Glen Adrian

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Glen Adrian,
a prisoner at HMP Durham,
on 8 March 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Glen Adrian was found hanged in his cell on 8 March 2023 at HMP Durham. He was 27
years old. I offer my condolences to Mr Adrian’s family and friends.
Mr Adrian was the seventh prisoner to take his life at Durham in three years and the fourth
in four months.
Yet again we found that reception staff did not properly assess the risk of suicide and self-
harm when Mr Adrian arrived at Durham. However, it was another seven weeks before Mr
Adrian took his life. He gave no indication to staff during that time that he was at risk of
suicide. We are satisfied that staff could not have foreseen his actions.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
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Summary
Events
1. On 18 January 2023, Mr Glen Adrian was remanded in prison charged with
breaching a sexual harm prevention order. While he was in the escort van being
taken to HMP Doncaster, Mr Adrian began banging his head against the inside of
the van. The van was diverted to HMP Durham so that he could receive medical
attention. A nurse checked him and found only a superficial abrasion. Mr Adrian
remained at Durham.
2. Because he had arrived at Durham at around 7.00pm in the evening, Mr Adrian did
not have an initial health screen. An officer and supervising officer spoke to him and
had no concerns.
3. On 20 January, Mr Adrian had his initial health screen. This took place on the wing,
so the nurse did not have access to all Mr Adrian’s records. The nurse noted Mr
Adrian’s history of anxiety and depression and noted that he should be referred to
the mental health team. Mr Adrian told the nurse about previous suicide attempts
but said he had no current thoughts. The nurse recorded on the medical record that
Mr Adrian was being managed under suicide and self-harm prevention procedures
(known as ACCT), which was not the case.
4. On 23 January, a nurse triaged Mr Adrian’s mental health referral. He noted that the
medical record indicated that Mr Adrian was under ACCT management and that
therefore he would be seen by mental health staff at ACCT reviews (which was not
the case).
5. On 21 February, Mr Adrian appeared in court by video link and was sentenced to
ten months imprisonment. An officer spoke to him and did not have any concerns
about his wellbeing. He informed the healthcare department that Mr Adrian had
appeared in court, so a healthcare assistant also spoke to Mr Adrian and had no
concerns.
6. At around 5.30am on 8 March, during a routine check, an officer found Mr Adrian
hanging. He called an emergency on his radio and, when other staff arrived, they
entered the cell and lowered Mr Adrian to the floor. Mr Adrian was clearly dead, so
staff did not attempt resuscitation.
Findings
7. None of the staff who saw Mr Adrian in reception on 18 January started ACCT
procedures, despite him having self-harmed in the prison van. We acknowledge
that it was another seven weeks before Mr Adrian took his life, but this
demonstrates poor assessment of risk by reception staff at Durham, which is an
issue we have raised before. We were told in response to a previous
recommendation that changes have been made to reception procedures and that
further training on risk assessment had been provided to staff.
8. Mr Adrian was seen by a nurse when he arrived, but he did not have an initial
health screen. This is an issue we have raised before. We were told that if late
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arrival meant that an initial health screen could not take place, it would happen the
next day. However, Mr Adrian had to wait a further two days.
9. The nurse who carried out Mr Adrian’s initial health screen did not have access to
Mr Adrian’s PER, and he recorded that Mr Adrian was under ACCT management
when he was not. This meant that the nurse undertaking the mental health triage
thought that Mr Adrian would be seen by mental health staff as part of ACCT
reviews when this was not the case.
Recommendations
• The Head of Healthcare should ensure that:
• If an initial health screen cannot be carried out on the day of arrival, it is carried
out the next day.
• Records of initial health screens are accurate.
• Mental health staff assessing prisoners verify whether that prisoner is under
ACCT management.
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The Investigation Process
10. HMPPS notified us of Mr Adrian’s death on 8 March 2023. The investigator issued
notices to staff and prisoners at HMP Durham informing them of the investigation
and asking anyone with relevant information to contact him. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Adrian’s prison and
medical records. He interviewed nine members of staff at Durham.
12. NHS England commissioned a clinical reviewer to review Mr Adrian’s clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews of
medical staff.
13. We informed HM Coroner for County Durham and Darlington of the investigation.
We have sent the Coroner a copy of this report.
14. The Ombudsman’s family liaison officer contacted Mr Adrian’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
no questions but asked for a copy of our report.
