Kevin Smith

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Kevin Smith,
a prisoner at HMP Doncaster,
on 22 April 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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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 Kevin Smith was found hanged in his cell at HMP Doncaster on 22 April 2023. He was
18 years old. I offer my condolences to his family and friends.
It was Mr Smith’s first time in an adult prison, and he had been at Doncaster for under two
months when he died. Mr Smith was concerned for his safety at the prison and, although
he declined a cell move, little else was done to investigate his fears. Mr Smith’s risk to
himself was not considered holistically and was not well managed. Mr Smith did not benefit
from a consistent key-worker to build a trusting relationship with.
The clinical reviewer found that Mr Smith’s mental health care was not equivalent to that
which he would have received in the community. In particular there was a lack of regular
planned support from the mental health team.
I have been worried for some time about the impact for prisoners of running out of phone
credit and being unable to call family or friends in times of crisis, which came up in this
case.
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 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 1
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ......................................................................................................................... 12
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Summary
Events
1. On 1 March 2023, Mr Kevin Smith, who was 18 years old, was remanded to HMP
Doncaster charged with various offences including burglary and theft of a motor
vehicle. Mr Smith had been released on licence from HMYOI Wetherby a little over
a week earlier and had failed to arrive at an approved premises where he was
required to live for a period of time.
2. Mr Smith was very briefly supported through prison suicide and self-harm
monitoring procedures (known as ACCT) on three occasions in April 2023. On the
first two occasions, Mr Smith cut himself and said he did so because he was under
threat and was also having difficulties with his partner. On the third occasion, Mr
Smith said that he had showed an officer his existing cuts and had just been
wasting staff time as he was bored.
3. At 8.50am on 22 April, an officer found Mr Smith hanging from a ligature tied to the
cell shelving unit. The officer radioed a medical emergency code and went into the
cell, followed immediately by another officer. The officers cut the ligature and
started cardiopulmonary resuscitation (CPR). Nurses arrived two to three minutes
later. They noted that Mr Smith had signs of rigor mortis but continued to give CPR.
4. Ambulance paramedics arrived at 9.03am and after checking Mr Smith, they
instructed that efforts to try to resuscitate him should stop as he was dead.
5. Staff found a letter in Mr Smith’s cell which made clear his intent to die.
Findings
6. ACCT support for Mr Smith ended with insufficient exploration of his concerns or
consistent attendance of healthcare staff at reviews.
7. Mr Smith did not have a consistent key-work officer. He ran out of phone credit
twice in the days before his death, meaning he could not make calls to family or
friends as and when he wanted or needed to.
8. Officers did not make a routine check of prisoners at 6.15am on 22 April as
required.
Recommendation
• The Director and Head of Healthcare should ensure that there is a robust quality
assurance process to ensure that healthcare staff attend ACCT reviews in line with
policy to facilitate an informed and considered approach to risk management.
• The Director should ensure that intelligence regarding a prisoner feeling at risk is
properly investigated, the prisoner is appropriately supported and that there is a
quality assurance process in place to ensure that this is being routinely done.
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The Investigation Process
9. HMPPS notified us of Mr Smith’s death on 22 April 2023.
10. The investigator issued notices to staff and prisoners at HMP Doncaster informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. The investigator obtained copies of relevant extracts form Mr Smith’s prison and
medical records.
12. The investigator interviewed 13 members staff and two prisoners at HMP Doncaster
between 27 July and 6 September.
13. NHS England commissioned a clinical reviewer to review Mr Smith’s clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews with
clinical staff.
14. We informed HM Coroner South Yorkshire East District of the investigation. She
provided us with a copy of the post-mortem and toxicology reports. We have sent
her a copy of this report.
15. We contacted Mr Smith’s father to explain the investigation and to ask if he had any
matters that he wanted us to consider. Mr Smith’s father raised the following
questions and matters:
• Why was his son not seen by a psychiatrist?
• He was concerned about the way his son’s ACCT was managed including
ACCTs being closed before care plan actions were completed and without
input from healthcare staff.
• Why was no action taken in response to the threats that his son was being
bullied, including the incident on 21 April when another prisoner dragged him
into a cell.
• Did the investigator interview another prisoner?
• Why were no routine early morning checks made on his son on 22 April?
• He was upset that he learned of his son’s death from another prisoner.
16. We have addressed these issues in our report and in the clinical review. Mr Smith’s
father raised a number of other issues that we have addressed in separate
correspondence.
17. Mr Smith’s family received a copy of our initial report. The solicitor representing Mr
Smith’s father wrote to us asking two questions about our investigation that do not
impact on the factual accuracy of this report. We have provided clarification by way
of separate correspondence to the solicitor.
18. The initial report was also shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and clarification of information and
this report has been amended accordingly.
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Background Information
HMP Doncaster
19. HMP Doncaster is a local prison operated by Serco. It holds remanded or convicted
men and young adult men. Practice Plus Group provides healthcare services.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Doncaster was in February and March 2022.
