Graham Taylor

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Graham Taylor,
a prisoner at HMP Dartmoor,
on 17 December 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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 Graham Taylor died after he was found hanged in his cell on 17 December 2021 at
HMP Dartmoor. Mr Taylor was 64 years old. I offer my condolences to his family and
friends. Mr Taylor was the fourth prisoner to take his own life at Dartmoor in three years.
The clinical reviewer concluded that the clinical care provided to Mr Taylor at Dartmoor
was equivalent to that which he could have expected to receive in the community. She
makes recommendations for HMP Exeter, Mr Taylor’s previous prison, regarding
management of his pain relief.
We found that the non-clinical care provided to Mr Taylor at Dartmoor was good overall.
However, we are concerned about the delays in providing pain relief medication at Exeter
and the impact this had on Mr Taylor’s mental health. The process must be reviewed to
improve future care.
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 December 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. Mr Graham Taylor was convicted of sex offences on 2 August 2021. On 12
November, he was sentenced to six years imprisonment and sent to HMP Exeter.
2. Mr Taylor was distressed when he arrived at Exeter. He told staff on reception that
he wanted to take his own life by going on a hunger strike. Staff began monitoring
him under suicide and self-harm prevention procedures (known as ACCT).
3. Mr Taylor was prescribed with pain relief medication for a historic back injury. The
medication was not reconciled for four weeks while the healthcare team assessed
its appropriateness. The delay had a significant impact on Mr Taylor’s wellbeing. He
said he would take his own life if he did not receive his prescription.
4. On 13 December, Mr Taylor was transferred to HMP Dartmoor while subject to
ACCT monitoring. The next day, at his first ACCT review meeting at Dartmoor, staff
decided to close the ACCT because they were satisfied his risks had reduced. They
put post-closure monitoring in place to review the decision.
5. At 5.14am on 17 December, during the morning routine check, an officer opened Mr
Taylor’s cell observation panel and found him ligatured from a bar on the window
with a piece of towel. She immediately radioed a medical emergency code,
indicating a life-threatening situation and requesting an ambulance.
6. Staff responded quickly to the code blue; however, they did not attempt cardio-
pulmonary resuscitation (CPR) as it was clear that Mr Taylor had been dead for
some time. Paramedics confirmed that Mr Taylor had died at 5.45am.
Findings
Clinical care
7. The clinical reviewer concluded that the clinical care Mr Taylor received at Dartmoor
was of a reasonable standard and equivalent to that which he could have expected
to receive in the wider community.
Management of risk
8. Staff at Exeter rightly monitored Mr Taylor under ACCT when he shared suicidal
thoughts about his chronic pain. The healthcare team was assessing his pain relief
prescription, during which time a weaker form of relief was issued. Mr Taylor
continued to report pain and the significant impact it was having on his mental
health, but the medication assessment was not expedited. It took four weeks to
reconcile the prescription which was an unacceptable delay in the circumstances.
9. Mr Taylor’s ACCT was transferred with him to Dartmoor. Staff reviewed the risks
one day after his arrival and decided to close the ACCT. Mr Taylor’s medication had
been organised and he was feeling safer and more positive at Dartmoor. Staff put
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Mr Taylor’s ACCT in ‘post-closure’ with regular reviews of the decision to close,
which did not find any concerns. Although the decision to close the ACCT was quick
and staff had a limited period of time to get to know Mr Taylor, we consider the
decision was proportionate in the circumstances. Staff had no reason to consider
there was an imminent risk of harm and had the opportunity to regularly review Mr
Taylor’s safety through the post-closure process.
Recommendations
• The GP Lead at HMP Exeter should review prescribing processes to ensure
high-risk medication assessments are completed in a timely way, with
consideration of the impact on the individual
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The Investigation Process
11. We were notified of the death of Mr Taylor on 17 December 2021. The investigator
issued notices to staff and prisoners at HMP Dartmoor informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded.
