Imogen Mellor

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Imogen Mellor,
a prisoner at HMP/YOI Styal, on
4 June 2018
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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.
Ms Imogen Mellor was found hanging in her shared room at HMP Styal on 4 July 2018 and
died that evening in hospital. She was 29 years old. I offer my condolences to Ms Mellor’s
family and friends.
Ms Mellor was very dependent emotionally on her relationship with her partner (a fellow
prisoner) and had had a heated argument with her shortly before she died. However, staff
were not aware of this. I am satisfied there was little to indicate that Ms Mellor was at
imminent risk of suicide, and I do not consider that staff at Styal could have predicted that
Ms Mellor intended to take her own life when she did.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman February 2023
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 3
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 14
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. In November 2014, Ms Imogen Mellor was sentenced to four years and eight
months imprisonment. She was released in April 2016 but recalled to prison in
August 2017 after committing further offences while on licence. She was released
again on 5 April 2018 and recalled again on 28 April after she breached the
conditions of her licence. She was returned to HMP Styal to complete her
sentence. She was due to be released on 13 August 2018.
2. Ms Mellor had a history of substance misuse and of self-harm from 2017. She had
been managed under suicide and self-harm management procedures (known as
ACCT) earlier in her sentence, mostly recently in January 2018, after she cut
herself. She said she had self-harmed to cope with stresses caused by her
relationship with her partner (a fellow prisoner). When she returned to Styal in April
2018, she began a methadone detoxification programme for her heroin misuse.
3. Around 3.00pm on 4 June 2018, Ms Mellor had a heated argument with her partner,
and returned to her residential house. Her partner shouted up at Ms Mellor’s room
window but, when Ms Mellor did not respond, she alerted an officer who went to Ms
Mellor’s room.
4. The officer found Ms Mellor hanging from a ligature around her neck which was
attached to the bunk bed ladder. The officer called for medical assistance using her
radio. Nursing staff arrived quickly and tried to resuscitate her. Ms Mellor was
taken to hospital but died at 10.30pm that evening.
Findings
Clinical Care
5. The investigation found that the standard of clinical care provided to Ms Mellor was
equivalent to that which she could have expected to receive in the community,
especially for her mental health and support for substance recovery.
Identifying risk of suicide and self-harm
6. Ms Mellor's offender manager (probation officer) was concerned that Ms Mellor was
very dependent on her partner, and, in April 2018, she said that Ms Mellor would be
at risk of serious self-harm if their relationship ended.
7. While Ms Mellor had some risk factors for suicide and self-harm, we are satisfied
that in the days leading to her death, there was nothing to indicate that she was at
increased risk. Staff were not aware that she had argued with her partner, and we
do not consider that they could have foreseen her death.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Emergency response
8. The officer who found Ms Mellor unresponsive in her room radioed for assistance
and an ambulance at 3.44pm but did not use an emergency response code.
Although in practice this did not cause a delay before an ambulance was called and
CPR was initiated, it could make a critical difference in other medical emergencies.
Recommendations
• The Governor should remind all staff that they should use the appropriate
emergency medical code to communicate the nature of the emergency efficiently.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
9. The investigator issued notices to staff and prisoners at HMP Styal informing them
of the investigation and asking anyone with relevant information to contact him.
One person asked to speak to him.
10. The investigator visited Styal on 20 June 2018. He obtained copies of relevant
extracts from Ms Mellor’s prison and medical records and interviewed four
prisoners, including Ms Mellor’s partner.
11. Another investigator took over the investigation in August. She interviewed eleven
members of staff in September and October 2018.
12. NHS England commissioned a clinical reviewer to review Ms Mellor’s clinical care at
the prison. The clinical reviewer conducted seven joint interviews with the
investigator.
13. We informed HM Coroner for Cheshire of the investigation. We suspended the
investigation until we received the results of the post-mortem investigation. We
have sent the coroner a copy of this report.
