy of our initial report. They did not raise
any issues or comment on the factual accuracy of the report. Other issues were
addressed separately, via their solicitor.
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Background Information
HMP Holme House
18. HMP Holme House is a category C training prison holding over 1200 men. G4S
provides health services at the prison. There is a 24-hour healthcare unit with 16
beds.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Holme House was in February and March 2020.
Inspectors reported that the safer custody team had undertaken some recent work
to improve the quality of the ACCT case management process through stringent
quality assurance, but it was too soon to judge its effectiveness. Inspectors found
that in the sample of ACCTs they reviewed, case managers were not always
consistent and reviews not always multidisciplinary. Some care maps lacked detail
and observational entries were often limited. Prisoners they spoke to who were
being monitored under ACCT had mixed views about the quality of staff care and
support.
20. Inspectors found that all prisoners in the inpatient unit had a care plan and they saw
caring interactions from nursing and prison staff on the unit. Mental health services
operated seven days a week. Prisoners could be seen on the same day by the duty
worker or within seven days for non-urgent referrals. Members of the team attended
all initial ACCT reviews and were present in the segregation and inpatient units
daily.
Independent Monitoring Board
21. 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 report, for the year ending 31 December 2018, the IMB found
that the prison was less volatile and dangerous for both prisoners and staff, that the
mental health team were fully staffed, and that they had observed excellent
examples of a caring and consistent approach to ACCT reviews.
Previous deaths at HMP Holme House
22. Mr Bell was the 13th prisoner to die at Holme House since December 2017. Of the
previous deaths, eight were from natural causes, one was self-inflicted, and three
were drug-related. There are no similarities between our investigation findings in Mr
Bell’s case and our investigation findings from the previous deaths.
ACCT
23. Assessment, Care in Custody and Teamwork (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.
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24. 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
irregular 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 caremap (plan of care, support and intervention) is put in place. The
ACCT plan should not be closed until all the actions of the caremap have been
completed.
25. 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 64/2011, Management of prisoners at risk of harm, to
self and from others (Safer Custody).
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Key Events
26. Mr Gary Bell was remanded in custody on 27 May 2017, charged with arson, and
sent to HMP Holme House. He showed mild withdrawal from opiates and was
placed on a methadone (opiate substitute) programme. Mr Bell also said he had
pain and mobility difficulties because of a deformed right knee. He was prescribed
pain relief and anti-inflammatory medication.
27. Mr Bell was moved to HMP Durham on 9 August 2017. On 19 January 2018, he
was sentenced to five years and six months imprisonment.
28. On 31 January, staff started Prison Service suicide and self-harm prevention
procedures (known as ACCT) after Mr Bell told them that he had thoughts of taking
his life and that he had taken an intentional overdose in the past.
HMP Holme House
29. Mr Bell was moved to Holme House on 1 February. He continued to be monitored
under ACCT until 8 February.
30. Mr Bell had a history of leg infections, cellulitis, and knee pain due to an old injury
and subsequent knee surgery. In April, he was told that his leg needed to be
amputated due to recurring infection.
31. On 20 May, staff started ACCT procedures for Mr Bell who said he was feeling low
because of the possible loss of his leg and because he was in constant pain. Staff
stopped ACCT procedures on 22 June when Mr Bell appeared to accept that
amputation was inevitable.
32. Over the next few months, Mr Bell remained on varying doses of gabapentin,
dihydrocodeine and codeine (painkillers). He continued to have his methadone
dose adjusted, with a view to being off it by the time of his release in February
2020. Staff put a personal care plan in place, to assist Mr Bell with tasks such as
showering. He was allocated two 30-minute sessions each week which he accepted
on occasions, while other times he said he could manage by himself.
33. On 18 June, Mr Bell received a letter from the hospital, which said his only option
was for an above the knee amputation. Mr Bell agreed but was given a ‘cooling off’
period in which to decide.
34. Mr Bell met with a MIND counsellor on 12 September, but missed the next
appointment and declined the service on 3 October. Mr Bell said he knew how to
access the service should he need it.