12. The investigator obtained copies of relevant extracts from Mr Taylor’s prison and
medical records.
13. The investigator interviewed six members of staff at Dartmoor. The interviews were
completed by video link due to the restrictions imposed as a result of the COVID-19
pandemic.
14. NHS England commissioned a clinical reviewer to review Mr Taylor’s clinical care at
the prison. The interviews were conducted jointly by the clinical reviewer and the
investigator.
15. We informed HM Coroner for Exeter and Greater Devon of the investigation and
have sent the coroner a copy of this report.
16. The Ombudsman’s family liaison officer contacted Mr Taylor’s son to explain the
investigation and to ask if he had any matters that he wanted the investigation to
consider. He did not ask any specific questions but shared some additional
information on Mr Taylor’s circumstances with us, which are referenced in this
report. He also requested a copy of this report.
17. We shared the initial report with HM Prison and Probation Service. They did not
identify any factual inaccuracies.
18. We also shared the initial report with Mr Taylor’s son. He did not provide any
comments.
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Background Information
HMP Dartmoor
19. HMP Dartmoor is a Category C prison, which holds up to 640 adult male prisoners.
Healthcare services are provided by Care UK and mental healthcare is provided by
Devon Partnership NHS Foundation Trust.
HM Inspectorate of Prisons
20. The last full inspection at HMP Dartmoor was in August 2017. HMIP completed a
short scrutiny visit in September 2020 (scrutiny visits focused on how
establishments were recovering from the challenges of the COVID-19 pandemic).
Inspectors reported that the quality of ACCT documents was poor, with entries that
lacked detail, incomplete initial action and care plans and no quality assurance
process to address these issues. Inspectors were also concerned that key work (a
scheme where assigned prison officers meet with prisoners for an average of 45
minutes a week, in an effort to build meaningful relationships with them) had not got
back on track after being halted at the start of COVID-19 related regime restrictions.
Inspectors recommended that key worker sessions should be resumed for all
prisoners, with a focus on wellbeing and rehabilitation.
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 annual report, for the year to 30 September 2022, the IMB
reported that the number of self-harm incidents was lower than the previous year,
and that Listeners continued to play a vital role in supporting vulnerable men.
22. They reported that ACCT reviews were being conducted professionally, with a focus
on the needs of the individual. Detailed records were presented at the review
meetings and there was clear evidence of a multidisciplinary approach.
23. In its previous annual report, for the year to 30 September 2021, the IMB reported
that COVID-19 restrictions meant prisoners were locked-up for extensive periods,
had no face-to-face visits for much of the year and had their activities restricted. All
these measures were affecting prisoners’ wellbeing.
Previous deaths at HMP Dartmoor
24. Mr Taylor was the twelfth prisoner to die at Dartmoor since December 2018. Of the
previous deaths, eight were from natural causes and three were self-inflicted. We
found no similarities between these deaths and the death of Mr Taylor.
25. Since Mr Taylor’s death, one further prisoner took his own life at Dartmoor in
October 2022. We found no similarities between this death and the death of Mr
Taylor.
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Assessment, Care in Custody and Teamwork
26. Assessment, Care in Custody and Teamwork (ACCT) is the HMPPS 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 irregular to prevent the prisoner
anticipating when they will occur. There should be regular multidisciplinary review
meetings involving the prisoner.
27. 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. 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.
28. Following the closure of an ACCT, the 7-Day Post-Closure Monitoring Form must
be completed for a minimum of 7 days in order to inform the post-closure review.
The form will need to be completed up until the day the post-closure review takes
place.
29. As soon as practically possible following this 7-day monitoring period, the ACCT Case
Coordinator must chair a post-closure review, reviewing the Support Actions and the
progress made since the ACCT was closed. During the post-closure review,
consideration should be given to the current feelings of the prisoner, access to
support (both formal and informal), and progress since closure.