Inspectors found that levels of violence had reduced significantly since the previous
inspection in September 2019 and were lower than at similar prisons. Inspectors
noted that acts of violence were investigated promptly, and the dynamic daily
residential meeting considered the initial findings from the incidents and considered
options, such as relocation of the prisoners involved.
21. Inspectors noted that violence was managed by a separate team to the safer
custody team, which focused on suicide and self-harm. Inspectors found that well-
attended safer custody meetings were held monthly, and a safer custody analyst
provided detailed data and analysis of trends. Doncaster had developed a strategy
to reduce levels of harm, and the number of ACCTs opened had reduced over the
last two years. Recent data had also shown a promising decline in the number of
recorded incidents of self-harm. Inspectors found that most prisoners they spoke to
felt cared for by staff and the quality of ACCT documents had improved since the
last inspection and care plans generally reflected the issues identified. Inspectors
also noted that wing supervisors checked the quality of ACCT documents every 24
hours and highlighted any concerns appropriately.
22. Inspectors found that key-worker sessions had continued throughout the pandemic
and were recorded more regularly than normally seen. However, inspectors also
found that key-worker sessions were often formulaic and that prisoners did not
always see the same key-worker each time, affecting their ability to build rapport.
23. Inspectors found that the mental health team was rich in skill mix and experience
delivering evidence-based treatment using the stepped care model. (The stepped-
care model aims to deliver the most effective yet least resource intensive treatment
first.)
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 November 2023, the IMB published a report that covered the period 1
October 2020 to 31 August 2022. The IMB explained that for most of the reporting
period, the IMB had had only two active members and for much of the period, only
one member. As a result, the IMB’s capacity to carry out its full role had been
significantly impacted. The IMB reported its view that across most observable
indicators, the prison had improved and felt calmer, cleaner and with improved staff-
prisoner engagement. Among a number of areas for development, the IMB noted
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that some prisoners were uncertain how they should engage effectively with
healthcare staff.
Previous deaths at HMP Doncaster
25. Mr Smith was the 26th prisoner to die at Doncaster since February 2020. Of the
previous deaths, six were self-inflicted, four were from drugs and 15 were from
natural causes. Since the death of Mr Smith, there has been one death due to
natural causes.
26. In our investigation into a self-inflicted death in December 2020, we found
deficiencies in the operation of the key-worker scheme at Doncaster. We again
found deficiencies with the operation of the key-worker scheme in our investigation
into a self-inflicted death in July 2022.
27. In our investigation into a death from natural causes in December 2020, we found
that there had been no early morning check on the prisoner, and he was then found
dead in his cell at 9.30am.
28. In an investigation in January 2021, staff attempted to resuscitate a prisoner despite
clear indications that he had been dead for some hours.
29. We identified deficiencies with mental health input in three of the deaths we
investigated between June 2020 and July 2022.
Assessment, Care in Custody and Teamwork
30. 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.
31. 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.
Key-worker scheme
32. The key-worker scheme aims to improve safer custody by engaging with prisoners,
building better relationships between staff and prisoners and helping prisoners
settle into life in prison. It provides that all adult male prisoners will be allocated a
key-worker who will spend an average of 45 minutes a week on key-worker
activities, including having meaningful conversation which each of their allocated
prisoners.
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Key Events
HMYOI Wetherby
33. Between May 2021 and February 2023, Mr Kevin Smith spent time at HMYOI
Wetherby on three separate occasions for a variety of offences including assault,
arson, robbery, burglary and various motoring offences. He had a difficult childhood
and while in custody often used illicit drugs and alcohol, was in possession of
weapons and displayed inappropriate behaviour towards female staff and violence
towards other prisoners.
34. During his time at Wetherby, Mr Smith was supported a number of times by prison
suicide and self-harm monitoring procedures (known as ACCT). Incidents that led to
ACCTs included Mr Smith being found with a ligature around his neck, making cuts
to his hand and swallowing screws and a battery. This usually followed Mr Smith
receiving bad news and he would often assure staff that he would not repeat the
self-harm.
35. On 10 March 2022, Mr Smith was alleged to have stabbed another prisoner with an
improvised weapon. This led to an additional criminal charge that remained
outstanding for a year.
36. On 13 February 2023, staff checked on Mr Smith after receiving a telephone call
from a friend expressing concerns about him. Staff found Mr Smith with a ligature
around his neck. A nurse noted that Mr Smith was conscious and talking but he was
pale and shaking and had a red mark to his neck. Staff re-opened a recently closed
ACCT that remained open for Mr Smith’s remaining week at Wetherby.
37. On 20 February, Mr Smith was released on licence and met his offender manager
at his local probation office. As part of his licence conditions, Mr Smith was initially
required to live in an approved premises, but he failed to arrive and his
whereabouts were unknown.
HMP Doncaster
38. On 1 March, Mr Smith was arrested and remanded to HMP Doncaster charged with
various offences including burglary and theft of a motor vehicle allegedly committed
between 24 and 27 February. It was Mr Smith’s first time in an adult prison.