2019
35. On 24 January 2019, Mr Bell requested a second opinion about his planned leg
amputation. In February, he was told his leg could not be repaired. On 20 March, Mr
Bell referred himself to the mental health team as he felt depressed as he was still
waiting for his leg surgery. He was added to the mental health team’s waiting list.
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Mr Bell had a mental health assessment on 24 June. He said he had no need to
see them anymore, but he had just felt frustrated waiting for his operation.
36. Mr Bell’s knee became ulcerated on 29 June, and prison healthcare staff managed
his infection. He continued to complain of leg pain. A GP assessed him on 4
September. She prescribed him a two-week course of doxycycline. Mr Bell’s
methadone was also increased to help with pain relief.
37. On 30 October, Mr Bell had his leg amputated above the knee. He only remained in
hospital for 24 hours, and then returned to Holme House. He was admitted to the
prison’s inpatient unit in the healthcare department and used crutches and a
wheelchair, as he had done before the surgery. He was due to have amputation
physiotherapy approximately six weeks after his surgery. This was to help him
mobilise and possibly prepare for a prosthetic limb. (The Prosthetic Limb Service
telephoned with an appointment for Mr Bell in January 2020.) Healthcare staff put a
care plan in place to manage Mr Bell’s wound, to dress it and keep it free from
infection.
38. Mr Bell complained of pain during the early hours of 3 November and was given
Oramorph (liquid morphine). He remained comfortable after that. Mr Bell remained
in the inpatient unit. He was assisted with showering and his wound was dressed,
and he appeared to be mobile. His wound appeared to be healing well and there
were no signs of infection.
39. On 24 November, Mr Bell complained of phantom leg pain from his amputated leg.
(Phantom pain happens after a limb amputation when the brain reacts as if the limb
is still there and so reacts to the previous pain experience.) He was given pain
relief and the next day was assessed by a GP. He noted that Mr Bell’s leg pain was
getting worse and the gabapentin pain relief did not seem effective. He was
reluctant to prescribe dihydrocodeine, as it was made less effective by methadone,
but agreed to prescribe it for the short term.
ACCT: 25 November to 6 December
40. On 25 November, Mr Bell made a cut to his left arm. He said he felt low as his pain
was not being managed. Staff started ACCT procedures and put him on hourly
observations until the first ACCT case review. During an assessment interview, Mr
Bell told staff that following his leg amputation, he was not only in great pain, but he
was also struggling mentally as he did not know how his life would be on release.
Mr Bell said his actions were a distraction, and he had no intention of taking his life.
Mr Bell said he felt anxious about moving out of the inpatient unit and returning to a
standard cell on a houseblock in due course.
41. Staff held the first ACCT case review at 11.10am, the same day. Two mental health
nurses attended with prison staff and Mr Bell. At the review, Mr Bell told them he
now felt fine but was concerned about where he might live when he was released
from prison in February. They discussed Mr Bell’s pain relief and said an
appointment to see a doctor had been made for later that day. Mr Bell said he did
not want to end his life but could not promise he would not harm himself again. It
was agreed that there would be no further input from the mental health team, but
that Mr Bell could refer himself at any point. It was agreed that Mr Bell would remain
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on hourly observations. A GP prescribed Oramorph that afternoon and Mr Bell said
he experienced no pain that night.
42. Staff held the second ACCT review on 28 November, at 3.30pm. No healthcare
staff attended, but they had telephone input beforehand. Staff assessed Mr Bell’s
level of risk as low, and reduced his observations to two each morning, afternoon
and evening. Mr Bell seemed well during the review. He said he was on pain
medication and had no thoughts of suicide or self-harm. Mr Bell spoke about his
future and wanted to focus on getting a prosthetic leg and becoming mobile. Mr Bell
said he was aware of the support networks available to him and would ask for help
if he needed to.