15. We shared our initial report with HMPPS. They found no factual inaccuracies.
16. We sent a copy of our initial report to Mr Adrian’s mother. She did not notify us of
any factual inaccuracies.
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Background Information
HMP Durham
15. HMP Durham is a local prison, serving the courts of Tyneside, Durham and
Cumbria. It has a maximum capacity of 985 men. Spectrum Community Health CIC
provides primary healthcare services. Tees, Esk and Wear Valleys Foundation NHS
Trust provides mental health services.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Durham was in November 2021. Inspectors
reported impressive improvements since their previous inspection, and that Durham
had reduced the supply of drugs and achieved a more than 60% fall in violence.
There were concerns that prisoners arriving late or at busy times did not always get
full healthcare screenings. Prisoners’ healthcare was affected by serious staff
shortages in the department. Many prisoners were locked in their cells for long
periods. Recorded levels of self-harm were lower than similar prisons and there was
good interrogation of self-harm data.
Independent Monitoring Board
17. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 October 2022, the IMB
reported that the prison was a safe environment. Improvements were needed to
ensure that all prisoners arriving in reception received a healthcare screening.
Staffing shortages had impacted on the mental health team.
Previous deaths at HMP Durham
18. Mr Adrian was the eighteenth prisoner at Durham to die since March 2020. Of the
previous deaths, ten were from natural causes, one was drug related and six were
self-inflicted.
19. We have previously made recommendations about reception staff properly
assessing risk. We were told that a meeting was held in July 2023 to review
reception procedures and an action plan developed. Training had also been
delivered by the National Safety Team on risks, triggers and protective factors.
20. We have also previously made recommendations about the timely provision of initial
health screens. We were told that an advanced nurse practitioner would review late
arrivals and the initial screen would be completed the next day. However, this did
not happen in Mr Adrian’s case.
Key worker scheme
21. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
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people, building better relationships between staff and prisoners and helping people
settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available
for an average of 45 minutes per prisoner per week for delivery of the key
worker role, which includes individual time with each prisoner.
22. Within this allocated time, key workers can vary individual sessions in order to
provide a responsive service, reflecting individual need and stage in the sentence.
A key worker session can consist of a structured interview or a range of activities
such as attending an ACCT review, meeting family during a visit or engaging in
conversation during an activity to build relationships.
23. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
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Key Events
24. On 18 January 2023, Mr Glen Adrian was remanded in prison, charged with
breaching a sexual harm prevention order.
25. Mr Adrian’s Person Escort Record (PER) said that he was to be taken to HMP
Doncaster. However, a nurse at HMP Durham told us that Mr Adrian had been
banging his head in the escort van and it was diverted to Durham so that Mr Adrian
could get medical attention.
26. The escort van arrived at Durham shortly before 7.00pm. The nurse went into the
van and assessed the cut to Mr Adrian’s head to ascertain whether it was
appropriate for him to be held in prison. The nurse assessed that Mr Adrian had a
superficial abrasion but was otherwise well. Mr Adrian was admitted to Durham. It
was not his first time at Durham, having been released from there in December
2022.
27. An officer saw Mr Adrian in reception for a welfare check. She advised him of
support available and how to access it. A supervising officer (SO) also spoke to Mr
Adrian in reception. He noted that Mr Adrian said he had no thoughts of suicide or
self-harm and that his relationship with his mother was a protective factor. The SO
noted that Mr Adrian had good body language and that he had no concerns about
him. He did not record that Mr Adrian had been banging his head in the escort van
or that he had a head wound.
28. Mr Adrian was not given an initial health screen due to his late arrival. The nurse
reviewed Mr Adrian’s clinical record and confirmed with prison staff that there were
no concerns about Mr Adrian’s risk of harm to himself.
29. On 19 January, healthcare staff prescribed Mr Adrian’s medication (salbutamol and
fluticasone for asthma, and sertraline for anxiety and depression).
30. On 20 January, a nurse carried out Mr Adrian’s initial health screen. Because the
screening took place on the wing and not in reception, he did not have access to Mr
Adrian’s PER. He noted that Mr Adrian had a history of anxiety and depression and
was prescribed sertraline. Mr Adrian said that he had previously taken overdoses
and had attempted to jump off a bridge but had no current thoughts of harming
himself. The nurse noted that Mr Adrian was calm and engaged well, though also
noted signs of emotional distress. He noted that ACCT procedures had been
opened, which was not the case. (At interview, he said that he had used information
from a previous health screen by mistake.) He also noted that Mr Adrian needed a
referral to the mental health team.