14. The investigator contacted Ms Mellor’s parents to explain the investigation and to
ask if they had any matters, they wanted the investigation to consider. Ms Mellor’s
mother asked what her daughter had used as a ligature and whether the healthcare
emergency response was appropriate. Her father asked if staff should have
prevented her from taking her life.
15. We have addressed these questions in this report. Following the publication of our
initial report Ms Mellor’s family responded and raised some questions regard the
findings of both our investigation and that of the clinical review. The family
questions have been responded to in separate correspondence.
16. An inquest was concluded in May 2024 and found the following:
‘… Ms Mellor deliberately chose to ligature, with the physical evidence suggesting
suicide, however the true extent of Ms Mellor’s desire to live or die cannot be
determined …’
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Styal
17. HMP and YOI Styal is a women’s prison in Cheshire which holds up to 486 women.
There is a variety of residential units, including 16 separate houses each holding
about 20 women in shared rooms.
18. Spectrum Community Health runs healthcare services at the prison. Greater
Manchester West Mental Health NHS Foundation Trust provides mental health
services. There are nurses on duty at all times, with one registered nurse and a
healthcare support worker available at night. GP sessions are held every day
except Sundays when there is an out of hours service. There is no inpatient facility.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Styal was in May 2018. Inspectors reported
that women were well cared for when they arrived at Styal and induction was
thorough. Nearly all the women arrived with significant need including a history of
suicide attempts and self-harm, mental health, and substance misuse issues. They
found that the management of prisoners on ACCTs was good. The availability of
illicit substances was high and over 50% of women said they had a drug problem on
arrival. However, inspectors found that the drug supply reduction strategy was
practical, well informed and focused on supporting women, alongside preventative
measures.
20. Levels of self-harm were very high due to a small number of women who harmed
themselves prolifically, but the vast majority of staff were caring and supportive and
inspectors were confident that most women had a member of staff they could turn
to if they had an issue. Most safety incidents or problems were related to the
breakdown of or tensions within relationships among the women, but levels of
violence were low.
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 April 2018, the IMB reported that
appropriate care was given to new prisoners in reception and the first night centre.
They found that ACCT procedures were generally being used effectively.
Previous deaths at HMP Styal
22. Ms Mellor’s death was the first self-inflicted death at Styal since 2016. There have
been two further self-inflicted deaths in 2019, and two deaths from natural causes in
2020.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Assessment, Care in Custody and Teamwork
23. ACCT is the care planning system the Prison Service uses to support prisoners at
risk of suicide or self-harm. The purpose of ACCT is to try to determine the level of
risk posed, the steps that staff might take to reduce this and the extent to which
staff need to monitor and supervise the prisoner. Part of the ACCT process
involves assessing immediate needs and drawing up a caremap to identify the
prisoner’s most urgent issues and how they will be met. Staff should hold regular
multidisciplinary reviews and should not close the ACCT plan until all the actions of
the caremap are completed. Guidance on ACCT procedures is set out in Prison
Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm to self,
to others and from others (Safer Custody).
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
24. In November 2014, Ms Imogen Mellor was sentenced to four years and eight
months imprisonment for conspiracy to supply class A drugs.
25. She had a history of crack cocaine, heroin, and benzodiazepine misuse since the
age of 15. She also had a history of self-harm and suicidal thoughts and had taken
an overdose when she was 16 years old. While in custody, Ms Mellor was
diagnosed with an eating disorder, dissocial personality disorder, and mixed anxiety
and depressive disorder.
26. Ms Mellor met her partner (Prisoner A) at HMP Peterborough in 2015. She was
released on licence in April 2016 and her relationship with Prisoner A continued in
the community.
HMP Styal – 12 August 2017 to 5 April 2018
27. In August 2017, Ms Mellor was recalled to prison on further charges of robbery and
assault and was taken to HMP Styal. She tested positive for opiates and
methadone. She subsequently completed detoxification treatment and remained on
methadone maintenance therapy, gradually reducing her methadone intake.