43. On 2 December, Mr Bell’s leg wound became infected. A GP prescribed him a
course of antibiotics. She told the clinical reviewer that she had treated Mr Bell for
pain management both before and after the amputation. She said she believed the
prescribed pain relief had been appropriate and she noted a reduction in Mr Bell’s
reported level of pain once he was able to mobilise again.
44. Staff held the third ACCT case review on 4 December. There was no healthcare
input. Mr Bell said his pain was under control, but he was still waiting to speak to
someone from Through the Gate (TTG) about accommodation on his release. Mr
Bell said he had no thoughts of suicide or self-harm. Staff reduced his observations
to one in the morning, afternoon and evening, and three times during the night.
45. Staff held Mr Bell’s fourth ACCT case review on 6 December. Mr Bell seemed well
and said he was due to meet with TTG on 22 December who would assist him with
his release. Staff noted that all the actions on Mr Bell’s caremap had been
completed and they agreed to stop ACCT procedures. They scheduled a post-
closure review for 13 December, but there is no evidence that it took place.
ACCT: from 17 December onwards
46. On 17 December, an officer started ACCT procedures for Mr Bell, after he cut his
arm with a razor blade. During the assessment interview, Mr Bell said prisoners in
healthcare were talking about him and he would consider moving to a houseblock.
Mr Bell said he felt his mental health was declining, he felt paranoid, and was
worried about his release as he was not sure where he would live. Mr Bell said he
would like to work with the prison’s mental health team before he felt worse. The
officer put Mr Bell on hourly observations until the first ACCT case review.
47. Later that morning, Mr Bell met with a worker from Links Care Path to discuss his
substance use. They discussed the amputation, and Mr Bell said the operation had
gone well and he was hoping for a prosthetic leg in the New Year. Mr Bell said he
felt more positive. They then discussed his substance use care plan. Nothing had
changed on the plan and Mr Bell was due to reduce his methadone dose once he
felt stable. They agreed to review Mr Bell in six weeks, with a view to methadone
reduction.
48. At 2.30pm, three managers and the mental health team leader met with Mr Bell for
the ACCT case review. Mr Bell spoke about his anxiety about being released and
his request to move out of healthcare. He was told that healthcare staff would need
to complete a Social Care Needs Assessment before he could move. Staff added
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the following actions to the caremap: that Mr Bell needed to meet someone from
TTG, that he needed a Social Care Needs Assessment, that he should move to a
houseblock when there was space, and to arrange a mental health appointment.
Staff assessed Mr Bell’s risk of suicide and self-harm as low. Staff did not record his
level of observations in the ACCT review or on the front of the ACCT document, but
the on-going record shows he was checked once in the morning, afternoon and
evening, and four times during the night.
49. On 19 December at 1.30pm, staff found Mr Bell with a piece of torn bedsheet. Mr
Bell said he intended to make it into a ligature. Mr Bell asked to see a member of
the mental health team because he was stressed and thinking of killing himself.
50. Shortly afterwards, Mr Bell met with a mental health nurse. Mr Bell said he felt very
low in mood, was anxious and nervous, had disturbed sleep and a lack of appetite.
Mr Bell said he was hearing voices, but she noted he did not appear preoccupied or
distracted. Mr Bell said he felt embarrassed about the loss of his leg and did not feel
ready to return to a houseblock. Mr Bell said he enjoyed seeing his friends and
playing cards on the inpatient unit. He spoke about support from his family. Mr Bell
said he had no further thoughts of suicide or self-harm, and felt better by talking to
her, but asked if she could chase up a follow up outpatient hospital appointment,
which was overdue.
51. Staff held an ACCT review an hour later, with representatives from healthcare
present. Mr Bell said he did not want to die, but was concerned about his
medication and his mental health. Staff increased Mr Bell’s observations to two an
hour and made an appointment for him to see a member of the mental health team.
They also arranged counselling.
52. From 8.00pm, on 19 December, until 6.00am the next morning, Mr Bell was
checked hourly rather than twice an hour. No explanation was given.