30. At the end of the review, the Case Coordinator and any other members of the case
review team present will decide whether there needs to be any further post-closure
reviews (and, if so, their frequency), or whether the ACCT needs to be re-opened.
The review (including the outcome and discussion) must be documented on the
Post-Closure Review Form.
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Key Events
HMP Exeter
31. On 2 August 2021, Mr Graham Taylor was convicted of sex offences and released
on bail awaiting sentencing. On 12 November, he was sentenced to six years
imprisonment and sent to HMP Exeter. It was his first time in prison. Mr Taylor told
his barrister that he was thinking about taking his own life because he was innocent.
32. At the initial healthcare screening, Mr Taylor said he was in ‘constant pain’ due to
shoulder and back injuries. He was prescribed tramadol (pain relief) in the
community.
33. Mr Taylor was distressed when he arrived at Exeter. He told staff on reception that
he was struggling to come to terms with being in prison for something he did not do
and was concerned about the length of his sentence. He said he wanted to take his
own life by going on hunger strike. Staff began monitoring Mr Taylor using suicide
and self-harm prevention procedures known ACCT. Initially, Mr Taylor was placed
on hourly ACCT observations.
34. The next day, at Mr Taylor’s initial ACCT assessment, he told staff that he wanted
to die of a heart attack. He said he could stop taking his diabetes medication in
order to cause his death. He also said it would be easy to electrocute himself in his
cell, but that he did not “have the guts” to do it. Later on, at Mr Taylor’s first ACCT
review, he presented more positively. Although he talked a lot about how his
conviction was a “stitch up” and that he was innocent of all charges, he said he
would like to transfer to a prison where he could spend more time outside. He also
said he wanted to speak to his son and a friend, once the appropriate checks had
been completed. Following the review, staff agreed that the ACCT should remain
open but changed the level of observations from hourly to two conversations per
day and hourly observations at night.
35. On 15 November, staff at Exeter received Mr Taylor’s medical records. The records
confirmed he had been prescribed tramadol for some time, to treat chronic pain in
his shoulder and back. Healthcare staff did not automatically issue a prescription
due to concerns regarding opioid based medication in a prison setting (namely the
high risk of misuse, diversion and the potential psychoactive effects). They
prescribed paracetamol and ibuprofen as an alternative pain relief medication while
assessing the appropriateness of tramadol.
36. On 18 November, Mr Taylor tested positive for COVID-19 and was required to self-
isolate for a period of 14 days. Staff completed daily wellbeing checks and reported
no serious concerns.
37. On 19 November, the next ACCT case review took place. Mr Taylor told staff that
he had no thoughts of suicide or self-harm but said he was suffering with physical
pain which was affecting his sleep. He was starting to adjust to prison life day by
day. Following the review, staff reduced the number of nightly observations to four
based on Mr Taylor’s improved presentation and behaviour. No one from the mental
health team attended the review.
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38. On 25 November, a further ACCT case review took place. Mr Taylor told staff that
he had no thoughts of suicide or self-harm but was still struggling with physical pain
and wanted his tramadol reinstated. Staff decided that Mr Taylor’s risks had
reduced so placed his ACCT under review in a “post-closure” state, meaning it
could be reopened if additional concerns arose.
39. On 27 November, Mr Taylor’s twin brother died. This was a very difficult time for Mr
Taylor, and his anxiety increased. In interview, the prison chaplain who spent time
with Mr Taylor at both Exeter and Dartmoor, told us that she found it difficult to
obtain information about the death and said that Mr Taylor’s family did not want him
to attend the funeral.
40. On 29 November, a mental health nurse from the primary care mental health team
assessed Mr Taylor through his cell door. Mr Taylor said he was not doing well
following his twin brother’s death. He told her that he was in so much physical pain
it was causing him to have suicidal thoughts. She requested that the GP see Mr
Taylor to discuss his pain medication. She also diarised a full triage for 1
December, when Mr Taylor was due to finish his COVID-19 isolation. Mr Taylor
recovered well from COVID but said he found the isolation period difficult.