28. In September and October, Ms Mellor was managed under ACCT procedures after
she made cuts to her arm on several occasions. She said that she was feeling very
low because she thought she might get a long sentence at her upcoming trial while
Prisoner A, who was her co-defendant, walked free. She also said she was upset
because she was unable to communicate with Prisoner A, who was also in Styal, as
they were co-defendants.
29. A comprehensive caremap was put in place to provide support with the issues that
Ms Mellor had raised. In October, Ms Mellor met with mental health nurse, who had
been assigned as her case worker. Ms Mellor was very tearful and said that she
had been self-harming and making herself vomit after each meal because she felt
she had no control over her life. She said she was worried about her trial in
January and her relationship with Prisoner A. A prison GP prescribed mirtazapine,
an anti-depressant. Ms Mellor retained regular contact with her case worker. She
said that she could not handle being separated from Prisoner A and that, if this
happened, her ‘head will go’. The ACCT was closed at the end of October.
30. An ACCT was opened again a week later after Ms Mellor cut her arm again. She
said she was upset because she had been told Prisoner A could not live on the
same spur of the wing because of concerns raised by her offender manager
(probation officer) about their relationship. She cut her arm again a couple of
weeks later.
31. In January 2018, Ms Mellor told her case worker that she was struggling to believe
that Prisoner A would remain with her. She said that she did not care what
sentence she received as long as they were together.
32. Later that month, Ms Mellor was sentenced to 21 months for offences of violence.
She was returned to Styal. At an ACCT case review, Ms Mellor was said to be
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
‘ecstatic’ as she had only had five and a half months to serve. She said she had no
thoughts of self-harm and agreed that she would continue to work with the mental
health team on her eating disorder. The ACCT was closed.
33. In February, Prisoner A was released to an Approved Premises (AP) with a licence
condition that she should not contact Ms Mellor. On 5 April, Ms Mellor was
released on Home Detention Curfew. One of her licence conditions was to live in
supported accommodation provided by the Mulberry Community Project (MCP).
The following day she was recalled to prison after taking cocaine at the MCP
premises, being aggressive to other residents and contacting Prisoner A without
permission. Ms Mellor remained unlawfully at large until the end of April, when she
was arrested and returned to Styal.
34. During this period, Ms Mellor’s offender manager completed an OASys report
(which sets out an offender’s risks and needs). This referred to a letter to Prisoner
A, in which Ms Mellor said that she could not live without her. Ms Mellor had
previously told her offender manager that she only had Prisoner A for support as
she did not have contact with her own family. Her offender manager wrote that this
indicated ‘a level of fixation on the relationship, and a high level of dependency on
Prisoner A’. The report concluded that if Ms Mellor’s relationship with Prisoner A
broke down, her risk of serious self-harm could increase.
HMP Styal – 28 April to 4 June 2018
35. When she returned to Styal, Ms Mellor was assessed by a nurse. She told the
nurse that she had ‘ligatured’ two weeks previously in the community because she
was ‘stressed’. The nurse wrote in Ms Mellor’s clinical record that her presentation
was normal, and that she did not have current suicidal thoughts or thoughts of
deliberate self-harm. She noted her history of depression and anxiety. Ms Mellor
tested positive for cocaine, benzodiazepine and opiates and said that she had been
spending £100- £200 a day on heroin. The nurse prescribed methadone to support
her drug withdrawal.
36. The case worker, who had established a rapport with Ms Mellor during her previous
stay at Styal, went to see her in the first night centre on the day she arrived.
However, as Ms Mellor was detoxing, she asked to see the case worker another
time. On 1 May, Ms Mellor’s case was discussed at the mental health team
allocations meeting and she was formally allocated to the case worker’s caseload.
37. On 6 May, Ms Mellor completed a five-day review of her detoxification treatment
with a Healthcare Support Worker. Ms Mellor said that she was currently on 30mls
of methadone and wanted to begin a reduction prior to release. On 7 May, Ms
Mellor’s methadone prescription began reducing by 5mls weekly.