21 December
53. Officer A was working in the inpatients unit on 21 December, and knew Mr Bell
should be on two ACCT checks an hour. Another officer had checked him at
6.00am, and 6.30am, before handing over to Officer A.
54. At approximately 6.55am, Officer A looked through Mr Bell’s observation panel and
saw him hanging from his bed frame by a ligature made from a strip of pillow case.
Officer A radioed a code blue call (a medical emergency code used to indicate a
prisoner who is unconscious or having breathing difficulties) and went straight into
Mr Bell’s cell. A nurse responded to the call immediately, taking a bag of equipment
with him. The nurse loosened the ligature by putting his fingers in-between the
ligature and Mr Bell’s neck. Officer A cut the ligature and Mr Bell fell to the floor and
then got onto the bed. He was conscious throughout. The ligature had left a deep
mark on his neck. Officer A left the nurse to assess Mr Bell.
55. The nurse assessed Mr Bell and found he was physically well, apart from red marks
around his neck, but seemed “vacant” and did not say much about what had
happened. The nurse requested an urgent mental health assessment. Officer A
returned to speak to Mr Bell at approximately 7.20am. He told the investigator that
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they had a good chat, although could not remember what they had spoken about.
Mr Bell was checked every 15 minutes.
56. Staff held the second case review on 21 December at 8.25am. Mr Bell attended
with a prison manager, Officer A and a nurse. He said he felt paranoid and was
hearing voices. Mr Bell said people were calling him a “nonce “and he had thoughts
of taking his life. Mr Bell said he had a visit booked with his father, but did not want
to go. The prison manager suggested it might be a positive thing to do, and Mr Bell
agreed. Officer A said he would arrange for TTG to visit Mr Bell. Staff assessed Mr
Bell’s risk as raised. There is no record of the level of observations agreed, but the
on-going record shows he was checked four times an hour.
57. Later that afternoon, a Mental Health Locality Manager, who was the on-call
manager that day, met with Mr Bell. He had read Mr Bell’s ACCT and SystmOne
record before speaking to him. Mr Bell told him he was adjusting to the loss of his
leg, did not feel ready to leave the inpatient unit, and was anxious about his release
and lack of hospital appointments. He spoke about his earlier self-harm and said he
was pleased to be alive. The Mental Health Locality Manager noted that Mr Bell
could concentrate and follow their conversation. Mr Bell said he had support
available in the inpatient unit, in particular from Officer A. Mr Bell said he had no
further thoughts of self-harm. They agreed his ACCT observations would remain at
four an hour. The Mental Health Locality Manager told him he would be reviewed
again the next day by a member of the mental health team.
58. The Mental Health Locality Manager told the investigator that Mr Bell did not appear
to be flat in mood. He said that Mr Bell was pleased to have had a visit from his
father that morning and had reflected on his actions the previous day and the
impact it would have on his family. He said that Mr Bell had arranged to live with his
father on release and seemed to have a long-term plan. The Mental Health Locality
Manager said that Mr Bell did not present as someone who had plans to end his
life.
22-24 December
59. A nurse met with Mr Bell on 22 December at 11.35am. On her way to see him,
another prisoner mentioned to her that Mr Bell had said he was hearing voices. Mr
Bell told the nurse he had recently had a visit from his father and did not want to let
his family down any more. He said he would remain focused on his release and
stay drug free. Mr Bell said he felt “all over the place”, had no appetite and was
hearing voices. He said the voices were calling him a “nonce” and a “wrong ‘un”. Mr
Bell said he used his television to distract him and drown out the voices. He said he
wanted to be alive and felt happy that he could return to his father’s house on his
release.
60. At 2.20pm, Mr Bell attended another ACCT review. A nurse attended with a
member of the safer custody team and another manager. Mr Bell said that he felt
better and more positive after seeing his father, who had said he could stay with
him on release. He said he was thankful for the support he had received from
healthcare staff and was looking forward to seeing someone from TTG. Staff
agreed that Mr Bell would remain in the inpatient unit until a Social Care Needs
assessment had been completed, that he would be referred for physiotherapy and
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to the remedial gym, and to the dentist as Mr Bell was having difficulty eating
because of problems with his teeth. Staff arranged a soft food diet for him. Staff
assessed Mr Bell’s risk as low, but they did not record the agreed level of
observations, either on the case review paperwork or on the front of the ACCT. The
on-going record shows he was checked twice an hour during the day, and hourly
during the night.
61. A mental health manager met with Mr Bell on 23 December. Mr Bell said he thought
people were talking about him. They discussed this and looked at ways for Mr Bell
to challenge these thoughts. He admitted he only heard voices when he was
standing at his cell door and agreed it might be linked to his anxiety about his
release. She noted Mr Bell had an ACCT review the next day, so would see a
member of the mental health team then.
62. In the afternoon, Mr Bell’s key worker saw him. He recorded that Mr Bell said that
“his head has gone again” but that he did not know why because his medication
had been sorted and he had good contact with his family. Mr Bell said he was
feeling better after speaking to the mental health manager, but he was worried
because he did not know what was causing these feelings. He hoped he would feel
better in time for his release in February 2020.
63. On 24 December, at 8,40am, Mr Bell stood at his cell door shouting that people
were talking about him. Staff assured him this was not the case, but he did not
believe them. This continued for about an hour, until Mr Bell was given some
emergency credit to make a telephone call.
64. Staff held Mr Bell’s last ACCT review on 24 December. A SO attended along with a
nurse and Mr Bell. Mr Bell spoke about his plan to live with his father when he was
released. He said he had no thoughts of suicide or self-harm. Staff noted that he
was still waiting for a Social Care Needs Assessment before he could be moved to
a houseblock. Staff assessed Mr Bell’s risk of suicide and self-harm as low and
reduced his observations to hourly. They scheduled the next review for 30
December.
65. The GP that was on duty on 24 December met Mr Bell for the first time on the
inpatient rounds. Mr Bell asked for pain relief. The GP noted that Mr Bell was
already taking methadone and gabapentin, both of which have sedative effects, and
he was not willing to increase the dosage of gabapentin. The GP prescribed
carbamazepine (used for neuropathic pain) instead.
66. That evening, at 9.28pm, pressed his cell bell and a nurse responded. He told her
he felt as if he were having a heart attack and palpitations. She arranged to go into
his cell to assess him further. Mr Bell’s palpitations had subsided by then and he
said he got them when he felt stressed. The nurse said she would continue to check
him throughout the night and he agreed to press his cell bell if he felt unwell again.
Two nurses checked on Mr Bell six times during the night and there were no issues.
25 December
67. At 9.16am on 25 December, Mr Bell telephoned his father (this was the last call he
made) then played cards with other prisoners. He collected his lunch and was
locked in his cell from approximately 11.30am. An officer had arranged to cover a
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colleague over the lunch period and they met for a handover just before 12.30pm.
The officer looked through all the ACCTs and noticed Mr Bell was due to be
checked. At 12.30pm, the officer went to Mr Bell’s cell and looked through the
observation panel and saw Mr Bell was hanging from a ligature, made from a
bedsheet, tied to his bed. The officer had not been designated to hold a radio that
day, so he shouted for code blue assistance from healthcare staff before he went
into the cell. A nurse called a code blue over her radio and went to Mr Bell’s cell.
68. The officer cut the ligature and placed Mr Bell on the cell floor. The nurse started
chest compressions. Three more nurses arrived at Mr Bell’s cell. One was coming
back into the prison when he was told about the emergency. He went straight to Mr
Bell’s cell and saw nurses carrying out cardiopulmonary resuscitation (CPR) while
another nurse administered breaths via an ambu-bag. Mr Bell was given one shock
of the defibrillator at 12.35pm.