31. On 23 January, a member of the healthcare administration staff noted that no
mental health referral had been made for Mr Adrian. She made a referral, and a
nurse carried out a mental health triage. He noted Mr Adrian’s recent suicide
attempts and that he had worked with the mental health team in the past. He noted
that Mr Adrian was on an open ACCT and would be seen as part of the ACCT
process (which was based on the incorrect entry made during the initial health
screen). He referred him to ReThink, a charity that provides mental health services.
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32. On 28 January, a SO introduced herself to Mr Adrian as his prison offender
manager (POM). Mr Adrian said that he had been in custody before so was aware
of the support available to him. He reported good family ties in the community via
his mother. He said that he was struggling for money in custody and could not
afford any vapes. She advised him how to apply for a job using the prisoners’
electronic kiosk system. Mr Adrian told her that he had no concerns but was aware
of how to contact her if he needed anything. She noted that Mr Adrian had been
allocated a key worker but had not had any contact with him so far.
33. On 21 February, Mr Adrian appeared in court by video link and was sentenced to
ten months imprisonment for breaching a sexual harm prevention order. An officer
spoke to Mr Adrian afterwards. They discussed his sentence and how much longer
he would likely have to remain in prison. In interview, the officer said that he did not
have any concerns about Mr Adrian’s wellbeing. He informed the healthcare
department that Mr Adrian had had a video link court appearance, so a healthcare
support worker spoke to Mr Adrian at his cell door. He told her that he was okay,
and she did not note any concerns.
34. On 28 February, the POM attended a Multi-Agency Public Protection Arrangements
(MAPPA) meeting and discovered that Mr Adrian had previously committed a
sexual assault on a cellmate. As a result, Mr Adrian’s cell sharing risk assessment
was reassessed from standard to high risk and he was moved to a single cell.
35. On 2 March, Mr Adrian wrote to his probation officer. He set out some actions he
hoped would help him settle back into society on release. He also said that he was
struggling being back in prison as he was ashamed of himself. Mr Adrian did not
make any phone calls or receive any visits during his time at Durham.
36. At around 8.45pm on 7 March, during a routine check, Officer A saw Mr Adrian in
his cell and had no concerns. Prisoners later told staff that they heard what
sounded like Mr Adrian moving furniture at approximately 11.00pm.
37. Staff do not conduct checks on prisoners at night unless there are specific safety or
medical checks to be made, or if the prisoner activates his cell bell or otherwise
attracts staff attention. None of these applied to Mr Adrian, and staff did not have
any interaction with him during the night.
Events of 8 March
38. At 5.29am on 8 March, during a routine check, Officer A saw Mr Adrian suspended
by a ligature made from a blanket tied to the bedframe.
39. Officer A radioed a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties). Staff responded and the control room
called an ambulance. A nurse arrived first. Body worn video camera (BWVC)
footage shows her looking through the observation panel and saying, “He’s
hanging”.
40. Officer B arrived and used his radio to ask a custodial manager (CM), who was the
officer in charge at that time, for permission to open the door. The CM gave
permission, but Officer B was unable to open the sealed pouch in which night
officers carry keys for emergency use. The nurse handed him her key and he
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unlocked the door, and the staff went into the cell. He tried to cut the blanket with
his anti-ligature knife, but it was too thick to cut, so another nurse supported Mr
Adrian’s weight while he removed the ligature from his neck. They lowered him to
the floor.
41. Both nurses assessed Mr Adrian, but he showed no signs of life and appeared to
have been dead for some time. They did not therefore attempt to resuscitate him. At
5.41am, paramedics arrived. At 5.42am, they confirmed that Mr Adrian had died.
Contact with Mr Adrian’s family
42. The prison appointed two family liaison officers. They travelled to Mr Adrian’s
mother’s home and informed her of her son’s death. They remained in contact with
her to provide support. In line with guidance, Durham offered a contribution to the
cost of Mr Adrian’s funeral.
Support for prisoners and staff
43. After Mr Adrian’s death, the duty governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
44. The prison posted notices informing other prisoners of Mr Adrian’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 Adrian’s death.
Post-mortem report
45. The post-mortem report concluded that Mr Adrian died from hanging.
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Findings
Assessment of Mr Adrian’s risk of suicide and self-harm
46. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), contains national requirements
on the assessment and management of suicide and self-harm risks in prisons. The
instruction lists risk factors and potential triggers that staff should be alert to and act
appropriately to address. Any prisoner identified as at risk of suicide and self-harm
must be managed under ACCT procedures.
47. No one started ACCT procedures for Mr Adrian when he arrived at Durham on 18
January 2023, despite him having self-harmed by banging his head in the escort
van. Neither of the officers who saw him in reception even noted that he had been
banging his head. The nurse who assessed his head injury did not consider ACCT
procedures either. We acknowledge that it was another seven weeks before Mr
Adrian took his life, but this demonstrates poor reception screening by staff at
Durham.
48. Inadequate reception screening is an issue we have raised with Durham before. We
were told that in July 2023, a meeting was held between prison and healthcare staff
to review reception processes. Following that, an action plan had been produced
and changes had been made to ensure that staff access and consider all relevant
risk information. Training had also been delivered to staff on assessing risk of
suicide and self-harm. We make no recommendation.
49. Mr Adrian gave no indication to staff that he was at risk of suicide or self-harm after
he had arrived at Durham.
Clinical care
50. Mr Adrian was seen by a nurse when he arrived at Durham, but he did not receive
an initial health screen until two days later. The clinical reviewer noted that the
delay in Mr Adrian receiving a reception health screen meant that staff did not have
the opportunity to make an early assessment of any risks to his health and
wellbeing.
51. The lack of an initial health screen for late arrivals at Durham is an issue we have
raised before. In January 2023, we were told that prisoners who arrived late and
could not receive their initial health screen, would be reviewed by an Advanced
Nurse Practitioner and that the screening would be completed the next day.
However, this did not happen in Mr Adrian’s case, as he did not get his initial health
screen until 20 January, two days after he arrived.
52. The nurse who carried out Mr Adrian’s initial health screen noted that Mr Adrian
was under ACCT management, which was not the case. This note informed
subsequent healthcare staff’s assessments of Mr Adrian, and a referral to the
mental health team was delayed as there was an assumption that he would be
assessed as part of the ACCT process. The clinical reviewer noted that while it is
not possible to say whether this affected Mr Adrian’s death, it may have resulted in
a different treatment pathway.
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53. We recommend:
The Head of Healthcare should ensure that:
• If an initial health screen cannot be carried out on the day of arrival, it is
carried out the next day.
• Records of initial health screens are accurate.
• Mental health staff assessing prisoners verify whether that prisoner is
under ACCT management.
54. The clinical reviewer concluded that with the delayed initial health screen and the
errors noted within it, the physical care provided to Mr Adrian was not equivalent to
that which he could have expected in the community. The incorrect noting of Mr
Adrian being under ACCT management consequently meant that his mental
healthcare fell below that which he could have expected in the community.
Key work
55. Prisoners should have around 45 minutes of key work with an allocated officer each
week. Although Mr Adrian was told that he would be allocated a key worker, his
prison record shows that he had no key worker sessions in his seven weeks at
Durham. The CM responsible for key work at Durham said in interview that the
prison faced various pressures, including staffing levels and the high number of
prisoners who arrived in a large local prison. This meant that they had to prioritise
key work sessions for prisoners who were the most vulnerable. Durham was
continually assessing the scheme and were working to introduce a first key work
session as part of prisoners’ second day induction programmes.
Governor to Note
Emergency response
56. Policy on access to cells during the night is contained in Prison Service Instruction
(PSI) 24/2011 Management and Security of Prisons at Night and Durham’s local
security policy. Staff should not open a cell without permission from the officer in
charge of the running of the prison and only when other staff are present. Staff may,
however, enter a cell without authority or support in an emergency to preserve the
life of a prisoner. They should make a dynamic risk assessment, and only unlock
the cell if they feel safe to do so.
57. There was a delay of around two minutes between Officer A finding Mr Adrian
hanging, and staff entering the cell. In interview, Officer A said that he did not
consider entering the cell as he did not think he was allowed to do so. Mr Adrian
had been dead for some time by this point, so the outcome was not affected.
Nonetheless, in other cases quick action could be vital, and it is important that staff
know this. We bring this to the Governor’s attention.
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Good practice
58. On 21 February, Mr Adrian was sentenced to ten months imprisonment. Staff spoke
to him afterwards to check on his welfare, as did a healthcare assistant, and no
concerns were identified. This was good practice.
59. Several staff responding to the emergency activated their body worn video
cameras. This was good practice and provided us with good quality evidence.
Inquest
60. The inquest, held from 25 to 28 November 2024, concluded that Mr Adrian died by
suicide.
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