38. On 11 May, Ms Mellor did not turn up for her first appointment with her case worker.
She went to the healthcare unit and said that she had forgotten about her
appointment and asked for another date. She was given a rescheduled
appointment for 23 May.
39. In May, Ms Mellor’s offender manager, who had previously advised that Ms Mellor
and Prisoner A should not be on the same residential unit, agreed with prison
managers that Ms Mellor might benefit from having her partner’s support. On 22
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
May, they both moved to Wilson House, one of the residential units, where they
shared a room with two other women.
40. Prisoner A told the investigator that after she and Ms Mellor returned to Styal in
April, their relationship was going well, although Ms Mellor was sleeping more and
appeared anxious, which she thought might be because of their different release
dates. She thought Ms Mellor’s mood was low, but she said she did not speak to
officers about it as Ms Mellor had a GP appointment and she thought her
medication would be sorted out then.
41. On 23 May, Ms Mellor did not attend her mental health appointment with her case
worker. The case worker told the clinical reviewer that she was not particularly
worried by this because Ms Mellor would always contact her if she wanted another
appointment and that they engaged well. She did not think Ms Mellor was trying to
avoid her. Another appointment was made for 7 June.
42. Prisoner A told the investigator that she thought Ms Mellor did not attend her
appointments with the case worker because she did not like ‘opening up’ and simply
wanted to see the GP and get antidepressants.
Events of 4 June
43. On the morning of 4 June, Ms Mellor saw a prison GP. Ms Mellor said that she had
mixed anxiety and depressive disorder and had tried several types of anti-
depressants, but that trazadone had helped in the past. The GP wrote in Ms
Mellor’s clinical record that she had mental health input, difficulty sleeping, previous
bulimia, no motivation, was tearful, and had no suicidal ideation. She requested
blood tests to exclude physiological causes, prescribed trazodone and said that she
would see Ms Mellor in two weeks for a review.
44. Prisoner A told the investigator that she saw Ms Mellor’s name on a ‘debt list’
belonging to another prisoner. This meant that Ms Mellor had obtained drugs and
owed them a payment (although she said she later discovered this was not the
case). Prisoner A was angry because they were both trying to keep off drugs and
were detoxing with methadone. She said she had not seen Ms Mellor taking drugs
in Styal and had not seen her under the influence or suspected she was taking
anything.
45. At about 3.00pm, Prisoner A confronted Ms Mellor about her drug use, and they
had a heated argument. Ms Mellor was very angry and grabbed Prisoner A’s face.
Prisoner A told the investigator that she had never seen Ms Mellor so angry, and
she was afraid of making a scene and attracting the attention of officers. Ms Mellor
grabbed their shared room key from her and said, “This will be on your head”.
Another prisoner who was working nearby said she heard Ms Mellor say, “Watch
what I do now, and it’s on your fucking head”. Ms Mellor walked off towards Wilson
House and Prisoner A let her go as she thought she had gone to calm down.
46. An officer told the investigator that she was patrolling the grounds that afternoon
when Ms Mellor asked her to let her into Wilson House because she had finished
work for the day. She said Ms Mellor did not seem upset or show any behaviour
that made her concerned for her wellbeing. She unlocked the door to Wilson House
and Ms Mellor went in.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
47. Prisoner B, who was friends with Ms Mellor, told the investigator that she had
walked around the prison grounds with Ms Mellor that morning. She said Ms Mellor
had seemed a little down. In the afternoon, she saw Ms Mellor and Prisoner A
having an argument. She said that although both were upset and crying, it did not
appear to be particularly serious. When she saw Ms Mellor grab Prisoner A’s face,
she was concerned that they might get into trouble, so she told them to stop, and
Ms Mellor walked off.
48. Prisoner B told the investigator that Prisoner A said Ms Mellor had said she was
going to kill herself (though Ms Hickey denies this). A few women had gathered
around and were saying Ms Mellor would not kill herself. Prisoner B said she would
check on Ms Mellor and walked to Wilson House. As the front door was locked, she
shouted Ms Mellor’s name until she appeared at the window of her room. She said
Ms Mellor was crying a lot and seemed a bit hysterical. She was doing something
with her hands. Prisoner B talked to her at the window for a few minutes and then
went to get Prisoner A, as she felt something was not right. They returned a couple
of minutes later and shouted for Ms Mellor to come to the window, but she did not
appear.