69. One of the nurses took over chest compressions from another nurse until the
paramedics arrived at the cell at 12.39pm. The paramedics took over CPR and after
approximately two minutes they detected a carotid pulse and spontaneous
circulation. The paramedics said they needed to have a “hands off” period before
they could move Mr Bell. After ten minutes they put Mr Bell onto a stretcher and
took him to hospital, leaving the prison at 1.07pm. At this point, paramedics
reported Mr Bell’s heart was beating and he was breathing by himself.
70. Mr Bell was taken to North Tees General Hospital, where he was placed in an
induced coma. His father and brothers visited him on 27 December, when he also
had a brain scan which detected no activity and it was agreed that his life support
would be withdrawn. Mr Bell was pronounced dead at 2.33am on 28 December.
Contact with Mr Bell’s family
71. Two family liaison officers visited Mr Bell’s father at home at 3.30pm, on 25
December and arranged to meet him and Mr Bell’s brothers at the hospital. Prison
staff remained at the hospital throughout until Mr Bell died on 28 December. The
prison contributed to Mr Bell’s funeral, in line with national guidelines.
Support for prisoners and staff
72. A prison manager held a debrief on 25 December. Some staff told the investigator
they had not felt supported after this incident and this was not the first time that they
had felt this way.
73. The prison posted notices informing other prisoners of Mr Bell’s death, and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr Bell’s death.
Post-mortem report
74. The post-mortem and toxicology reports were not available at the time of issuing
this report.
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Findings
Management of Mr Bell’s risk of suicide and self-harm
75. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that staff should follow when they identify that a prisoner is at risk of
suicide and self-harm.
76. Mr Bell was being monitored under ACCT when he was found hanging on 25
December. He was being checked once an hour. His level of observations had
been four an hour on 21 December, after he was found hanging but conscious, but
these were reduced to two an hour on 22 December, and then to one an hour on 24
December.
77. We consider that overall, the ACCT procedures were managed well. Healthcare
staff were frequently part of the ACCT case reviews and staff identified appropriate
caremap actions to help support Mr Bell.
78. We note that staff reduced the level of observations on Mr Bell on 22 December,
and again on 24 December. While with hindsight this appears to have been ill-
advised, we consider that staff’s assessment of Mr Bell’s risk, and the lowering of
observations, was not unreasonable based on the evidence they had at the time. Mr
Bell received a visit from his father on 22 December and had agreed to live with him
on release, which appeared to make him much more positive about his future.
Mental health staff noted that he engaged well, was remorseful about his suicide
attempt on 21 December, and was making long-term plans. As Christmas is known
to be a difficult time for many prisoners and Mr Bell had been found hanging only
four days earlier, it may have been wiser to have maintained him on twice hourly
observations until after Christmas Day. Nevertheless, we consider that there were
reasonable grounds to assess that Mr Bell’s risk had reduced and that the lowering
of observations was not unreasonable.
79. However, we are concerned that Mr Bell was not always checked at the agreed
frequency. From 8.00pm on 19 December to 6.00am on 20 December, Mr Bell was
checked once an hour, rather than twice an hour as agreed at his ACCT review on
19 December. The frequency of observations required was never recorded on the
front of the ACCT document, as it should have been. Mr Bell’s on-going record also
shows that there were times when he was checked at regular and, therefore,
predictable intervals. We make the following recommendation:
The Governor should ensure that staff:
• record the agreed frequency of ACCT observations on the front of the
ACCT document and in the case review notes;
• carry out observations at the correct frequency; and
• vary times of ACCT checks, while remaining within set observation
periods, to avoid prisoners being able to predict when they will be
checked.
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Clinical care
Mental health
80. The mental health team saw Mr Bell on several occasions prior to his amputation.
He was anxious about the life changing nature of his planned surgery and frustrated
about waiting for his operation. He was discharged on 24 June 2019, after saying
he no longer needed mental health support. After his surgery on 30 October, he
refused a mental health referral.
81. Mr Bell had more frequent interaction with the mental health team following his self-
harm on 25 November. After this, healthcare staff including mental health staff were
involved in his ACCT reviews, and he was assessed by The Mental Health Locality
Manager and a nurse in some depth.