39. A nurse noted that Mr Smith’s Person Escort Record (PER) that accompanied him
from court to Doncaster, stated that he had harmed himself three days before, but
he refused to tell the nurse more details. Mr Smith said he had no current thoughts
of suicide or self-harm and the nurse noted he seemed unconcerned about being
back in prison. She noted that Mr Smith had attention deficit hyperactivity disorder
(ADHD), for which he received medication. (People with ADHD can seem restless,
may have trouble concentrating and may act on impulse.) The nurse referred Mr
Smith to the mental health team.
40. A prison custody officer (PCO) in the first night centre noted that they had seen the
PER, and that Mr Smith had a history of self-harm, but also noted that Mr Smith had
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no present thoughts of suicide or self-harm. There is no record that the reception
officer discussed Mr Smith's recent self-harm with him.
41. On 2 March, a psychiatrist prescribed Mr Smith medication for ADHD. He did not
see Mr Smith in person.
42. On 3 March, a chaplaincy worker met Mr Smith to give him information about the
services offered by the chaplaincy team. The chaplaincy worker noted that Mr Smith
raised no issues or concerns.
43. The same day, during a further screening Mr Smith told a PCO that he was in a
relationship, he had two children from previous relationships and good support in
the community. He said that he did not need help in managing his temper or
impulsivity and he had no current thoughts of suicide or self-harm.
44. On 7 March, a mental health nurse reviewed Mr Smith. He said he had no thoughts
of suicide and self-harm. The nurse told the investigator that Mr Smith had good
support from his partner and father and from his presentation she had no concerns
for his safety. However, she referred him to the learning disabilities nurse for
support.
45. On 13 March, Mr Smith moved to a single cell on Houseblock 2D. He remained in
this cell until his death. Mr Smith had been assessed as high risk for sharing cells
due to his history of violence towards other prisoners.
46. On 23 March, a PCO saw Mr Smith for a key-worker session. Mr Smith said that he
was feeling in good general health but was waiting to speak to the mental health
team. He also said that he had good family support but was not able to telephone
them as he had no money. He said that he enjoyed going out for exercise and
associating with other prisoners.
47. On 29 March, a PCO saw Mr Smith for a key-worker session. Mr Smith said that his
main concern was that he had no job and no other income which meant that he was
limited in making canteen orders (canteen is the prison shop) and telephone calls to
his family. Mr Smith said that he had good support from his father and partner and
that she was going to visit him at the weekend. Mr Smith said that he had a history
of self-harm, but he had no current thoughts of suicide or self-harm.
48. Also on 29 March, a nurse who specialises in learning disabilities (the learning
disabilities nurse) saw Mr Smith. He noted that Mr Smith was anxious about a
video-link court hearing later that day and he also reported having problems with his
sleep. He sent a task to the psychiatrist to review Mr Smith’s medication. He added
Mr Smith to his caseload, but he did not formally review him again. However, he
said he met him informally a number of times when visiting other prisoners and he
had no concerns about him. He said that he told Mr Smith to come to him at any
time if he wanted to chat.
49. During his video-link court hearing that afternoon, Mr Smith was further remanded
into custody until 11 May. A PCO spoke to Mr Smith after the hearing and noted
that he said he was unconcerned about the outcome and did not need any support.
50. On 2 April, the psychiatrist reviewed Mr Smith’s medical records and prescribed him
Promazine to help with stress and problems sleeping. He noted that Mr Smith’s
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ADHD medication seemed to be working, so he made no adjustment to that
prescription.
51. Also on 2 April, Mr Smith had a key-worker session when he said that he felt safe
on the wing. He said that he did not have much that he needed help with, although
he still had no job.
52. On the same day, Mr Smith had a video-conference with his solicitor after which he
raised no issues with staff.
53. On 7 April, wing staff noted that Mr Smith was unsteady on his feet and possibly
under the influence of an illicit substance. A nurse tried to examine him, but he
refused to be examined or treated. Staff notified the substance misuse team and
submitted an intelligence report.
54. On 11 April, a substance misuse worker telephoned Mr Smith on his in-cell phone
and asked if he had been taking illicit drugs. She told the investigator that Mr Smith
was adamant that he did not use drugs, but he said that he and his cousin were
both under threat on their wing and they needed to move to a different wing. She
telephoned the wing office to report the conversation, and an officer told her that Mr
Smith had already reported the threats.
55. The same day staff submitted an intelligence report. This indicated that Mr Smith
and another prisoner were possibly under threat due to drug debts. The report
stated that the information had been shared with the houseblock managers and the
safer custody team but that no further action was required at that time.
56. At just before 6.00pm on 13 April, Mr Smith rang his cell bell and told a PCO that he
needed a nurse as he had made cuts to his neck. He said that he was under threat
on the wing and also had issues in his home life. The PCO opened an ACCT and a
manager set Mr Smith’s observation at one an hour pending an ACCT review. At
interview (in March 2024), the PCO could not recall whether she had done so for Mr
Smith but told the investigator that her normal practice would have been to call a
nurse. There is no record that a nurse assessed Mr Smith.
