Johnpaul Digweed

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Independent investigation into
the death of Mr Johnpaul
Digweed, a prisoner at HMP
Garth, on 13 April 2024
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, 2026
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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 Johnpaul Digweed died after being found hanged in his cell on 13 April 2024 at HMP
Garth. He was 36 years old. I offer my condolences to Mr Digweed’s family and friends.
Mr Digweed was in the early years of a twenty-five year sentence for drug supply. There
was significant evidence that he was involved in prison drug culture and he was found in
possession of a mobile phone numerous times. I did not find any evidence that he was at
heightened or imminent risk of suicide when he died. However, information received after
he died suggested his sentence was putting his relationship under strain and he might
have been worried about money.
I am concerned that there is a widespread issue at Garth with prisoners blocking their
observation panels and that staff do not always follow local guidance when completing
routine checks and welfare checks. The prison has taken some steps to address this but
more needs to be done. I cannot say whether this would have changed the outcome for Mr
Digweed but it would have led to his earlier discovery.
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 August 2026
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 16
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Summary
Events
1. On 11 March 2021, Mr Johnpaul Digweed was remanded to HMP Liverpool
charged with conspiracy to supply class A drugs. It was his first time in custody. He
had misused cocaine and ecstasy in the community. He had no significant history of
mental or physical health issues and no significant history of attempted suicide or
self-harm. Mr Digweed also spent time in HMP Forest Bank and HMP Leeds. He
consistently denied any thoughts of suicide or self-harm. Intelligence was received
at each prison that he was involved in prison drug culture. In December 2021, he
told his partner in a phone call that he would hang himself if he received a thirty-
year sentence. This is the only reference in his prison record to suicidal thoughts.
2. On 24 June 2022, Mr Digweed was sentenced to 25 years in prison and on 8 July
he transferred to HMP Garth. Throughout his time in Garth, the prison received
significant intelligence that he was involved in organising drone deliveries of drugs
and other illicit items and on six occasions he was found with a mobile phone in his
possession.
3. Between 21 and 24 September 2023, Mr Digweed was suspected to be under the
influence of an illicit substance. Mr Digweed tested positive for cocaine. During this
period Mr Digweed harmed himself by making superficial cuts to his chest. He also
injured himself by kicking his door. He was offered support from the substance
misuse team but declined to work with them. His emails from this period indicated
that his relationship with his partner was breaking down. There is no evidence that
staff considered starting Prison Service suicide and self-harm support procedures,
known as ACCT.
4. On 27 September, staff removed Mr Digweed’s prison laptop after they noticed he
had damaged the screen. A prison disciplinary hearing (adjudication) was opened
and adjourned. The hearing was not completed before Mr Digweed died and he did
not receive a replacement laptop meaning he had less control over ordering items
from the prison shop, adding credit to his prison telephone account, choosing meals
and making applications as prisoners without laptops must use kiosks on the wing.
(He complained about this in March 2024 and was told that he could not have a
replacement until his adjudication had been heard.)
5. On 10 March 2024, Mr Digweed asked to be assessed for attention deficit
hyperactivity disorder (ADHD). A nurse replied that this would not be possible as he
had no indications it was necessary.
6. Mr Digweed’s prison telephone calls from 9 April – 12 April indicated that his
relationship with his partner was under strain. After his death, police confirmed this
and that he might have been worried about money. Staff and prisoners that knew
him well said that he appeared in a good mood and his normal self on 12 April.
7. Mr Digweed was last seen alive during a routine count of prisoners at 7.39pm on 12
April. At 5.17am on 13 April, his observation panel was covered during the early
morning routine roll check. It was still covered at a welfare check at 9.07am. The
staff responsible for checking him took no action. At about 11.30am, an officer
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unlocked Mr Digweed but did not look into his cell. Shortly afterwards, Mr Digweed
was found by a prisoner hanged by a sheet from a light fitting. Officers cut the
ligature and started cardio-pulmonary resuscitation (CPR). Nurses attended and
asked staff to stop CPR when they discovered unequivocal evidence that Mr
Digweed had died. Paramedics attended and confirmed death soon afterwards.
Findings
8. Mr Digweed had no significant history of attempted suicide or self-harm and
relatively few factors that indicated he might be at risk. Overall, there was no
indication that he was at heightened or imminent risk of harming himself in the
period leading to his death.
9. There is no evidence that ACCT monitoring was considered as it should have been
after Mr Digweed behaved uncharacteristically over a period of three or four days in
September 2023, despite him making made superficial cuts to his chest and injuring
his ankle and foot repeatedly kicking his cell door. This was a missed opportunity to
identify risk.
10. The roll check, welfare check and unlocking of Mr Digweed’s cell were not
completed in line with national or local guidance. We are satisfied that the prison
has dealt with the individuals making the checks but we are concerned there is a
more widespread problem with how staff respond to finding covered observation
panels at Garth and that this means checks are not being done properly and
records are not accurate.
11. Mr Digweed was without a prison laptop for over six months before he died. This
impacted on his ability to control aspects of his daily prison life and might have
negatively impacted his mental health and ability to maintain family ties. A backlog
of prison adjudications meant that he was unable to complete the first step in the
process for obtaining a replacement.
12. Garth’s rural location, large perimeter, proximity to several major roads and high
number of prisoners associated with organised crime means that it is especially
vulnerable to drugs being brought in by drone. We are satisfied that the prison is
considering new measures to combat this threat.