82. The clinical reviewer concluded that Mr Bell received a good and prompt response
from the mental health team when he was in crisis. Mr Bell’s wider needs were
identified and mental health practitioners acted appropriately to address or mitigate
these.
Physical health
83. The clinical reviewer concluded that overall, Mr Bell’s health care needs were well
managed. She found, however, that there were some aspects of his care that were
not equivalent to that which he could have expected to receive in the community.
84. Mr Bell had longstanding pain and mobility difficulties due to his deformed right
knee. After his amputation, Mr Bell continued to complain of severe pain. On 25
November and 17 December, he self-harmed by cutting his arm and said that his
pain was not being managed properly.
85. The clinical reviewer noted that Mr Bell was on a methadone programme, which
influenced what pain relief medication he could be prescribed. (The management of
pain for someone with opiate dependence is complex and requires a balance
between ensuring the safe use of opiates and ensuring pain is controlled as well as
possible. There is evidence to indicate that the sensitivity to pain experienced by
someone with opiate dependence is greater than someone who is not dependent.
In addition, many of the medicines usually prescribed for both chronic and acute
pain will either contain opiates and/or be less effective in the presence of an opioid
substitute such as methadone.) The clinical reviewer concluded that there was
effective and informed prescribing of pain relief medication to Mr Bell. However, she
considered that it would have been helpful for healthcare staff to have considered
referring Mr Bell for specialist pain management advice.
86. Mr Bell should have had physiotherapy six weeks after his amputation. This was to
help him mobilise with his stump and prepare him for a prosthetic limb. The prison
did not follow this up and Mr Bell had no physiotherapy before he died. There is
also no evidence of occupational therapy input to prepare Mr Bell for independent
living after his release.
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87. We make the following recommendations:
The Head of Healthcare should ensure that prisoners with complex pain
management needs have access to a local specialist pain service.
The Head of Healthcare should ensure that prisoners have access to
appropriate therapy services, such as physiotherapy and occupational
therapy, following major surgery.
The family’s concerns about possible bullying
88. Mr Bell’s father asked us to look into whether Mr Bell was being bullied and to listen
to Mr Bell’s telephone calls. Unfortunately, the prison could only provide the
investigator with the recording of Mr Bell’s final telephone call that he made on the
morning of 25 December. They said that they had deleted all the other recordings.
89. The investigator listened to Mr Bell’s final telephone call. Mr Bell appeared anxious
and said, ‘I can’t take much more of this’, and, ‘If anything happens to me, it’s them
that done it’, but it is unclear who he was talking about. Later, when his father asked
him if had told someone at the prison, Mr Bell said, ‘There’s nothing she can do…All
the screws are saying it.’ It is unclear what he meant.
90. There is nothing in the prison records to indicate that Mr Bell was in debt or being
bullied. The Mental Health Locality Manager told the investigator that when he saw
Mr Bell on 21 December, he asked him whether he had any debts or any other
issues that would make him reluctant to move to a houseblock, but he said he had
no issues.
91. We have found no evidence that Mr Bell was being bullied at Holme House. We
note that Mr Bell had said he was feeling paranoid and had told staff he could
hearing voices talking about him. It is possible that this explains his telephone call
on 25 December.
Staff support
92. PSI 02/2018, Post Incident Care, says that effective post-incident care should be
made available to staff who are exposed to potentially traumatising incidents during
the course of their duties. It is disappointing that some staff did not feel they were
supported after Mr Bell’s death. We make the following recommendation:
The Governor should ensure that local systems and arrangements are in
place for effective post-incident care for staff who are exposed to distressing
or traumatic events during their duties.
Inquest
93. At the inquest, held from 7 to 10 October 2024, the jury concluded that Mr Bell died
by suicide contributed to by Mr Bell’s recent above the knee amputation and
associated mental health. They also found that failure to implement safeguarding
measures such as constant watch and/or safer cells and anti-ligature
bedding/clothing were contributing factors.
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