57. In the early morning of 14 April, a PCO noted that Mr Smith had had a calm and
settled night. He had asked for writing paper and envelopes and had written some
letters. He also spent time watching television and had then slept well for the rest of
the night.
58. On the afternoon of 14 April, a Custodial Operations Manager (COM) chaired an
ACCT review with Mr Smith. A PCO also attended the review, along with a mental
health nurse and a senior mental health practitioner. Mr Smith said that he had cut
his neck the day before as he was frustrated following an argument with his partner.
He said that he now regretted his actions and had no current thoughts of suicide or
self-harm. He said that he was seeing the learning disabilities nurse and was taking
medication for ADHD. He also said that he was looking forward to his next court
appearance as he believed he would soon be released from custody but would like
a job in the meantime so he could keep busy and earn some money. The COM
wrote an ACCT care plan that included an action for Mr Smith to move to a different
Houseblock as he did not feel safe on Houseblock 2D. He noted that staff were in
process of moving him at that time. The COM noted that everyone at the review
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agreed that the ACCT could be closed. (The other actions on the care plan were for
Mr Smith to take his ADHD medication, to attend the gym on a regular basis and for
him to maintain family contact. The COM marked all these actions as completed.)
59. Despite the COM’s care plan entry, Mr Smith remained on Houseblock 2D.
17 April
60. On 17 April, Mr Smith telephoned his partner a number of times between 4.00pm
and 8.00pm. In their final conversations, Mr Smith’s partner confronted him about
his contact with another woman, possibly an ex-partner. Mr Smith’s partner ended
their final two calls abruptly.
61. At around 8.30pm, a PCO was making a welfare check on all prisoners when he
found that Mr Smith had made some cuts to his neck, and he said that he was not
going to make it through the night. The PCO radioed a code red emergency (to
indicate a prisoner is bleeding).
62. A nurse associate responded to the code red. She noted that Mr Smith had minor
wounds, which she dressed. Mr Smith said that he self-harmed because he did not
have enough credit to telephone his partner. (His telephone account confirms that
he had used up his remaining credit by 7.50pm that evening.)
63. A PCO re-opened Mr Smith’s ACCT and the officer in charge set observations at
two an hour pending an ACCT review.
18 April
64. At an ACCT assessment interview on the morning of 18 April, Mr Smith told a PCO
that he had been frustrated the evening before after arguing with his partner. He
also said that he was having issues on Houseblock 2D and wanted to move as
soon as possible. Despite these concerns, Mr Smith said that he had no current
thoughts of suicide or self-harm and would tell staff if that were to change.
65. Later that morning, a COM chaired an ACCT review with Mr Smith. Another COM
and a PCO also attended; no healthcare staff were present. Mr Smith said that he
had made scratches to his neck the night before as he was frustrated at having to
wait for a doctor’s appointment which he had self-requested on the ATM (at
Doncaster, the wings have ATMs on which prisoners make applications for services
they need). The COM noted that Mr Smith understood that he needed to wait for an
appointment to be set. (According to the information provided, Mr Smith did not
have an outstanding doctor’s appointment. He had last requested a medical
appointment on 25 March and was seen on 29 March.) Mr Smith told staff that he
had family support and was looking forward to another visit from his family that
weekend. Mr Smith again said that he was due in court in the near future and was
expecting to be released. Mr Smith spoke about having issues on Houseblock 2D
and the COM noted that staff had found a single cell for him on Houseblock 2B to
which he agreed to move. Staff closed Mr Smith’s ACCT.
66. The COM told the investigator that when staff told Mr Smith that the cell on
Houseblock 2B was ready, he no longer wanted to move.
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67. At around 10.15pm that evening, a PCO noted that Mr Smith had re-opened the
cuts to his neck and he said that he was planning to hurt himself further. The PCO
re-opened Mr Smith’s ACCT and called the officer in charge to complete an
immediate action plan. The officer in charge set Mr Smith’s observations at two an
hour pending an ACCT review the following morning. Mr Smith refused to see a
nurse.
19 April
68. A senior mental health practitioner emailed a contribution ahead of Mr Smith’s
ACCT review that day saying that he was on the learning disabilities nurse’s
caseload (this was correct, but the nurse was not seeing Mr Smith formally). The
practitioner wrote that Mr Smith was receiving medication for ADHD and was also
receiving medication for stress and sleep disturbance. She wrote that Mr Smith had
previously said that he would self-harm as a means of release, rather than with any
intent to end his life.
69. A COM chaired an ACCT review with Mr Smith later that morning. A PCO attended
the review, and the COM noted the senior mental health practitioner’s written
contribution. He told the investigator that Mr Smith said that he had not self-harmed
the previous evening but had showed the officer the same cut marks from a few
days earlier. He said that he had been bored so had wasted staff’s time. The COM
said that Mr Smith was a confident and boisterous man and he never believed that
he was at risk of taking his own life. He noted in Mr Smith’s record that all of the
care plan issues were resolved and that the ACCT could be closed.
20 April
70. On the afternoon of 20 April, Mr Smith attended a remand hearing by video-link in
connection with the incident from March 2022, when he was alleged to have
stabbed another prisoner. Mr Smith was further remanded into custody until his next
hearing date on 18 May. Staff noted that Mr Smith raised no concerns after the
hearing, and he declined support from healthcare or a prison buddy (buddies are
prisoners who provide social and welfare assistance to other prisoners).
71. Mr Smith telephoned his partner several times between 5.00pm and 8.00pm that
afternoon and evening. Mr Smith asked his partner to send him some money and
he also asked her to tell his mother about getting her name added to his list for
video-conference calls. With his final call to his partner, Mr Smith again used up all
of his remaining telephone credit.
72. Also on 20 April, Mr Smith called Doncaster’s prisoner advice line (PAL) and told
them that he was struggling with his mental health and would like to see the mental
health team. He also said that officers took two hours to answer cell bells. Prisoners
answer the calls on the PAL (supervised by staff) and pass messages on the
prisoner’s behalf where necessary. The prisoner taking the call filled in a form with
the details Mr Smith gave. Staff told the investigator that the request was sent to the
mental health team and that Mr Smith would have been told to submit a formal
prison complaint about cell bell delays. Staff said that if the prisoner taking the call
had had any concerns about Mr Smith’s risk these would have been communicated
directly to staff present who would have passed them on to wing staff immediately.
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There is no evidence that the prisoner taking Mr Smith’s call had any immediate
concerns about him.
21 April
73. CCTV shows that at 9.20am on 21 April, Mr Smith was standing on the ground floor
landing when another prisoner approached him, appeared to check his pockets,
and then pulled him into a cell followed by several other prisoners. At that moment,
a PCO walked across the landing towards the cell and the group came out of the
cell and dispersed. The PCO spoke to the other prisoner and Mr Smith, who had
initially walked away but then walked back again. Doncaster’s then Head of Safer
Custody told PPO investigators that the CCTV had not been viewed until after Mr
Smith’s death and, when asked by the prison, the PCO said that he had not noticed
anything untoward that morning, he had just been patrolling the landing as usual.
(The Head also said that the group of prisoners involved had been split to different
Houseblocks to prevent any further incidents.)
74. The investigator spoke to another prisoner about the incident. He said Mr Smith
was in debt to other prisoners for vapes, and that was why other prisoners had tried
to intimidate him. He said that he spoke to Mr Smith that evening to check if
anything was wrong and said he would help him with any debts. However, Mr Smith
said that there was nothing wrong and he did not need help.
75. After prisoners were locked in their cells for the evening, CCTV shows that Mr
Smith was checked at 8.13pm and again at 1.12am on 22 April (these were routine
checks made on all prisoners at those times). The investigator was unable to
establish what the officers observed when making their checks on Mr Smith. Of the
three officers who last checked him, two had since left Doncaster and the third
could not recall his interaction with Mr Smith. None of the officers responsible for
checking him raised any concerns that night.
22 April
76. The investigator watched CCTV footage. He also obtained information from
Yorkshire Ambulance Service. The following account is based on these sources
and documentation relating to the emergency response.
77. All prisoners on Houseblock 2D should have been checked at around 6.15am. This
check did not take place on 22 April.
78. At 8.50am, a PCO was unlocking prisoners on Houseblock 2D. When he got to Mr
Smith’s cell, he looked through his observation panel and saw him hanging from a
ligature made from a torn curtain and tied to a shelving unit. He radioed a medical
emergency code blue (to indicate a prisoner is unconscious or having breathing
difficulties). Control room staff immediately called an ambulance. He unlocked Mr
Smith’s cell and went in, immediately followed by another PCO. He supported Mr
Smith’s weight and his colleague cut the ligature. They placed Mr Smith on the floor
noting that he was cold and rigid. The other PCO began CPR.
79. Nurses arrived within two to three minutes. One nurse told the officers to bring Mr
Smith onto the landing where there was more room. She noted that Mr Smith was
cyanosed (where the skin turns blue through lack of oxygen), and that rigor mortis
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was present (stiffening of a body that sets in following death). She noted that it was
not possible to pass an airway into Mr Smith’s mouth as his jaw was locked. Nurses
continued to deliver CPR and tried to administer oxygen. Paramedics reached Mr
Smith at 9.03am and, after checking him, instructed that efforts to resuscitate him
should stop as he was dead. It was 9.05am.
80. Mr Smith had left a letter in his cell addressed to his partner which made clear his
intention to die. He wrote that nothing had gone well for him, that he did not get the
help he needed when he asked so his mental health problems took over.
Contact with Mr Smith’s family
81. A PCO was appointed as family liaison officer and was told at around 10.00am that
Mr Smith’s father had already contacted the prison as another prisoner on the wing
had telephoned him to tell him of his son’s death. (We do not know who contacted
Mr Smith’s father but all cells at Doncaster are fitted with a phone.) Due to the
circumstances, the PCO telephoned Mr Smith’s father to confirm what he had
already been told. He made several further calls to Mr Smith’s father, both that day
and in the following days.
82. Doncaster contributed to the cost of Mr Smith’s funeral in line with national
instructions.
Support for prisoners and staff
83. After Mr Smith’s death, the Duty Director debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. Staff were offered further support from the care team.
84. The prison posted notices informing other prisoners of Mr Smith’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 Smith’s death.
Post-mortem report
85. The pathologist gave Mr Smith’s cause of death as hanging.
86. Toxicology results found a therapeutic level of Mr Smith’s prescribed ADHD
medication in his system. (A therapeutic level means a dose prescribed to
effectively treat an illness.)
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Findings
Assessment and management of risk of suicide and self-harm
87. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of suicide or self-harm posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under Assessment, Care in Custody and
Teamwork (ACCT) procedures. PSI 64/2011 also states that any information that
becomes available which may affect a prisoner’s risk of harm to self must be
recorded and shared, to inform proper decision making. Mr Smith had a number of
risk factors: he had a history of suicide attempts and self-harm, he had ADHD, he
was a young man in an adult prison for the first time, he was still in his early days in
prison, and he had a history of conflict with other prisoners.
88. An early learning review (ELR) carried out by Yorkshire Prisons Group immediately
following Mr Smith’s death identified various shortcomings in the management of
his risk of suicide and self-harm. The review identified that staff did not ask Mr
Smith about information on the PER that he had self-harmed three days before
arriving in prison. The ELR noted that when Mr Smith self-harmed on 13 April, one
of the reasons he gave was that he felt under threat. However, the nature of the
threat and the names of potential perpetrators were never explored with Mr Smith.
The ELR noted that moving wings was one of the ACCT care plan actions and was
marked as completed on 14 April even though Mr Smith never moved from
Houseblock 2D. The ELR also found that when ACCTs were subsequently
reopened and closed again on 18 and 19 April, there was again a failure to properly
explore Mr Smith’s concerns about being at risk.
89. Doncaster’s present and previous Heads of Safer Custody told the investigator that
Mr Smith had been offered a wing move, however he then declined to move. They
said that in that circumstance, Doncaster would not enforce a move. However, they
acknowledged the findings of the ELR. They said that reception staff generally
explore warnings in PER forms, and they believed in Mr Smith’s case the issue was
that any such discussion was simply not recorded. They said that a secondary
measure to capture information for new arrivals is the use of a first night booklet to
note any information about thoughts of suicide or self-harm (this recorded that Mr
Smith was in a positive mood). They also said that all prisoners in the first night
centre are observed once every two hours.
90. The Heads of Safer Custody said that Doncaster has since done a lot of work to
upskill ACCT case managers to ensure that ACCT care plan actions are SMART
(specific, measurable, attainable, relevant, timebound) and properly address the
prisoner’s risks and needs. They said that they have provided in-house training on
this, concentrating in particular on risks and triggers. They were confident that there
were no longer problems in this area. They said that ACCTs are quality assured on
an ongoing basis and where deficiencies are identified, advice and guidance is
given to the individuals involved.
91. There were also omissions in the summary section of the ACCT form (this section
captures the prisoner’s mood and behaviour during the morning, afternoon, evening
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and night). The Heads of Safer Custody said that they had identified similar
omissions during their quality assurance checks and in the last 18 months, had
provided training and guidance to ensure that staff complete good quality
summaries.
92. While there is some clear evidence to suggest that Mr Smith might have been in
debt to others and was at potential risk because of this, we note that he was offered
a wing move which he declined. We also note the evidence of the prisoner who told
us that Mr Smith declined his offer of financial help on the evening of 21 April, as
well as noting Mr Smith’s comments in his goodbye letter when he spoke about his
mental health problems. Staff spoke about Mr Smith presenting as a confident
young man and this might have affected some of the judgments made in assessing
his risk.
93. Mr Smith ran out of phone credit twice in the week before his death. He had said
that his family and partner were protective factors and being unable to call them
when he wanted or needed to may have added to his mental distress. We draw no
conclusions about the link between this and his death, but prisoners being able to
make calls to people outside prison who can support them is clearly important.
ACCT review attendance
94. PSI 64/2011 says that healthcare staff must always be invited to ACCT reviews or
to provide a written contribution if unable to attend. The policy also says that where
possible healthcare staff should be given sufficient advance notice of ACCT reviews
and the healthcare representative should be somebody with knowledge of the
prisoner when possible. Two healthcare representatives attended Mr Smith’s first
ACCT review on 14 April, but there were no representatives at his other two reviews
on 17 April and 19 April. All three reviews were the first review following the opening
of the ACCT and the ACCT was closed each time at this first review. Mr Smith
specifically mentioned on 14 April that he had ADHD and was seeing the learning
disabilities nurse. The learning disabilities nurse told us that he could not be sure
that he was ever made aware that Mr Smith had been supported by an ACCT.
(Doncaster informed us that a report is published each day with a list of prisoners
being supported through ACCT and that the learning disabilities nurse was on the
circulation list). When staff closed the ACCT on 19 April, a senior mental health
practitioner gave a written contribution detailing that Mr Smith was having regular
contact with the learning disabilities nurse, but this was not the case.
95. While we cannot say for certain that Doncaster could have anticipated Mr Smith’s
true level of risk, we concur with the findings of the ELR that there should have
been greater exploration of the concerns he presented. The clinical reviewer noted
that Mr Smith’s distress was not evident through his appearance, presentation or
what he said. This indicates that more careful ongoing risk assessment and
management was needed, including attendance by a nurse, to further explore Mr
Smith’s risks and what further support he needed. We acknowledge the action
already taken by Doncaster to address the issues outlined in the ELR and make the
following recommendation:
The Director and Head of Healthcare should ensure that there is a robust
quality assurance process to ensure that healthcare staff attend ACCT
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reviews in line with policy to facilitate an informed and considered approach
to risk management.
Clinical care
96. The clinical reviewer found that the care Mr Smith received for his physical health
and substance misuse needs was of a reasonable standard and equivalent to that
which he would have received in the community.
97. However, the clinical reviewer considered that Mr Smith’s mental health care was
not of the required standard and was not equivalent to that which he would have
received in the community. In particular, the clinical reviewer noted that there was
an absence of regular planned support from the mental health team. In view of his
vulnerabilities, including his very recent history of self-harm and risk of impulsivity
from his ADHD, she concluded that more formal support could have been put in
place to support Mr Smith and to try to mitigate his risk. However, the clinical
reviewer also noted that the learning disabilities nurse had a caseload of between
40-70 prisoners at any time which could make regular scheduled contact difficult.
While we make no recommendation, the Head of Healthcare will wish to consider
the clinical reviewer’s findings about the equivalence of mental healthcare Mr Smith
received at Doncaster.
98. The clinical reviewer was also concerned about aspects of the healthcare input in
Mr Smith’s ACCT management which we have already detailed.
Key-worker scheme
99. Mr Smith had three key-worker meetings in his brief time at Doncaster. This is more
than we often see at comparable prisons, however, we note that the sessions were
delivered by three different officers. We note that HMIP found that key-worker
sessions at Doncaster were often formulaic, and that prisoners did not always see
the same key-worker each time.
100. Staff who met Mr Smith generally seemed to view him as a happy, chatty and open
young man. However, the letter that he left behind in his cell indicates that he was
clearly troubled. A consistent key-worker might have been able to start forming a
deeper and more trusting relationship, more conducive to Mr Smith revealing his
true feelings. We consider that a good key-worker relationship was particularly
important for an 18 year old man in an adult prison for the first time with evident
vulnerabilities.
101. Following our investigation into a death at Doncaster in December 2020, we
contacted the HMPPS Executive Director of Custodial Contracts about our repeated
findings and recommendations to Doncaster on the key-worker scheme, as well as
other areas of concern. The Executive Director responded to us in July 2021 to say
that following a review, the assessment team had been assured that the minimum
compliance requirements at Doncaster were being met. Despite this assurance, we
again identified deficiencies in the operation of the key-worker scheme in our
investigation into a death at Doncaster in July 2022. We note that this was also a
concern for HMIP when they last inspected Doncaster in March 2022.
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102. The Heads of Safer Custody told the investigator that once Mr Smith arrived on
Houseblock 2D, he should have been assigned a permanent key-worker. They
assured us that Doncaster has been working to ensure the scheme is now working
properly - they provided data to show that for the first five months of 2024 the prison
was delivering between 69% and 152% of the target for delivery of key-work
sessions. Given these positive figures, we make no recommendation, but the
Director will want to continue to monitor the delivery of key-work.
Risk to Mr Smith
103. CCTV shows that on the morning of 21 April, another prisoner appeared to attempt
to check Mr Smith’s pockets before he and several other prisoners pulled him into a
cell. Within seconds, the group dispersed, and Mr Smith came out of the cell as an
officer crossed the landing walking towards the cell. The officer said that he had not
noticed anything untoward, he had merely crossed the landing as he was carrying
out his duties.
104. Another prisoner told the investigator that Mr Smith was in debt to other prisoners
for vapes. As Doncaster were apparently unaware of the incident at the time it
happened, there was no investigation and no discussion with Mr Smith that day
about whether he was under threat. We note however, that once prison staff had
watched the CCTV footage after Mr Smith’s death, they dispersed the group of
prisoners involved across the prison.
105. Mr Smith spoke about feeling unsafe on Houseblock 2D and that he wanted to
move. Staff had found a cell on another Houseblock for him, but when he was told
this, he said that he wanted to stay on 2D. However, there is no evidence that staff
explored Mr Smith’s initial reasons for requesting a move.
106. The Heads of Safer Custody told the investigator that Doncaster has procedures for
dealing with violence, including referrals to the safety intervention meeting (SIM)
and use of a challenge, support and intervention plan (CSIP). CSIPs are
individualised plans that are used for both potential victims of violence and potential
perpetrators of violence. We have found no evidence that staff properly explored
any concerns Mr Smith might have had on Houseblock 2D or whether there was
ever any consideration for a referral for him to the SIM or for a CSIP. We make the
following recommendation:
The Director should ensure that intelligence regarding a prisoner feeling at
risk is properly investigated, the prisoner is appropriately supported and that
there is a quality assurance process in place to ensure that this is being
routinely done.
Routine checks
107. Staff made a standard welfare check on Mr Smith at 1.12am on 22 April while
checking all prisoners on the Houseblock. Staff did not check Mr Smith again until
8.50am when they unlocked him. We cannot say when Mr Smith died, but when he
was found, he had signs of rigor mortis so it is clear that he had been dead for
some time.
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108. The published regime said that staff should make routine checks on all prisoners at
6.15am. The primary purpose of these checks is to confirm that all prisoners are
present and correctly accounted for. Not completing the check is, therefore, a
serious breach of security. However, these checks are also an opportunity to check
on prisoners’ well-being and to identify any obvious signs that a prisoner may be ill
or dead.
109. During an investigation into a death in Doncaster in December 2020, we also
discovered that staff failed to make a routine early morning check. The
circumstances surrounding the omission in that case were different to those in Mr
Smith’s case. However, in response to our recommendation the Director issued a
notice to staff reminding them of the times of the four standard checks of the day
between 6.15am and 7.30pm and adding two further checks at 8.00am and at
midnight. The Director stressed in his order the need to take extra care in looking
after prisoners’ welfare.
110. The Heads of Safer Custody told the investigator that the staff on duty that day had
been confused whether the standard regime applied as it was the weekend. Since
Mr Smith’s death, they said that the regime had been republished, and that
managers make random checks to ensure compliance. They said that there had
been no omissions since Mr Smith’s death and if any omissions were to occur, that
would lead to a full disciplinary investigation.
111. We cannot say that if he had been found sooner, the outcome would have been any
different for Mr Smith, but carrying out effective routine and welfare checks is critical
to the safety and security of prisoners and staff. We are reassured by steps the
prison have taken to address this recurring issue and make no further
recommendation.
Family liaison
112. Mr Smith’s father complained that he learned of his son’s death from another
prisoner. Unfortunately, there is always the possibility that a family might be told the
distressing news of the death of a relative before the prison is able to deliver the
news, and in this case, a prisoner had called Mr Smith’s father within an hour of Mr
Smith’s death. While we have sympathy for Mr Smith’s father, Doncaster could not
have reasonably prevented other prisoners from contacting him.
Director to note
Cell Bells
113. On 20 April, Mr Smith complained on the prisoner advice line that officers took too
long to answer cell bells. The investigator was not able to check Mr Smith’s cell bell
records for his final days as the data could not be downloaded due to a technical
problem. However, the investigator was able to review Mr Smith’s cell bell records
for the period 15 to 17 April. On those three days, Mr Smith rang his cell bell 15
times. Most of the time, the bells were answered within the five minute response
target, but on five occasions it took staff between 8 and 15 minutes to respond.
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114. The Heads of Safer Custody told the investigator that a prisoner survey on use of
cell bells found that the system was misused 98% of the time with prisoners ringing
bells to ask basic questions or to request items such as toilet rolls. They said that
officers are now expected to explain clearly to a prisoner that cell bells are for
emergencies only and if a prisoner misuses their cell bell three times, they a liable
to punishment by a reduction in their incentives and earned privilege level. It is
imperative that prisoners understand that cell bells should not be misused and that
when bells are used, that officers respond promptly. The Director will wish to assure
himself that officers are compliant in answering cell bells within target and that
sanctions are being fairly and consistently applied where prisoners misuse their
bells.
Head of Healthcare to note
Attempted resuscitation
115. In September 2016, the National Medical Director at NHS England wrote to Heads
of Healthcare for prisons to introduce new guidance to help staff understand when
not to perform cardiopulmonary resuscitation (CPR). This guidance was designed to
address concerns about inappropriate resuscitation following a sudden death in
prison. It was taken from the European Resuscitation Council Guidelines which
states, “Resuscitation is inappropriate and should not be provided when there is
clear evidence that it will be futile”. The European Guidelines were updated in May
2021, but the same principles apply.
116. Mr Smith had signs of rigor mortis when he was found. These normally set in
between two and six hours after death, indicating that Mr Smith had been dead for
some time. Both prison and healthcare staff carried out CPR until paramedics
arrived. A nurse told us that she was aware of the guidelines but it was the first time
she had seen signs of rigor mortis and did not feel confident to stop resuscitation.
Other nurses were also present and continued CPR. On arrival, the paramedics
immediately pronounced Mr Smith dead. The Head of Healthcare will wish to
consider how best to build staff confidence in this sensitive area.
Inquest
117. An inquest into Mr Smith’s on 25 September 2024 concluded that his cause of his
death was suicide by hanging.
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