13. The clinical reviewer concluded that the healthcare Mr Digweed received for his
physical health was responsive and equivalent to that he would have received in the
community. She concluded his mental healthcare was moderate and only partially
equivalent on the basis that he was not reviewed after harming himself in
September 2023 and the nurse responding to his request for an ADHD assessment
showed insufficient clinical curiosity.
Recommendations
• The Governor should introduce a robust quality assurance process until he is
satisfied there is not a systemic issue with false entries.
• The Governor should evidence how the prison will monitor the challenging of
blocked observation panels to ensure compliance with local processes.
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• The Governor should introduce a robust quality assurance process to satisfy
himself that that all staff look through the observation panel before unlocking cells.
• The Governor should set out how he intends to reduce the number of unheard
adjudications.
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The Investigation Process
14. HMPPS notified us of Mr Johnpaul Digweed’s death on 13 April 2024.
15. The investigator issued notices to staff and prisoners at HMP Garth informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
16. The investigator visited HMP Garth on 22 April 2024. She watched CCTV during the
opening visit. She obtained copies of relevant extracts from Mr Digweed’s prison
and medical records. She also obtained body worn video camera (BWVC) footage
and radio communications from 13 April 2024 and Mr Digweed’s prison account
telephone calls. As of October 2024, the prison were unable to provide Mr
Digweed’s cell bell records due to technical difficulties.
17. The investigator interviewed six members of staff and three prisoners at Garth
between April and July 2024. She obtained further information from the Head of
Drug Strategy, the Deputy Governor, the Head of Healthcare and Lancashire police.
18. NHS England commissioned a clinical reviewer to review Mr Digweed’s clinical care
at the prison. The clinical reviewer and investigator interviewed the healthcare staff
together.
19. We informed HM Coroner for Lancashire and Blackburn with Darwen of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
20. The Ombudsman’s office contacted Mr Digweed’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Digweed’s mother raised some issues with us at initial report stage via her solicitor
that we have dealt with in separate correspondence.
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Background Information
HMP Garth
21. HMP Garth is a category B training prison and holds long-term and life-sentenced
prisoners. It is part of the Long-Term High Security Estate (LTHSE). Greater
Manchester Mental Health NHS Foundation Trust provides physical health, mental
health, social care and clinical substance misuse treatment. Delphi Medical is
subcontracted to provide psychosocial substance misuse services. Prisoners live in
single cells.
HM Inspectorate of Prisons
22. The most recent inspection of HMP Garth was in November 2022. Inspectors
reported that a key concern was the availability of drugs. The mandatory drug
testing rate was high and searching procedures were insufficient. Links with the
police were good and the police had led some effective work to reduce drugs and
illicit items getting into the prison via drone. There was interagency work to manage
gangs and work to tackle staff corruption was very good.
23. The leadership team was committed to improving the standard of keywork and 92%
of prisoners surveyed had a named keyworker, although sessions rarely happened
at the required frequency and some entries were superficial. Time out of cell was
inadequate and there were frequent wing lockdowns due to staff shortages.
Independent Monitoring Board
24. 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 November 2023, the IMB
reported that the prison had made significant changes to its security measures
which had improved the finding of illicit items, however the prison still had significant
issues with drugs. Drone activity was a particular problem. Staff patrols inside and
outside the gate had proved effective and windows damaged in order to receive
parcels were quickly replaced.
25. The IMB raised a number of other concerns, including staff recruitment and
retention. Staff shortages meant constant regimes changes which was unsettling for
prisoners. The keyworker system was not working effectively.
Previous deaths at HMP Garth
26. There were 11 deaths in the three years before Mr Digweed died. Three of these
were self-inflicted, two were drug related and six were from natural causes. Our
investigation into a self-inflicted death in August 2023, found that a routine check of
prisoners had not taken place and the record falsified. An officer also did not
respond appropriately to finding the prisoner’s observation panel was blocked.
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As of end September 2024, there had been three further deaths at the prison: one
self-inflicted, one from natural causes and one suspected to be drug related. Our
investigations into these deaths were ongoing at the time of writing.
Incentives and Earned Privileges (IEP) scheme
27. Each prison has an Incentives and Earned Privileges scheme which aims to
encourage and reward responsible behaviour, encourage sentenced prisoners to
engage in activities designed to reduce the risk of re-offending and to help create a
disciplined and safer environment for prisoners and staff. Under the scheme,
prisoners can earn additional privileges such as extra visits, more time out of cell,
the ability to earn more money in prison jobs and to wear their own clothes. There
are three levels, basic, standard and enhanced.
Laptops
28. Since July 2022, all prisoners at Garth have been given the opportunity to have a
laptop in their cells and sign a compact agreeing to abide by the rules outlined in
the Laptop Control Framework. The laptops are used to order items from the prison
shop, add credit to their prison telephone account, choose meals and make
applications (prisoners without laptops must use kiosks on the wing). There is
limited access to YouTube on the laptops where prisoners can watch films
uploaded by the prison.
Assessment, Care in Custody and Teamwork (ACCT)
29. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
30. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
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Key Events
31. On 11 March 2021, Mr Johnpaul Digweed was remanded to HMP Liverpool
charged with supplying class A drugs. It was his first time in prison. During a
Probation Service assessment Mr Digweed admitted historic use of cocaine and
ecstasy in the community. He had no significant history of mental or physical health
issues.
32. Mr Digweed told a nurse at an initial health assessment that he had no current or
previous issues with drugs, suicide or self-harm or his mental health. The nurse
noted he seemed settled and stable and was not on any medication.
33. On 12 March, the prison received intelligence that Mr Digweed was involved in the
prison’s drug culture. The same day he told a nurse at a secondary health
assessment that he had been diagnosed with schizophrenia as a teenager, had
stopped taking medication for this at 18 and had not had contact with mental health
services since. He also said he had taken an overdose “years ago” after which he
saw a psychiatrist once but received no follow up care. Mr Digweed answered some
short verbal questions designed to assess whether he had anxiety or depression
and scored zero for both.
34. In July, staff suspected Mr Digweed was using cannabis. In September, intelligence
indicated that he was still running his drug trafficking operation in the community
using an illegal mobile phone and in October intelligence indicated he was involved
in organising deliveries of drugs to the prison by drone.
35. On 2 November, Mr Digweed moved to HMP Forest Bank. On 12 November, an
intelligence led search of his cell found a mobile phone and charger (each time staff
found a mobile phone or illicit items, they were confiscated).
36. On 22 November, Mr Digweed moved to HMP Leeds after he attended court and
Forest Bank was full and unable to accept him back. On 29 November, Mr Digweed
self-referred to the mental health team. He said he had seen another prisoner trying
to cut his throat and it was affecting his sleep, mood, appetite and ability to cope. Mr
Digweed had to isolate in his cell for a few days as his cellmate had COVID-19 and
he did not receive a mental health assessment before he returned to HMP Liverpool
after a court appearance on 6 December.
37. At Liverpool he told a nurse at an initial health assessment that he felt traumatised
after seeing a prisoner cut his neck in the wing showers at Leeds. He declined
mental health intervention and said he was aware how to self-refer. He denied any
thoughts of suicide or self-harm.
38. On 8 December, Mr Digweed told his partner in a prison telephone call that he was
worried about the length of sentence he might receive and said he would hang
himself if he was sentenced to 30 years. Staff listened to a recording of this call and
submitted an intelligence report. They did not note any details in Mr Digweed’s
general prison record or take any further action.
39. On 3 February, 9 March and 22 April 2022, officers found mobile phones during
searches of Mr Digweed’s cell. He was charged with breaking prison rules and
found guilty at a prison disciplinary hearing (known as an adjudication).
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40. On 24 June, Mr Digweed was sentenced to 25 years for several counts of supplying
class A and class B drugs. He told a nurse on 27 June that he felt he was coping
well despite the length of his sentence and was spending as much time as possible
in the gym.
HMP Garth
2022
41. Mr Digweed moved to HMP Garth on 8 July 2022. He told a nurse that he had no
current or previous issues with drugs, suicide or self-harm or his mental health. The
nurse noted he seemed in good spirits and had no long-term physical health
conditions.
42. On 12 July, officers found a mobile phone, SIM card and charger during their
search of Mr Digweed’s prison property received from HMP Liverpool. The same
day, Mr Digweed told a member of the prison’s drug and alcohol team that he did
not want to work with them. On 16 July, Mr Digweed moved from the induction unit
to C Wing. On 23 August, Mr Digweed gained enhanced level on the Incentives and
Earned Privileges (IEP) Scheme, meaning he had access to additional privileges
such as visits, access to the prison shop, and more opportunity to earn money.
43. On 14 September, Mr Digweed was sent a DVD player that was found to have Wi-
Fi capability and he was not allowed to keep it in possession. The next day he
tested negative in a random drug test. On 16 September, officers noted his cell
smelled of cannabis and was full of smoke. A member of the substance misuse
team visited him a couple of days later in response, but Mr Digweed again declined
to work with them and refused harm minimisation advice.
44. On 28 September, Mr Digweed had a keywork session with an officer. The officer
said he was a regular C Wing officer on Mr Digweed’s landing right up until he died.
He was Mr Digweed’s dedicated keyworker but also saw Mr Digweed every day he
was on duty. He said Mr Digweed was always very polite to him and seemed to get
on well with everyone. He knew Mr Digweed had family and was in regular contact
with them but Mr Digweed never talked to him about any personal issues he had.
45. On 1 November, the security department received intelligence that Mr Digweed and
a number of other prisoners might have access to a mobile phone.
2023
46. On 6 February 2023, a prison offender manager (POM), completed a Probation
Service risk assessment. She reported that Mr Digweed said he was coping well in
prison. He said he had good and bad days was not feeling depressed or like
harming himself. His relationship was “up and down” but he kept in contact with his
family on a daily basis. Mr Digweed said he thought he might have attention deficit
hyper-activity disorder (ADHD – people with this condition may be restless, have
trouble concentrating and act on impulse) but had not been diagnosed. The POM
noted there was no evidence that Mr Digweed was at risk of suicide and self-harm.
She said he appeared settled and planned her next significant contact with him for
June 2023 when he was due for a review of his security category.
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47. On 13 February, Mr Digweed tested negative after a mandatory drugs test (MDT).
On 5 April, he was given a job in the kitchens.
48. On 3 June, Mr Digweed told an officer during a keywork session that he was very
happy with his job and also enjoyed going to the gym. On 14 June, Mr Digweed
again tested negative after an MDT. Mr Digweed told his dedicated keyworker at
successive keyworker sessions on 17 June and 17 July that he was happy and had
no issues.
49. On 20 July, staff found a mobile phone in Mr Digweed’s cell during an intelligence-
led search. He was demoted to basic level of the IEP Scheme for 28 days and
sacked from his job in the kitchens.
50. On 24 August, the security department received intelligence that Mr Digweed was
overheard discussing receipt of a parcel of contraband.
51. Mr Digweed’s security record indicated that he had several episodes of disruptive
behaviour between 21 and 24 September and that wing staff had commented that
this was out of character for him. At about 3.00am on 24 September, the night
orderly officer called a nurse to Mr Digweed’s cell after he was observed under the
influence of an illicit substance suspected to be a psychoactive substance (PS) and
had made cuts to his chest. The nurse recorded that the cuts appeared to be
superficial and the cell was not safe to enter due to the PS smoke. Mr Digweed was
placed on hourly observations for the rest of the night. There is no evidence that
staff considered starting Prison Service suicide and self-harm monitoring (known as
ACCT) in line with national guidance.
52. At 5.47am, the C Wing night patrol officer recorded that Mr Digweed had pressed
his cell bell, shouted, kicked his door and smashed the glass in his observation
panel during the night. At 7.00am, an officer reported seeing Mr Digweed throwing
the contents of his cell out of his broken window. At 9.23am, another officer noted
that Mr Digweed had been disruptive all night, was clearly under the influence of an
unknown substance and had been taken to the segregation unit.
53. A nurse examined Mr Digweed’s foot and ankle after he injured it kicking his door in
the night. He said wing staff thought Mr Digweed was under the influence of
cocaine. The nurse told the orderly officer (the officer in charge of running the
prison regime) that Mr Digweed needed to go to hospital to have his foot examined.
The orderly officer said he did not have enough staff on duty to enable a hospital
escort that day but would arrange it for the next day.
54. The same day, Mr Digweed’s prison emails indicated he had received videos via a
mobile phone and had argued with his partner because of the content of these.
Officers searched his cell and found the mobile phone and a charger. Mr Digweed
attended hospital the next day, 25 September, to have his foot examined.
55. On 26 September, a member of the prison’s drug and alcohol team spoke to Mr
Digweed following the incident on 24 September. Mr Digweed said the incident was
a “one off” and he did not want any intervention or support. Mr Digweed was not
seen by the mental health team following his self-harm and there is no evidence
that anyone considered whether Prison Service suicide and self-harm monitoring
(known as ACCT) was appropriate for Mr Digweed.
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56. On 27 September, staff removed Mr Digweed’s prison laptop after it was noticed
that he had damaged the screen. He was charged with damaging prison property
and a prison disciplinary hearing was opened and adjourned. The investigator was
informed that there was a significant backlog of adjudications at the time and this
hearing was not completed before Mr Digweed died. In the meantime, he had no
access to a laptop and had to use the wing kiosk.
57. On 2 October, results of tests on Mr Digweed’s urine sample provided for a
mandatory drug test on 19 September were positive for cocaine.
58. On 31 October, Mr Digweed tested negative in a random drug test.
59. On 1 November, CCTV showed that four prisoners entered Mr Digweed’s cell. Staff
subsequently discovered Mr Digweed with injuries consistent with him being
slashed with a blade. Mr Digweed insisted to staff that he had fallen and would not
consent to photographs of his injuries or any other action being taken. The prison
informed the police but the investigation was not proceeded with because Mr
Digweed refused to cooperate.
60. Mr Digweed’s security file indicated that the incident was thought to be drug debt
and gang related. A nurse assessed Mr Digweed’s injuries. He said Mr Digweed
had several slash wounds to the top of his left arm, left elbow and the left side of his
chest which he closed with staples or steri-strips and dressed.
61. On 8 November, an officer considered whether Mr Digweed required support under
Prison Service violence reduction and anti-bullying measures (using a challenge,
support and intervention plan - CSIP). The officer noted that the prisoners
suspected of assaulting Mr Digweed were associates of a prisoner thought to be in
debt to Mr Digweed. He said Mr Digweed continued to insist that he sustained his
injuries falling over in his cell. Mr Digweed had been out on the wing during social
time and had not had any further issues. The officer concluded that Mr Digweed did
not need ongoing support via CSIP procedures but that staff should continue to
monitor him via keywork sessions.
62. On 6 and 18 November, the security department received intelligence that Mr
Digweed had a mobile phone. On 20 November, he started a job in one of the
prison workshops. On 21 November, Mr Digweed told an officer during a keywork
session that he was happy and settled and had no issues.
63. On 26 November, staff searched Mr Digweed’s cell and found a mobile phone and
charger after the security department received intelligence that Mr Digweed had
received a mobile phone via a drone a couple of nights before. On 30 November,
intelligence indicated Mr Digweed once again had a mobile phone.
64. On 27 December, Mr Digweed was sacked from his job for refusing to attend.
2024
65. On 6 January 2024, the security department received intelligence that Mr Digweed
was involved in organising drone deliveries to the prison of contraband including
mobile phones. On 24 January, another mobile phone and charger was found in his
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cell and on 30 January further intelligence indicated that Mr Digweed received
mobile phones via drones and had threatened other prisoners.
66. On 22 February, an intelligence report showed that certain prisoners on C Wing,
including Mr Digweed, were making about £400,000 - £500,000 every couple of
months from the proceeds of contraband sent into the prison by drone. The security
department assessment acknowledged that there was significant drone activity in
and around the prison at that time and windows had been compromised in order to
receive packages brought by drone.
67. Mr Digweed’s dedicated keyworker spoke to Mr Digweed during a keywork session
on 28 February. He noted that Mr Digweed’s regular possession of unauthorised
articles was preventing him from getting a job in the prison. Mr Digweed told him he
had no issues or concerns, was happy on the wing and enjoyed using the gym.
68. On 10 March, Mr Digweed self-referred to the mental health team and asked for a
test to see if he had attention deficit hyperactivity disorder (ADHD). A nurse replied
that this would not be possible as he had no previous history of ADHD and there
was no current need. The nurse was on maternity leave during the investigation,
and we did not interview her.
69. On 18 March, officers found another mobile phone in Mr Digweed’s cell during a
search of the wing.
70. On 25 March, Mr Digweed submitted a complaint form asking for a replacement
laptop. He said he had made several requests to wing staff for one and that not
having one was affecting his mental health and impacting on his ability to keep in
contact with his family and friends.
71. On 1 April, the Digital and Communications Manager replied to Mr Digweed’s
complaint about not having a prison laptop. She said that the process outlined in the
laptop compact was that prisoners that damage their laptops are subject to the
prison disciplinary process and are not considered for replacement laptops until the
outcome of the hearing. She said she was unable to issue Mr Digweed with a new
laptop because he had not had his adjudication. She reminded Mr Digweed where
he could access support for his mental health and noted that he could access the
kiosk on the wing to top up his prison telephone account.
72. The Digital and Communications manager told the investigator that there was a
backlog of adjudications at Garth. As a result the digital team would have reviewed
Mr Digweed’s case at the beginning of May because they reviewed all cases where
the adjudication had not taken place within eight months of the laptop being
removed. These reviews took account of the prisoner’s behaviour including whether
they had been found with weapons, unauthorised items or under the influence of
illicit substances. They also liaised with the mental health team and spoke to wing
staff.
73. Mr Digweed’s dedicated keyworker said Mr Digweed’s lack of laptop meant that he
was increasingly using his cell bell to ask officers to let him out to use the wing
kiosk. He said he thought that Mr Digweed might have been using this as an excuse
to be let out of his cell more often. On one occasion two or three weeks before he
died, he refused to unlock Mr Digweed to let him use the kiosk. He said that the
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next time he saw Mr Digweed out of his cell, Mr Digweed had been “a bit volatile”
towards him and not his usual polite self. Mr Digweed had later apologised to him.
74. The investigator listened to recordings of Mr Digweed’s prison telephone calls from
9 April – 11 April. He spoke several times to his partner and to a female relative. In
his calls with his partner, it appears that their relationship is under strain. In
contrast, during his calls to a female relative, Mr Digweed sounded in a good mood
and laughed and joked throughout. At 10.05pm on 11 April, Mr Digweed told her he
had “a few years left in me”. The call ended with both agreeing to speak the
following day.
75. Mr Digweed spoke to his partner at 10.45pm on 11 April. He tried to speak to his
son, but he was too tired. His partner asked whether he wanted her to visit him the
following Sunday and Tuesday because it was expensive to get to the prison. Mr
Digweed told her not to come at all. He said visits were a waste of time, there was
nothing to do in the visits hall and they spoke every day on the phone. Mr Digweed
complained about another prisoner. He said he was not feeling well, wanted to
spend as much of the next day in bed as possible and wanted some ear plugs as
people on the wing were noisy.
76. At 9.15am on 12 April, Mr Digweed phoned his partner briefly. He said he had a
cold and as she was about to go to work they agreed to speak later. This was his
last prison telephone call.
77. The investigator was provided with the investigation report completed for the
Coroner by Lancashire police. Mr Digweed’s partner told them that Mr Digweed
phoned her from a mobile phone at about 1.30pm. She said Mr Digweed was drunk
and told her that he had had “a couple” and “felt better after a drink”. She said she
told him he should not call her in that state and to leave her alone and call her back
when he had sobered up. This was the last time they spoke. She said Mr Digweed
called her again but she did not answer. Mr Digweed’s partner said this was a minor
argument compared with some of their previous ones. She said Mr Digweed had
given her no indication that he was feeling low or suicidal. She thought he might
have been stressed about money issues but could not be certain. She knew him to
drink alcohol when stressed.
78. Mr Digweed’s dedicated keyworker said he saw Mr Digweed before he was locked
in his cell that evening. Mr Digweed was cooking chips and gave him one to try. He
said Mr Digweed was in his usual good spirits and laughing and joking.
79. CCTV showed that Mr Digweed went into his cell for the night at 5.06pm. At
5.07pm, an officer locked his door. Staff checked Mr Digweed, in line with routine
checks of all prisoners, at 5.17pm and 7.39pm and noted no concerns. From the
CCTV footage, these checks appear to have been done correctly and Mr Digweed’s
observation panel was not obstructed.
80. A prisoner said he had met Mr Digweed in HMP Liverpool in 2021. He thought Mr
Digweed’s mental health was deteriorating in the period leading to his death and he
was using more cocaine. He thought Mr Digweed was good at “putting a mask on”
and hiding his feelings. On 12 April, the prisoner said that Mr Digweed had
appeared to be in a good mood and his normal self.
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81. Another prisoner had known Mr Digweed for almost two years. He said that Mr
Digweed was always smiling and laughing and playing jokes on other prisoners. He
seemed to get on well with everyone. He said Mr Digweed had been frustrated at
being without a prison laptop and this had impacted on his ability to contact his
family. He had spent a lot of time on basic regime due to being found in possession
of mobile phones and this meant he did not have a TV to distract him during long
hours locked in his cell. The prisoner said he did not notice any change in Mr
Digweed’s mood or behaviour and he had seemed his normal self. On 12 April, he
said that Mr Digweed had seemed in a good mood before being locked in his cell
and had cooked some food for himself and some others.
82. Another prisoner lived in the cell next door to Mr Digweed and said he was very
good friends with him. He said Mr Digweed enjoyed taking cocaine in prison and
could get hold of it relatively easily, although it was harder to get drugs in Garth
than in other prisons he had been in. He did not think Mr Digweed was in debt or
under pressure because he was in “the right circle”. Mr Digweed got on with
everyone and he thought if he had any issues they came from outside the prison.
He said he had seemed his usual self in the period before he died.
Events of 13 April 2024
83. The investigator watched CCTV, body worn video camera footage (BWVC), listened
to radio traffic and obtained information from North West Ambulance Service. She
was also provided with the prison’s internal investigation into whether staff
discharged all their duties in respect of the 13 April roll checks and welfare checks
on Mr Digweed. The following account has been taken from all these sources. The
timings have been taken from CCTV.
84. At 5.17am, an operational support grade (OSG) completed a routine count of
prisoners on C Wing (known as the morning roll check). The OSG told the senior
prison manager conducting the internal investigation that Mr Digweed’s observation
panel was covered. She knocked on the door and used her torch to try to see into
the cell. On her third knock she said she heard Mr Digweed respond “Yo! Yeah, yo!”
and so moved on to the next cell. At the time of interviews, the OSG was subject to
the prison’s internal investigation and was not interviewed.
85. At 9.06am, an officer checked Mr Digweed as part of a welfare check on every
prisoner. He opened the observation panel but did not look into the cell. He told the
senior prison manager that he saw the observation panel was covered, knocked on
the door and thought he had got a verbal response from Mr Digweed but could not
be certain. He signed the welfare daily check sheet to confirm that all welfare
checks had been completed correctly. The officer resigned from the Prison Service
before interviews took place and we did not interview him.
86. At 11.28am, an officer unlocked Mr Digweed’s cell door for lunch. He did not look
through the observation panel or the cell door before or after doing so. At 11.31am,
A prisoner went into Mr Digweed’s cell and discovered him hanged by a sheet from
the cell light fitting. He left the cell immediately and raised the alarm. The officer
who unlocked Mr Digweed’s cell door entered the cell first. He turned on his BWVC
and radioed in quick succession for emergency assistance and a code blue (an
emergency code used when a prisoner is having difficulty or has stopped breathing)
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before cutting the ligature and placing Mr Digweed on the floor. A supervising officer
(SO) arrived and the officer asked her to start cardio-pulmonary resuscitation
(CPR). The SO did so, despite being in obvious distress. At the time of our
investigation, the officer was on long term sickness absence following serious
injuries received in an assault and was not interviewed.
87. North West Ambulance Service records showed that, following the code blue, the
control room officer immediately rang 999 and informed the emergency call handler
that Mr Digweed was not breathing and an ambulance was dispatched with the
highest priority.
88. At 11.35am, a nurse and other healthcare staff arrived and asked for Mr Digweed to
be moved on to the landing to allow more room to work on him. The nurse said she
arrived to
89. a chaotic scene because prisoners were out of their cells and clearly very upset.
She completed some initial checks and found she was unable to insert an airway
into Mr Digweed’s mouth because his jaw was too stiff. She then noticed other
signs unequivocally associated with death, including blood pooling, and instructed
the staff to stop CPR.
90. Paramedics arrived at the prison at 11.42am and at 11.51am, confirmed that Mr
Digweed had died. Their report noted rigor mortis and blood pooling were obvious
indications that Mr Digweed had been dead for some time.
Information received after Mr Digweed’s death
91. The same day the prison received intelligence from prisoners that Mr Digweed was
“wanted” by organised crime gangs outside the prison and was worried about debts.
92. The prison discovered a mobile phone during a search of Mr Digweed’s cell after he
died, which they passed to Lancashire police. The Lancashire police report showed
that Mr Digweed and his partner had exchanged a number of text messages
between 10-12 April. These indicated they were arguing about their relationship,
money and visits. In several of the messages Mr Digweed referred to being “sick of”
things and said that he could not be bothered any more.
Contact with Mr Digweed’s family
93. The prison appointed an officer as family liaison officer. The officer and another
trained family liaison officer travelled to Mr Digweed’s mother’s home and broke the
news of his death in person. The officer maintained contact with Mr Digweed’s
mother and returned his property to her. This included tracking down some of Mr
Digweed’s property (as requested by his mother) to HMP Leeds. The prison made a
financial contribution to Mr Digweed’s funeral in line with national guidance.
Support for prisoners and staff
94. 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.
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95. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
96. The prison posted notices informing other prisoners of Mr Digweed’s death, and
offering support. The prison delivered postvention support from Listeners supported
by safer custody staff. Staff reviewed all prisoners assessed as being at risk of
suicide or self-harm in case they had been adversely affected by Mr Digweed’s
death. The prisoners we interviewed said they felt supported after Mr Digweed died.
Post-mortem report
97. The pathologist gave the cause of death as hanging. The Coroner did not request
toxicology tests.
Inquest
98. The Coroner’s inquest concluded on 24 June 2026 and determined that Mr
Digweed had died from suicide by hanging. The jury found that there were missed
opportunities to assess Mr Digweed’s mental health and provide appropriate
support. Routine checks were not carried out as they should have been and these
gaps in care possibly contributed to Mr Digweed’s death. Following the inquest, the
Coroner issued the Governor of Garth with a Report to Prevent Future Deaths
under Coroner’s Regulation 28.
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Findings
Assessment of risk of suicide and self-harm
99. Mr Digweed had few risk factors that indicated he might be at risk of suicide or self-
harm. Apart from a self-reported overdose “years ago”, he had no history of
attempting suicide and, aside from making superficial cuts while apparently under
the influence of illicit substances in September 2023, no history of self-harm. He
had no significant history of mental illness aside from an episode in his teens after
which he saw a psychiatrist a single time.
100. The clinical reviewer concluded that Mr Digweed’s self-harm in September 2023
was unusual and should have been regarded as a new risk. It does not appear that
he was seen by the mental health team in response to this or that anyone
considered whether he required support under ACCT procedures in line with
national guidance. Due to the amount of time between this and Mr Digweed’s death,
we have not made a recommendation but the Governor will wish to assure himself
that ACCTs are opened after a prisoner self-harms.
101. In addition, when Mr Digweed’s prison emails were interrogated around this time
and found to indicate that he had a mobile phone, his cell was searched but no one
appears to have considered that his emails also indicated that his relationship was
in crisis. Relationship breakdown is a known risk associated with suicide and self-
harm in prison. This was a missed opportunity to explore whether Mr Digweed’s
behaviour was explained by this and whether he needed extra support or was at
further risk of harming himself.
102. There is significant evidence that Mr Digweed was involved in prison drug culture
and he was found several times in possession of a mobile phone. The investigator
was informed by a prisoner during the investigation that a mobile phone cost about
£10,000 in the prison at the time Mr Digweed died. There is a strong possibility that
his involvement in drug culture might have led to him being in debt. Although Mr
Digweed had apparently been the victim of an assault in November 2023,
subsequently there was no evidence that Mr Digweed was being bullied or was
vulnerable in prison. He was at the outset of a very long sentence and on 8
December 2021, he confided to his partner that he was worried about the length of
sentence he would receive and would hang himself if he received 30 years. This
was contained in his security record and was the only identified reference to suicide
in his prison record.
103. Mr Digweed consistently refused the opportunity to engage with the drug and
alcohol support team at Garth and maintained to his dedicated keyworker, who
knew him well, that he was happy on the wing and had no issues. Although one of
his friends believed that his mental health was deteriorating in the period leading to
his death all agreed that he appeared in a good mood the day before he died and
that he was his normal self. None thought he was vulnerable in prison and all were
very shocked by his death.
104. We have seen no evidence that staff should have assessed Mr Digweed as at
heightened or imminent risk of suicide in the period leading to his death or at any
other time in prison. We do not consider that staff could have predicted or
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prevented his death. Information gathered after his death by the police indicates
that his relationship was under strain and he might have been worried about money.
Roll checks, welfare checks and blocked observation panels
105. In January 2024, the Governor at Garth issued an order reminding staff of the
mandatory actions they should take when discovering that a prisoner had covered
their observation panel. The order reiterates the guidance set out in Prison Service
Instruction (PSI) 74/2011, Residential Services, that if staff find observation panels
obstructed, they must try to get a verbal response from the prisoner and try and see
through the sides or top of the door if possible. If the prisoner does not respond to
requests to remove the obstruction, staff must radio for assistance to enter the cell,
or if they feel there is a risk to life, to make a dynamic risk assessment whether to
enter the cell alone. Staff must not leave the cell door unless it is to raise the alarm.
Staff must challenge the prisoner after the event and manage them through the IEP
scheme and/or the adjudication policy.
106. At the same time, the Governor issued an order on welfare checks. This instructed
staff that best practice during a welfare check was to ensure they had full sight of
the prisoner and gained a verbal response from them.
107. Mr Digweed’s observation panel was covered when the OSG checked all prisoners
at 5.17am on 13 April 2024. She told the prison’s internal investigation that Mr
Digweed verbally responded to her. His observation panel remained covered at
9.06am when an officer checked Mr Digweed. He said he thought he got a verbal
response from Mr Digweed but he could not be sure.
108. The prison conducted an internal investigation into the roll check, welfare check and
unlock of Mr Digweed on 13 April. The investigation found that the OSG and officer
should face disciplinary hearings. The officer resigned during the internal
investigation and the OSG received a formal written warning to remain on her file
for 12 months. We are satisfied that the Governor has dealt with this matter and
make no further recommendation about individual staff.
109. In our investigation into a self-inflicted death at Garth in August 2023 we found that
a roll check had not been completed and the record falsified and that an officer did
not respond appropriately to finding the prisoner’s observation panel was blocked. It
is evident from the prison’s investigation that there remains a more widespread
problem with covered observation panels and this has impacted on the
effectiveness of roll checks and welfare checks and the accuracy of records. The
staff interviewed were aware of the local instructions but admitted that they did not
follow them that morning. We note that the roll was certified correct and the welfare
check log signed for despite no one seeing Mr Digweed alive and well in his cell
that morning. We informed police about this matter which they decided not to
investigate.
110. As a result of Mr Digweed’s death the prison reviewed their local security
instructions and the Governor introduced an extra roll check to be completed by day
staff at 7.45am. We welcome the action taken so far but we are concerned that they
do not fully address the underlying issues of staff failing to complete roll checks and
welfare checks in accordance with guidance yet signing to say that they have. We
make the following recommendations:
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The Governor should introduce a robust quality assurance process until he is
satisfied there is not a systemic issue with false entries.
The Governor should evidence how the prison will monitor the challenging of
blocked observation panels to ensure compliance with local processes.
Welfare checks at unlock
111. The Prison Officer Entry Level Training (POELT) manual instructs staff to physically
check that prisoners are present in their cells before they unlock the door. PSI
75/2011 requires all prisons to have a clearly understood system in place for staff to
assure themselves of the well-being of prisoners during or shortly after unlock. The
PSI deems it unacceptable for staff completing morning unlock not to notice that a
prisoner has died overnight.
112. CCTV showed that the officer did not look through the observation panel of Mr
Digweed’s cell before unlocking his door for the first time on 13 April. The officer
was investigated as part of the prison’s internal investigation into checking and
unlocking practice that morning. The investigation concluded that there was no
policy stating that a prisoner must be observed through the observation panel prior
to unlocking a cell door (although it was acknowledged that it was good practice to
check the well-being of prisoners at this time) and recommended that the officer
receive advice and guidance.
113. It is fundamental to prisoner safety that staff always satisfy themselves that each
prisoner is alive and well before they unlock their cell door. Equally, it is
fundamental to staff safety and the security of the prison that staff satisfy
themselves that the prisoner is not intending to harm them once the door is
unlocked. We make the following recommendation:
The Governor should introduce a robust quality assurance process to satisfy
himself that that all staff look through the observation panel before unlocking
cells.
Confiscation of laptops
114. The HMPPS Laptop Control Framework sets out the process for what should
happen when a prisoner is suspected of damaging their laptop. The first step is that
the prisoner should be charged with breaking prison rules within 48 hours of the
damage being discovered. All other steps follow from the outcome of the ensuing
adjudication. There is a tariff of fines according to the nature of the damage to the
machine. Depending on the circumstances prisoners are then given an opportunity
to pay a percentage of the fine and receive a new laptop.
115. We understand the need for such a process given the high cost of replacing such
items and a need to discourage their abuse. With increased time in cell caused by
staff shortages at Garth, the laptops are even more important to providing prisoners
with some control over their daily lives and helping them maintain contact with
friends and family. Maintaining family ties is known to reduce risk of suicide and
self-harm. Mr Digweed was clearly able to maintain some contact with his family via
illegal mobile phone but his ability to easily make orders, applications and arrange
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prisoner telephone credit without having to wait until he was unlocked would have
been very much reduced.
116. The backlog of adjudications at Garth meant that Mr Digweed was unable take the
first step in the process of regaining a laptop through no fault of his own. This must
have been deeply frustrating, and we know he complained that it affected his
mental well-being. His friends also thought his lack of laptop impacted him
negatively.
117. We are concerned that Mr Digweed was not the only prisoner to find himself in this
position. In July 2024, there were 26 prisoners at Garth whose laptops had been
removed due to damage. We understand that the digital team would have
automatically reviewed Mr Digweed’s case at the beginning of May if his
adjudication had not been heard but we consider eight months an unacceptably
long time for someone to wait without having the opportunity to make their case or
pay a fine and receive a new machine.
118. We understand that the reason for the backlog in adjudications includes those
referred to the police for further investigation and the high number of ongoing
charges that must be opened within a certain period of the charge being laid. The
Governor has recently asked a senior manager to hear extra adjudications to try to
reduce the backlog and we consider that hearings that materially affect individual
prisoners’ daily lives, such as those relating to laptop damage, should be heard as a
priority. We make the following recommendation:
The Governor should set out how he intends to reduce the number of
unheard adjudications.
Supply of drugs and other illicit items
119. There is a significant amount of evidence that Mr Digweed was involved in
organising deliveries of contraband items via drone and this is the most likely
source of the number of mobile phones that were found in his possession at Garth.
Garth’s rural location, large perimeter, proximity to several major roads and high
number of prisoners associated with organised crime means that it is especially
vulnerable to drugs being brought in by drone. We are aware that the prison has
been working with another prison facing similar issues and that two significant
initiatives are at an early stage. The prison has asked that we do not set these out
in detail to limit outside knowledge of their proposed countermeasures.
120. We note that the prison has made significant progress in the last two years in terms
of enhancing gate security, banning paper from entering the prison and increasing
searching and drug testing. In January 2023, the prison received a diagnostic
support visit from HMPPS substance misuse team who produced a detailed action
plan. A further support visit is planned for the coming months. In October 2024, a
new dedicated drug strategy manager was appointed with a remit for reviewing all
the processes and overall strategies for dealing with supply, demand and
supporting/challenging prisoners.
121. We are satisfied that the prison remains alive to the threat from drugs to the safety
and security of the establishment and the prisoners within it and that they are
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continuing to innovate in terms of measures to reduce this threat. We make no
recommendation.
Clinical care
122. The clinical reviewer concluded that the healthcare Mr Digweed received for his
physical health and substance misuse was responsive and equivalent to that he
would have received in the community. She concluded his mental healthcare was
moderate and only partially equivalent. This was on the basis that Mr Digweed was
not reviewed after harming himself in September 2023. In addition, the nurse
responding to Mr Digweed’s request for an ADHD assessment showed insufficient
clinical curiosity and should have explored why he considered that he needed one.
123. The clinical reviewer also concluded that Mr Digweed’s actions on 13 April were not
foreseeable.
Good practice
124. As well as investigating fatal incidents, the PPO investigates prisoner complaints,
the majority of which relate to lost property. We understand what a challenge
locating missing items is, especially high value ones. The officer appointed as
family liaison officer provided an excellent standard of family liaison and showed
admirable tenacity in locating Mr Digweed’s missing watch in one of his former
prisons and returning it to his mother. This is an example of good practice for which
she should be commended.
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