49. Prisoner C said that she was in Room 6 of Wilson House at about 3.00pm, with her
door open, when she saw Ms Mellor walk past, go into Room 4 and close the door
behind her. About five minutes later, she heard shouting outside the building and
when she looked through the window, Prisoner A (who was with Prisoner B) asked
her to check on Ms Mellor. She described Prisoner A as panicking and seeming
upset. Prisoner C tried to open Ms Mellor’s room door, but it was locked. She
looked through the window in the door but there did not seem to be anyone in the
room and all four bunk beds looked unoccupied. She and a prisoner in the room
next door shouted to Ms Mellor, but there was no reply.
50. Prisoner A saw two officers through an open window in an office in Gordon House
and asked one of them to let her in to Wilson House. Officer A said in her police
statement that she did not get the impression it seemed urgent. Officer B walked
Prisoner A to Wilson House, which was a couple of minutes away. Prisoner A told
her that Ms Mellor was not answering when they called. Officer B opened Ms
Mellor’s room door and, as she walked in, she saw Ms Mellor suspended by a
dressing gown belt from the bunk bed ladder.
51. At 3.44pm, Officer B radioed for an ambulance to be called immediately to Wilson
House. She did not use an emergency code blue, indicating that a prisoner is
having breathing difficulties or is unresponsive. Other officers told the investigator
that they ran immediately to Wilson House because the officer sounded distressed,
and they assumed something serious had happened.
52. Officer B cut the dressing gown sash from around Ms Mellor’s neck using her anti-
ligature knife and Ms Mellor fell to the floor, injuring her nose. Officer A was also
present but was too shocked to be able to help. Other officers arrived and escorted
the first two officers out of the room. An officer arrived and took Prisoner A away
from the scene.
53. A nurse responded to the radio call for assistance. She saw Ms Mellor lying on the
floor, with vomit on her clothes and the floor. She applied defibrillator pads, but a
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
shock not was not recommended, so she began chest compressions. A Matron
and another nurse helped until paramedics arrived.
54. Northwest Ambulance Service’s first responder arrived at 3.52pm and an
ambulance at 3.57pm. At 4.09pm, paramedics found a slight pulse and at 4.30pm,
Ms Mellor was put into an ambulance and left the prison at 4.45pm. She was
accompanied by two officers and a senior manager.
55. A hand-written note from Ms Mellor was found on a pillow in her room. It said, ‘All
I’ve ever done is love you and I always will forever and always. I mean that, love
Mushy Pea xxx.’
56. At 7.00pm, Prisoner A arrived at the hospital, accompanied by two officers.
57. Ms Mellor’s condition deteriorated, and she died at 10.30pm.
Contact with Ms Mellor’s family
58. A senior manager appointed two family liaison officers. Ms Mellor had named
Prisoner A as her next of kin. They arranged for her to be escorted to
Wythenshawe Hospital.
59. They also called Ms Mellor’s father’s telephone number, but there was no answer.
Cheshire police sought assistance from Staffordshire police, who located Ms
Mellor’s father. He was informed of his daughter’s death in person by the police
and this was followed up by visits from Styal’s family liaison officers to both her
parents.
Support for prisoners and staff
60. The residents of Wilson House were taken to the safer custody centre and
supported by Listeners and staff. The residents spoke about Ms Mellor and
Prisoner A’s relationship, that they had argued, and Ms Mellor was heard to say she
would not be in Prisoner A’s life anymore. They said Ms Mellor had been ‘up and
down’ and had seen the GP that day for anti-depressant medication.
61. The prison posted notices informing other prisoners of Ms Mellor’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 Ms Mellor’s death.