41. On 1 December, the mental health nurse attended Mr Taylor’s cell to complete the
planned triage. She was unable to complete the assessment properly because Mr
Taylor’s cell mate had to isolate for a further four days. She told Mr Taylor that he
would not be able to attend a GP appointment until his isolation period had ended.
Mr Taylor reiterated to her that the pain was causing him to have suicidal thoughts
and told her he could not continue to live like this. It is clear from Mr Taylor’s
records that his ACCT was reopened on 1 December, but this is not clear from the
ACCT document itself. It is also not clear when the ACCT closure was reviewed
and who attended the review. Staff decided that two conversations a day and hourly
observations at night was appropriate.
42. On 3 December, the next ACCT review took place. Mr Taylor told staff he had taken
tramadol for 18 years in the community and was struggling with constant pain. He
added that he was struggling emotionally following his twin brother’s death. A
mental health nurse attended the review and booked Mr Taylor in for a further
mental health assessment once his isolation period was over.
43. On 5 December, a mental health nurse completed a full mental health triage
assessment of Mr Taylor (23 days after he arrived at Exeter). Mr Taylor declined
antidepressants and said that stopping his physical pain was the only thing that
would improve his mood. He rated his mood as one out of ten and told the nurse, “if
anything happened to me it would be because of the pain and not being on correct
medication”. Mr Taylor cited his partner and son as protective factors, with whom he
had regular contact. The nurse told Mr Taylor that she had asked the GP to review
his medication but said the appointment had been delayed due to him and his
cellmate being in isolation. She also recommended that the chaplaincy support Mr
Taylor going forward.
44. On 6 December, Mr Taylor’s case was discussed at the multi-disciplinary team
(MDT) meeting. On 8 December, the next ACCT review took place. Both
operational prison staff and a mental health nurse attended it. Mr Taylor repeatedly
told staff that he had no thoughts or plans of suicide or self-harm but that the pain
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was causing him to have suicidal thoughts. Staff told him that a GP appointment
had been booked in to discuss pain relief.
45. On 9 December, the mental health team completed a comprehensive risk
assessment and care plan which detailed Mr Taylor’s recent life stressors including
the death of his brother, chronic pain and recent COVID-19 isolation.
46. On 10 December, a GP completed a telephone consultation with Mr Taylor to
discuss pain relief. Mr Taylor told the GP that historically, he suffered a serious
shoulder injury, underwent triple heart bypass surgery and had his toe amputated
(related to his diabetes) which subsequently became infected. He also had a fall
from a cattle lorry and hurt his back in 2020, and broke his ribs and coccyx. The GP
prescribed tramadol to help manage the pain.
HMP Dartmoor
47. On 13 December, Mr Taylor was transferred to HMP Dartmoor for longer term
prisoners and their associated needs. His ACCT was transferred too.
48. The reception nurse referred Mr Taylor to the mental health team on the basis of his
open ACCT. He recorded on Mr Taylor’s medical record that he was “now happy as
on medication” and that had no current thoughts of suicide or self-harm. He
described Mr Taylor’s mood as “normal” and raised no concerns.
49. At around 3.30pm, a Supervising Officer (SO) completed an interim review of Mr
Taylor as part of the induction process. She recorded that Mr Taylor was in a good
mood. He said the ACCT had been opened at Exeter due to the pain he was
experiencing. Mr Taylor said he was now in a much better place because he had
his medication and was no longer in pain.
50. An officer completed Mr Taylor’s induction and cell sharing risk assessment
(CSRA). Mr Taylor told him that he was happy to be at Dartmoor and would be able
to settle there. Mr Taylor also said that he hoped his ACCT would be closed soon
as he did not feel he needed it anymore.
14 December
51. On 14 December, at around 9.10am, Mr Taylor’s first ACCT review at Dartmoor
took place. This was undertaken by a SO and a chaplain. The mental health team
were not in attendance.
52. Mr Taylor declined mental health support on the basis that he felt much better and
happier at Dartmoor. He said he did not have any thoughts of suicide or self-harm
and cited his partner and son as protective factors. He said he was in the process of
appealing his sentence and had writing equipment to help him do so. He also said
that he felt safer in a single cell, liked the food and felt he was being treated well by
staff. However, his tramadol prescription had not been transferred from Exeter. In
interview, the SO told us that she got up from the review and rang healthcare, who
confirmed on the telephone that they would have his medication ready by 4.00pm
that day. Due to Mr Taylor’s improved presentation and mood, staff and Mr Taylor
agreed to close the ACCT.
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53. When a mental health nurse arrived for the planned ACCT review, the SO told her
that it had already taken place in her absence. The SO told the nurse that Mr
Taylor’s ACCT had been placed into post-closure (where it can be reopened at any
point during the next seven days) because his risks had sufficiently reduced - he
was happy to be at Dartmoor and denied any thoughts of suicide or self-harm.
54. The nurse decided to complete her own assessment of Mr Taylor in his cell. She
recorded in Mr Taylor’s medical record that the SO was under the impression that a
mental health representative was not required at the review, which she had
corrected her on. She was clear it was a requirement for mental health to attend all
initial ACCT reviews Dartmoor. She agreed with the earlier assessment of Mr Taylor
and that his ACCT should be closed. She explained the support that was available
to him and told him how to re-refer himself to the mental health team if he was
struggling.
15-17 December
55. On 15 December, staff saw Mr Taylor as part of ACCT post-closure monitoring
procedures and raised no concerns.
56. On 16 December, another ACCT post-closure meeting took place for Mr Taylor and
again raised no concerns. The post-closure monitoring record states, “Given
morning meds. Seems in a good mood”. Later that day, Mr Taylor spoke to his son
on the telephone for nearly ten minutes.
57. Shortly after 3.00pm, Mr Taylor spoke to his son for around 10 minutes. We were
unable to obtain a recording of the conversation, but Mr Taylor’s son shared some
information on the nature of the call with us following his father’s death. He had told
his father about potential allegations being made about him that might impact on the
appeal of his sentence. Staff do not routinely listen to prisoners’ calls unless a
specific risk has been identified. Mr Taylor did not mention any concerns so staff.
58. At around 8.00pm, an Officer Support Grade (OSG) checked Mr Taylor through his
cell observation panel during her evening routine check. In her statement, she
recalled him sitting on his bed and waving and raised no concerns.
59. At 5.14am on Friday 17 December, during the morning routine check, the OSG
opened the observation panel in Mr Taylor’s door and shone her torch into his cell.
She saw Mr Taylor slumped on the floor next to the head of his bed with a chair in
front of him. She shone the torch upwards and saw there was a ligature made from
a piece of towel attached to the bar on the window and that Mr Taylor was
unresponsive. She immediately radioed a medical emergency ‘code blue’, indicating
a life-threatening situation and triggering a call for an ambulance.
60. A Custodial Manager (CM) arrived in approximately 30 seconds. He cut the ligature,
pulled Mr Taylor’s body from the back of the cell and laid him on the floor, noting
that he was cold to the touch and that rigor mortis had set in. As he began
unbuttoning Mr Taylor’s shirt ready to deliver first aid, an officer arrived with the
defibrillator, closely followed by more staff. An officer followed the defibrillator
instructions and delivered a shock when asked, but the machine told him to stop. In
interview, the CM told us that it was clear Mr Taylor had been dead for some time,
so staff did not attempt cardio-pulmonary resuscitation (CPR).
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61. Healthcare services were not open at the time, but paramedics arrived at the cell at
5.45am and confirmed that Mr Taylor had died.
62. After Mr Taylor’s death, Devon and Cornwall Police provided us with a copy of diary
entries written by Mr Taylor in the week leading up to his death. On 15 December
Mr Taylor wrote, “stayed awake most of the night in pain” and 16 December he
wrote, “can’t stand the pain enymore (sic). Nothing to do with what I am falsely
accused of. Just the pain.” It is unclear whether this was a reference to physical or
mental pain.
Contact with Mr Taylor’s family
63. Mr Taylor had nominated his son as his next of kin. The Governor and the Family
Liaison Officer visited Mr Taylor’s son at his home address shortly after 1.00pm on
17 December to notify him of his father’s death. Dartmoor maintained contact with
Mr Taylor’s family, and in line with national instructions, contributed to the costs of
the funeral.
Support for prisoners and staff
64. After Mr Taylor’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
65. The prison posted notices informing other prisoners of Mr Taylor’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 Taylor’s death.
Post-mortem report
66. A post-mortem examination found that Mr Taylor died as the result of suspension by
ligature (hanging). The toxicology examination found nothing significant.
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Findings
Management of risk of suicide and self-harm
67. Prison Service Instruction (PSI) 64/2011, which contains national requirements on
Assessment, Care in Custody and Teamwork (ACCT) suicide and self-harm
prevention procedures, requires all staff who have contact with prisoners to be
aware of the risk factors and triggers that might increase the risk of suicide and self-
harm and take appropriate action. The triggers listed in the PSI include being in
prison for the first time, the period after a transfer between prisons and suicidal
planning. Any prisoner identified as at risk of suicide or self-harm must be managed
under ACCT procedures.
68. Staff at Exeter rightly opened ACCT procedures on 12 November 2021 when Mr
Taylor was experiencing severe pain, low mood and suicidal planning. The ACCT
was transferred with Mr Taylor when he moved to Dartmoor on 13 December.
However, it was closed one day after his arrival when staff agreed there were no
immediate risks. In interview, a SO and chaplain said Mr Taylor appeared settled
and said he felt safer at Dartmoor. He said he had no thoughts of suicide or self-
harm. He was worried his tramadol had not been transferred with him from Exeter
but healthcare staff were able to confirm it was on its way and would arrive later in
the day. Mr Taylor was happy with that, as pain relief had been the key cause of his
low mood and suicidal thoughts. He was aware of the support available to him and
talked about his partner and son as protective factors with whom he had regular
contact. In interview, a nurse told us that after completing her own assessment of
Mr Taylor, she agreed with the decision to close the ACCT.
69. We consider that the decision to close Mr Taylor’s ACCT was quick, given he had
recently lost his brother and had spent only one day at Dartmoor. Based on the
documentation and our interviews with staff, the decision was based largely on Mr
Taylor’s presentation and what he said about his mood and outlook, which
appeared positive. His main risk factor, the lack of pain relief, had been addressed.
Staff placed Mr Taylor’s ACCT in a post-closure state, to ensure review of the
decision. They carried out frequent post-closure checks, did not identify any
concerns and were satisfied that Mr Taylor had settled well at Dartmoor, with no
reasons to suspect his risk had increased again.
70. The day before he died, Mr Taylor spoke to his son on the telephone for around 10
minutes. Mr Taylor’s son told him about potential allegations being made against
him, which might impact on his sentence appeal. Mr Taylor did not report any
concerns to staff and therefore they had no reason to believe his risk might
increase. They did not observe any signs that made them concerned. Entries in Mr
Taylor’s diary, found by the police after he died, talked about him not being able to
‘stand the pain anymore’. We do not know if this related to physical or emotional
pain.
71. Overall, we are satisfied that the decisions made in relation to Mr Taylor’s ACCT
and wider risk management at Dartmoor were proportionate in the circumstances.
Staff had no reason to consider Mr Taylor was an increased risk to himself. We do
not make a recommendation.
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Clinical care
72. The clinical reviewer concluded that Mr Taylor’s clinical care at Dartmoor was of a
reasonable standard and equivalent to that which he could have expected to
receive in the wider community. She makes recommendations for HMP Exeter to
review medication reconciliation processes.
Management of Mr Taylor’s pain medication
73. The clinical reviewer found issues with Mr Taylor’s medication at HMP Exeter.
When he arrived, Mr Taylor told staff about his chronic pain following several
accidents in the community. He said he had been prescribed tramadol for some
time, which helped manage the symptoms. His medical record was received two
days after his reception, which confirmed his prescription. Healthcare provided
alternative, weaker forms of pain relief while they reviewed the appropriateness of
tramadol, which they had concerns about in a prison environment due to it being
opioid based. On several occasions, Mr Taylor complained of significant pain and
told staff it was impacting on his wellbeing, including wanting to die if he did not
have it. Despite this, it took healthcare over four weeks to conclude that he should
be prescribed tramadol. Mr Taylor had received his medication by the time he died
and reported feeling positive about this. However, it was a cause for decline in his
mental health over time and the assessment should have been expedited as a
result. We make the following recommendation, to improve future practice:
The GP Lead at HMP Exeter should review prescribing processes to ensure
high-risk medication assessments are completed in a timely way, with
consideration of the impact on the individual
74. The clinical reviewer noted a further issue with medication continuity when Mr
Taylor was transferred from Exeter to Dartmoor on 13 December. His tramadol
prescription was not transferred with him as intended. Mr Taylor missed one dose of
tramadol before the prescription was provided the next day. We make no
recommendation.
Attendance of mental health team at ACCT reviews
75. Prison Service ACCT Policy Guidance contains mandatory actions and operational
guidance for prisons delivering ACCT. It states that the ACCT Case Coordinator
must ensure that healthcare staff are always invited to, or provide a written
contribution to, the first case review and any subsequent case reviews where they
are relevant to supporting the prisoner. It states that healthcare staff should be
given sufficient advance notice of this wherever possible.
76. No healthcare representative was present at Mr Taylor’s first ACCT review on 14
December. In interview, a nurse told us that a representative from the mental health
team is expected to attend a prisoner’s first ACCT review at Dartmoor, regardless of
whether they have arrived on an open ACCT or just had one opened. There is no
written local policy containing these guidelines, but she said it was a requirement
that staff should be aware of.
77. A SO told us there were no representatives available in the prison at the time of Mr
Taylor’s first review meeting. A nurse told us that she noticed Mr Taylor was having
an ACCT review and was shocked to learn that she had not been invited to attend
it. She followed up with her own assessment and agreed with the decision to close
12 Prisons and Probation Ombudsman
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the ACCT. This proactive approach by her is recognised as good practice, which we
bring to the attention of the Head of Healthcare.
78. It appears that another SO was not aware that a member of healthcare should have
been invited to the ACCT review. In interview, the Head of Healthcare at Dartmoor
told us that as a result of the learning from Mr Taylor’s death, the prison has now
changed its practice. A supervising officer now attends a morning briefing with
healthcare staff. At the briefing, they discuss which ACCT reviews are due that day
to make sure they are multidisciplinary. We are pleased that Dartmoor have taken
steps to address the learning. As Dartmoor have already addressed the learning,
we do not make a recommendation.
Governor to note
79. We asked for a recording or summary of the call Mr Taylor made to his son the day
before he died, to ascertain its relevance. Despite several requests, we did not
receive the information from Dartmoor and the timeframe for retention of calls
lapsed so the call was no longer available. We note that we have not experienced
issues in obtaining evidence from Dartmoor in previous investigations and therefore
we do not consider this a systemic issue, but bring the learning to the Governor.
Inquest
80. The inquest into Mr Taylor’s death concluded on 7 July 2025 and recorded a verdict
of suicide.
Adrian Usher
Prisons and Probation Ombudsman August 2023
Prisons and Probation Ombudsman 13
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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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