62. At 5.10pm, staff had a hot debrief led by a senior manager, where they talked about
what had happened and received support from members of the care team.
Information received after Ms Mellor’s death
63. Prisoner B told the investigator that she had had a couple of conversations with Ms
Mellor the week before Ms Mellor’s death. Ms Mellor said she felt a bit low because
she would be released soon without Prisoner A (who was due to be released a few
weeks later). She said that Prisoner A was Ms Mellor’s ‘absolute life’. She said Ms
Mellor said she would like to come back to jail after her release so she could be with
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
her again as she had no one else in the community. She also said she did not
believe Ms Mellor was taking drugs.
64. Prisoner C said Ms Mellor was upset that healthcare staff did not give her
medication for depression on the day she arrived. She said Ms Mellor was taking
illicit drugs to help her sleep, and she had seen her take them twice, the last time
was a couple of days before she died. She did not know what they were but
thought it might have been quetiapine (an antipsychotic drug). She had not
disclosed this to anyone before. She also said she thought Ms Mellor might have
been worried that another prisoner wanted a relationship with Prisoner A.
Post-mortem report
65. The post-mortem report gave Ms Mellor’s cause of death as hypoxic ischaemic
brain injury (a lack of oxygen to the brain) caused by compression to the neck due
to hanging.
66. Toxicology tests showed therapeutic levels of methadone, trazadone, mirtazapine,
and olanzapine (an antipsychotic) in Ms Mellor’s system when she died. Ms Mellor
was prescribed methadone and had been prescribed trazadone that morning but
was not prescribed mirtazapine or olanzapine.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of risk
67. PSI 64/2011, which governs 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. We have, therefore, considered whether staff should have identified that Ms
Mellor was at risk before her death.
68. Ms Mellor had a history of depression and self-harm and had been managed
appropriately under ACCT procedures after cutting herself during previous periods
in prison when she said she was worried about her relationship with her partner.
69. Ms Mellor's offender manager was concerned that Ms Mellor was very dependent
on her partner and in April 2018, she warned that Ms Mellor would be at risk of
serious self-harm if their relationship ended. Ms Mellor confided to a friend that she
was worried about being released from prison alone, before her partner. Another
prisoner thought Ms Mellor may have been worried about their relationship.
70. On the day of her death, Ms Mellor asked a GP for an anti-depressant saying she
lacked motivation and had difficulty sleeping, but she did not mention her concerns
about her partner. Nor did she tell the officer who let her back into Wilson House
that she had argued with her partner and wanted to harm herself.
71. We are satisfied that in the days leading to her death, there was nothing to indicate
to staff that Ms Mellor was at increased risk. We consider that it would have been
difficult for staff to have foreseen her death.
Emergency Response
72. The officer who found Ms Mellor unresponsive in her room radioed for assistance
and an ambulance but did not use a medical emergency response code in line with
Prison Service Instruction 03/2013. In practice this did not cause a delay as several
staff responded immediately to her request because of her distressed tone. There
was no delay before an ambulance was called and CPR was initiated quickly.
However, it is important that staff use the appropriate emergency codes and, not
doing so, may cause delays in other medical emergencies.
The Governor should remind all staff that they should use the appropriate
emergency medical code to communicate the nature of the emergency
efficiently.
Clinical care
73. The clinical reviewer concluded that the clinical care Ms Mellor received at Styal
was equivalent to that which she could have expected to receive in the community.
74. The clinical reviewer noted that Ms Mellor had a positive therapeutic relationship
with her case worker, and that there was evidence of person-centred care in terms
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
of treatment with both antidepressants and emotional support in line with her overall
mental state, her previous addictions, and her eating disorder.
75. The clinical reviewer was also satisfied that Ms Mellor’s substance misuse care was
appropriate in terms of methadone withdrawal and, again, there was evidence of
person-centred care and appropriate education on harm minimisation. Ms Mellor
was offered further support by the Drug and Alcohol Recovery Service, but she
declined.
76. We make no recommendation.
Prisons and Probation Ombudsman 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE