Kien Vuong

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Independent investigation into
the death of Mr Kien Vuong,
a prisoner at HMP Leeds,
on 10 October 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 Kien Vuong, a Vietnamese national, died in hospital on 10 October 2024, after he was
found hanging in his cell at HMP Leeds earlier that day. He was 35 years old. I offer my
condolences to Mr Vuong’s family and friends.
Mr Vuong was the fifth prisoner to take his own life at Leeds in 12 months and there were
four more self-inflicted deaths in the four months after Mr Vuong’s death.
We are satisfied that Mr Vuong gave no indication to staff that he was at imminent risk of
suicide and that they could not have foreseen his actions. However, Mr Vuong spoke little
English and staff did not often use an interpreter to communicate with him, so the extent to
which he was supported to express any concerns is questionable.
The clinical reviewer found that the care Mr Vuong received for his physical and mental
health was not of the required standard and only partially equivalent to that which he could
have expected to receive in the community. There were delays in him receiving care for
his physical health and he was not adequately monitored after being prescribed
antidepressant medication.
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 July 2025
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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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 4 May 2024, Mr Kien Vuong, a Vietnamese national, was remanded in prison
charged with drug offences. He was moved to HMP Leeds on 29 May. It was his
first time in prison and he had limited English.
2. When Mr Vuong arrived at Leeds, reception staff noted that he had no medical
issues and no thoughts of suicide or self-harm.
3. In June, Mr Vuong completed an application to see healthcare staff as he was tired.
Blood tests were requested but not completed until 22 July due to the team’s
workload. The results (which were abnormal) were not uploaded to Mr Vuong’s
record until 15 September.
4. In August, Mr Vuong’s behaviour deteriorated and his mood declined. Wing staff
asked a nurse to see him and she referred him to the mental health team.
5. When Mr Vuong failed to attend work on 15 August, the workshop instructor went to
find him and spoke to him on the exercise yard. Mr Vuong said he was stressed and
unable to urinate. The next day, a nurse carried out a mental health assessment
and arranged for a urine test and a GP referral. The GP prescribed antibiotics for
the urine infection and an antidepressant to help with his mood.
6. Mr Vuong passed two kidney stones on 15 September and said he felt much better.
On 26 September, during a GP review, Mr Vuong said he had taken his
antidepressants for one week and then stopped. He agreed to restart and a GP re-
prescribed antidepressants but Mr Vuong never collected them.
7. On 8 October, Mr Vuong attended court by video link. His case was adjourned to 23
October. An officer recorded that Mr Vuong did not speak English but he seemed ok
with the outcome. She recorded that she had advised him of the support available.
There is no evidence she used an interpreter.
8. Mr Vuong telephoned his family in Vietnam at 12.22pm on 10 October and spoke to
his mother. He talked about his financial worries and said that he did not know how
long he might be in prison for and was finding everything very difficult. He was
crying by the end of the call.
9. At 3.09pm, an officer went to the cell to deliver a kettle (as requested by Mr Vuong
and his cellmate). He opened the door and saw Mr Vuong with a ligature around his
neck, suspended from the privacy curtain near the toilet. He shouted for staff. Staff
quickly came to the cell and attempted resuscitation. Ambulance paramedics
arrived and transferred Mr Vuong to hospital. However, at 4.24pm on 10 October,
hospital staff pronounced life extinct.
10. After Mr Vuong’s death, his cellmate said that Mr Vuong had tried to hang himself in
September but he did not tell staff.
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Findings
11. We are satisfied that Mr Vuong gave no indication to staff that he was at imminent
risk of suicide and that they could not have reasonably foreseen his actions.
12. The clinical reviewer found that the care Mr Vuong received for his physical and
mental health was not of the required standard and was only partially equivalent to
that which he could have expected to receive in the community. She considered
that he should have been monitored after being prescribed antidepressants and
referred back to the mental health team when he reported that he had stopped
taking them. She noted the long delay in uploading the blood test results and that
multiple appointments had been postponed due to workload. She also noted that
workshop staff had helped Mr Vuong to submit healthcare applications as these
forms were available only in English.
13. Prison staff rarely used a telephone interpretation service to communicate with Mr
Vuong. Records show that healthcare staff did use one for some assessments but
not all. Sometimes they used another prisoner to act as interpreter, which is
unacceptable for medical matters. We have identified this issue in a previous
investigation into the death of a foreign national prisoner at Leeds. The prison
accepted that the use of interpretation services needed to improve and were taking
steps to address this.
Recommendations
• The Head of Healthcare should ensure that those individuals who are newly
prescribed antidepressants due to low mood are monitored and if compliance is
poor, a referral to the mental health team is considered.
• The Head of Healthcare should ensure that medical investigation results are
reviewed in a timely manner and that this is audited on a regular basis to ensure
test results do not get delayed in being actioned.
• The Head of Healthcare should ensure that the workload of clinical teams is
reviewed and that if demand is impacting on completion of reviews, that this is
escalated and also a plan is put in place to deal with the increased demand.
• The Head of Healthcare should ensure that healthcare applications are available in
other languages, particularly those that are spoken widely within the prison.
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The Investigation Process
14. HMPPS notified us of Mr Vuong’s death on 10 October 2024.
15. The investigator issued notices to staff and prisoners at HMP Leeds informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
16. The investigator visited Leeds on 17 October 2024. She obtained copies of relevant
extracts from Mr Vuong’s prison and medical records.
17. The investigator interviewed five members of staff and one prisoner at Leeds in
October and December 2024.
18. NHS England commissioned an independent clinical reviewer to review Mr Vuong’s
clinical care at the prison and she conducted joint interviews with the investigator.
19. We informed HM Coroner for Wakefield 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 Vuong’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond.
21. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. Practice Plus Group
provided an action plan which is annexed to this report.
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Background Information
HMP Leeds
22. HMP Leeds is a local prison holding men who are on remand, convicted or
sentenced. The prison serves the courts of West Yorkshire. Practice Plus Group
provides healthcare services, including mental health and substance misuse
services.
HM Inspectorate of Prisons
23. The most recent full inspection of HMP Leeds was in June 2022, which was
followed up by an Independent Review of Progress (IRP) inspection in July 2023. In
June, inspectors noted that the prison needed to be safer and there needed to be
more purposeful activities for prisoners as they reported the number of deaths at
Leeds was high. They found that leaders had good oversight of the action plan
drawn up following PPO investigations into these deaths, which they reviewed
frequently to ensure recommendations were implemented and learning embedded.
Inspectors found the number of self-harm incidents had reduced and was
continuing to fall but some incidents had been very serious. They concluded that
measures to improve the well-being of prisoners should be a priority.
24. The IRP reported that there had been a failure by leaders to make progress in
reducing the rate of suicide at Leeds, although the prison was making progress in
some areas. Leeds had the second highest rate of self-inflicted deaths of any prison
in England and Wales.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 December 2023, the IMB
reported that they were concerned about the number of deaths in the prison over
the past 12 months, leading to Leeds being designated a ’cluster’ site. The IMB
noted that prisoners could make healthcare appointments and could be seen within
a few days, or more quickly if it was an emergency.
26. The IMB reported that a new key worker strategy had been planned for 2024 with
the aim of a key worker remaining with a prisoner to try to build good, meaningful
working relationships and continuity for prisoners.
Previous deaths at HMP Leeds
27. Mr Vuong was the 22nd prisoner to die at Leeds since October 2021. Of the
previous deaths, seven were due to natural causes,13 were self-inflicted and one
was drug related.
28. Mr Vuong’s death was the fifth self-inflicted death in the 12 months to October
2024. There were four further self-inflicted deaths between October 2024 and
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February 2025. As a result, Leeds has been receiving additional support and
monitoring from regional and national safety teams.
29. In previous investigations, we found that improvement was needed to mental health
referral, assessment and treatment. We also found a lack of use of interpretation
services for prisoners with limited English.
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Key Events
30. On 4 May 2024, Mr Kien Vuong, a Vietnamese national, was remanded in prison,
charged with drug offences. He was moved to HMP Leeds on 29 May. It was his
first time in prison. He had limited English.
31. An officer carried out a reception interview with Mr Vuong and completed a first
night reception form using Google Translate to help with the conversation. He noted
that Mr Vuong spoke no English, was unable to read or write in English and
requested help with learning. The officer noted that Mr Vuong said he did not have
any current thoughts of suicide or self-harm, but had taken an overdose two years
ago. He said he did not have any medical issues.
32. A nurse completed the reception health screen and noted that an interpreter was
needed (but did not indicate if one was used). She noted that Mr Vuong did not
have any medical conditions.
33. On 30 May, an officer completed a prisoner induction meeting with Mr Vuong. She
gave him details about the prison regime including how to access education,
employment and healthcare services. She made no mention of using any
interpreting services for this discussion or translated documents.
34. Mr Vuong had a court hearing by video link on 31 May. His case was adjourned
until 4 June. An officer noted that she was unable to communicate with Mr Vuong
due to the language barrier but he seemed well.
35. The first record of staff using an official interpreting service to speak to Mr Vuong
was on 5 June, when an officer used it to discuss the English language learning
plan with him.
36. On 9 June, an officer completed an introductory key worker session with Mr Vuong.
She noted that his cellmate acted as an interpreter for the ten-minute meeting. She
told us that another officer, was Mr Vuong’s allocated key worker. The other officer
never had any key worker meetings with Mr Vuong.
37. On 12 June, Mr Vuong submitted an application for a healthcare appointment as he
felt tired. He was referred for blood tests but these were not completed until 22 July.
(Several appointments were postponed and rearranged due to the primary care
team’s workload.)
38. From 21 June, Mr Vuong worked in a workshop in the mornings and had English
lessons in the afternoons. He received several positive entries in his record about
his high quality of work, input during his English language lessons and being polite
and respectful to others.
39. From August, staff noted a change in Mr Vuong’s demeanour. On 14 August, an
officer made a negative behaviour entry in his record. She described his behaviour
as “bizarre” as he appeared under the influence of something, had pushed past
staff and was unable to answer questions. At the request of wing staff, a nurse
reviewed Mr Vuong. She spoke to him with the assistance of another Vietnamese
prisoner. She noted he was low in mood and referred him to the primary care
mental health team.
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40. On 15 August, Mr Vuong did not attend the workshop so one of the specialist textile
instructors, went looking for him. At interview, the instructor said that he saw Mr
Vuong on the exercise yard so he went to speak to him. He asked another prisoner
to act as interpreter. He was aware that Mr Vuong had a urinary tract problem and
had been feeling down. He opened a Challenge, Support and Intervention Plan
(CSIP) for support as he was concerned about Mr Vuong’s failure to engage. The
CSIP noted that the workshop instructors were concerned that Mr Vuong appeared
visibly sad and withdrawn. Other Vietnamese prisoners had said he was feeling
stressed and fearful about being in prison. Through the unofficial interpreter, Mr
Vuong said he was overwhelmed and stressed and had some health problems. He
was unable to urinate and this was making him feel down. Wing staff said that a
healthcare referral had been submitted and healthcare staff were providing support.
41. On 16 August, a nurse completed a mental health assessment using Language
Line (a telephone interpreting service available to all staff at Leeds). Mr Vuong told
her he was worried about debt, family issues and how long he might be in prison.
The nurse noted that Mr Vuong said he had no thoughts of suicide or self-harm.
She made a GP referral for consideration of prescribing mirtazapine (an
antidepressant).
42. An officer added an entry to Mr Vuong’s CSIP on 20 August. She said that he had
assaulted staff on the wing on 14 August and she thought a contributory factor
might have been illicit drug use (which she said was not yet confirmed). Prison
managers interviewed Mr Vuong on 23 August using another Vietnamese prisoner
as interpreter. They noted that there was a language barrier and the described
events were not a pattern of behaviour for him. They concluded that there was no
reason to progress the matter to a CSIP.
43. On 22 August, a prison specialist textile instructor noted that Mr Vuong told her that
he was unable to urinate and was in pain. She said she contacted healthcare but a
nurse said she was too busy to see him. She noted she emphasised Mr Vuong
needed to be seen so the nurse scheduled an appointment and arranged for a
sample urine pot to be delivered to Mr Vuong so he could have a test for a possible
urine infection.
44. On 29 August, a GP at Leeds completed a review and used Language Line to
speak to Mr Vuong. She agreed to prescribe antibiotics for the urine infection and
antidepressants.
45. On 15 September, Mr Vuong passed two kidney stones and reported to healthcare
staff that he was feeling better. On the same day, Mr Vuong’s blood test results
(from the sample taken on 22 July) were entered on his record. These were
abnormal and it was noted that this was not unexpected given his urine infection.
46. On 26 September, a GP reviewed Mr Vuong and she used Language Line to ask
Mr Vuong how he was feeling about taking antidepressants. Mr Vuong said he had
taken the tablets for one week and then stopped. He agreed to restart. The GP re-
prescribed the antidepressants, but Mr Vuong never collected them.
47. On 8 October, an officer noted that Mr Vuong had another video link court hearing
and the matter was adjourned until 23 October. She noted he could not speak
English but had understood the proceedings and was ok with the outcome. She
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noted that she had advised him of the support available including the Samaritans,
Listeners (prisoners trained by the Samaritans) and healthcare staff.
48. Mr Vuong’s cellmate told the investigator that they worked and attended English
courses together. He said he heard telephone conversations when Mr Vuong rang
his family and Mr Vuong had told him about his journey to the UK, how he had
ended up in prison and that he was in pain and felt useless and depressed.
Sometimes Mr Vuong would cry through the night and not leave his cell. They
supported each other. He said that around a month earlier Mr Vuong had tried to
hang himself with a rope in their cell but changed his mind as he did not want his
cellmate to find him. They had not reported this to anyone. Mr Vuong was also
upset due to his ongoing urinary problems. A nurse had given him medication which
had helped but he was still having issues.
Events of 10 October 2024
49. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to the telephone calls and staff radio communications from 10 October.
She also obtained information from Yorkshire Ambulance Service NHS Trust.
50. CCTV shows that on the morning of 10 October, Mr Vuong left his cell at 8.11am
and returned to his cell at 11.27am. His cellmate returned at 11.33am. CCTV shows
Mr Vuong collected his lunch and returned to his cell. An officer completed a
routine roll check at 11.53am.
51. Mr Vuong telephoned his family in Vietnam at 12.22pm and the telephone call
lasted for 12 minutes. The investigator arranged for the translation of his
conversation from Vietnamese to English. Mr Vuong spoke to his mother. He said
he was feeling homesick and tired. He said she should sell property to clear a debt.
He said that he did not know how long he would be in prison for and he was finding
everything very difficult. He said that he was unable to pursue establishing a nail
shop business. He said that things were hard for him and he had a lot of debt. He
said he was not as strong as others. He said that his trial had not begun so he was
not sure the length of his sentence or possible release. He was worried that his
family would face bankruptcy as even if he was released, he may not be able to
secure work. He said his situation was complicated. The call ended with Mr Vuong
saying that it was very hard. He was crying.
52. Mr Vuong’s cellmate said he was in the cell when Mr Vuong used the telephone. At
1.54pm, Mr Vuong’s cellmate left the cell to attend English classes. Mr Vuong
remained in the cell. He briefly left the cell at 2.26pm and then returned and closed
the cell door at 2.29pm.
53. In his police statement, an officer said just after 3.00pm, he went to the cell to give
the occupants a kettle as they had requested. CCTV shows at 3.09pm, the officer
opened the cell door and entered the cell. He saw Mr Vuong with a ligature around
his neck, suspended from the privacy curtain rail near the toilet. He shouted for
staff. A second officer was the first to arrive. She supported Mr Vuong as the officer
cut the ligature and they placed him on the floor. They started CPR. Within
seconds, a third officer entered the cell and she radioed a code blue (a medical
emergency code used when a prisoner is unconscious or having breathing
difficulties). Staff in the control room immediately called an ambulance at 3.09pm.
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More prison staff attended and four healthcare staff also went to the cell at 3.12pm
to assist with the resuscitation attempt with the aid of emergency equipment that
had been brought to the cell.
54. Paramedics arrived at 3.20pm. They were joined by a critical care paramedic and a
second ambulance crew. Paramedics transferred Mr Vuong to hospital. However,
Mr Vuong did not regain consciousness and at 4.24pm, hospital staff pronounced
life extinct.
Contact with Mr Vuong’s family
55. The prison appointed an officer as the family liaison officer (FLO) when Mr Vuong
was found unresponsive in his cell and a second officer as her deputy.
56. The FLO noted that she had tried to call the number listed for Mr Vuong’s family in
Vietnam, but the number did not connect. She contacted Mr Vuong’s solicitor to see
if they had any family contact information. They did not. She contacted the
Vietnamese Embassy and was waiting for a response.
57. On 15 October, the deputy FLO tried the number for Mr Vuong’s family listed on his
prison telephone account and used a telephone interpreting service to speak to Mr
Vuong’s mother. Mr Vuong’s mother said she already knew her son had died as
another Vietnamese prisoner had contacted her. The deputy offered her
condolences and support.
58. The Prison Service contributed towards the cost of Mr Vuong’s funeral in line with
national policy and arranged for his ashes to be sent to his family in Vietnam.
Support for prisoners and staff
59. When Mr Vuong was found unresponsive in his cell, a senior manager went to
break the news face to face with his cellmate and arranged for his cellmate to be
relocated.
60. 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.
61. After Mr Vuong’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
62. The prison posted notices informing other prisoners of Mr Vuong’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 Vuong’s death. They also
deployed Listeners to the wing to offer support to prisoners when Mr Vuong died.
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Post-mortem report
63. The post-mortem report gave Mr Vuong’s cause of death as hanging.
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Findings
Assessment and management of Mr Vuong’s risk of suicide and self-
harm
64. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), which was in force at the time of
Mr Vuong’s death, listed risk factors and potential triggers for suicide and self-harm.
It said all staff should be alert to the increased risk of self-harm or suicide 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 ACCT procedures. (The PSI has been superseded by the Prison
Safety Policy Framework though ACCT procedures remain broadly the same.)
65. Mr Vuong did not have any significant risk factors for suicide and self-harm when he
arrived at Leeds, beyond the fact it was his first time in prison. There would have
been no reason to start ACCT procedures at that time.
66. A few months later, Mr Vuong’s behaviour deteriorated and his mood declined. He
was reviewed by the mental health team and prescribed antidepressants. However,
he said he had no thoughts of suicide or self-harm and gave no indication that he
was at risk. Again, we consider that there would have been no need for ACCT
procedures.
67. According to his cellmate, Mr Vuong tried to hang himself in September. Clearly this
should have triggered ACCT procedures had staff known about it. However, Mr
Vuong’s cellmate said they told no one. We are satisfied that, in the context of Mr
Vuong’s limited ability to communicate with staff, he gave no indication to staff that
he was at imminent risk of suicide in the lead up to his death and that staff could not
have foreseen his actions.
Clinical care
68. The clinical reviewer concluded that Mr Vuong’s physical and mental health care
was not of the required standard and was only partially equivalent to that which he
could have expected to receive in the community.
Mental health
69. On 29 August, a GP prescribed antidepressants to Mr Vuong for low mood. When
the GP reviewed him on 26 September, Mr Vuong said he had taken the
antidepressants for only one week and then stopped. The clinical reviewer
considered that the GP should have referred Mr Vuong back to the mental health
team for short-term monitoring of the antidepressant effects and of Mr Vuong’s
mood. We recommend:
The Head of Healthcare should ensure that those individuals who are newly
prescribed antidepressants due to low mood are monitored and if compliance
is poor, a referral to the mental health team should be considered.
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70. Mr Vuong never collected the antidepressants prescribed on 26 September. This
was not identified at the time. The Head of Healthcare told the clinical reviewer that
there was now a new process in place where the healthcare team reviewed any
non-collection of medication and decided on next steps.
Physical health
71. The clinical reviewer noted that there had been a long delay in entering Mr Vuong’s
blood test results from 22 July, which were not entered until 15 September, and that
appointments had been moved several times due to workload. She also noted that
workshop staff had helped Mr Vuong to complete healthcare applications as the
forms were available only in English. We recommend:
The Head of Healthcare should ensure that medical investigation results are
reviewed in a timely manner and that this is audited on a regular basis to
ensure test results do not get delayed in being actioned.
The Head of Healthcare should ensure that the workload of clinical teams is
reviewed and that if demand is impacting on completion of reviews, that this
is escalated and also a plan is put in place to deal with the increased demand.
The Head of Healthcare should ensure that healthcare applications are
available in other languages, particularly those that are spoken widely within
the prison.
Staff interactions with Mr Vuong and lack of use of interpreting services
72. There is no evidence in the records that interpreting services were used to
communicate with Mr Vuong when he arrived at Leeds and for his first month there.
After that they were used sporadically.
73. Mr Vuong attended court by video link on 31 May and 8 October. Both times, the
officer recorded that Mr Vuong could not communicate in English and there is no
evidence that an interpreter was used.
74. Prisoners should be reviewed after a court appearance, including one by video link,
to check that there has been no change in their risk of suicide and self-harm. The
prison told us that all prisoners receive a welfare check following a video link court
appearance. There is a printed sheet available with questions in Vietnamese, which
includes, “What happened in court today?” and “Are you OK?”. While Mr Vuong
could have maybe answered “Yes” or “No” in English to some of the questions, we
are not confident that he could have communicated effectively in the absence of an
interpreter. The value of the printed sheet for non-English speaking prisoners is
therefore questionable.
75. The officer who conducted Mr Vuong’s key worker session also did not use a
telephone interpreting service but instead relied on his cellmate to interpret. This is
not acceptable.
76. There was evidence that some healthcare staff used Language Line to
communicate with Mr Vuong but not all. There were occasions where another
prisoner was used as interpreter. This is not appropriate for health matters.
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77. We identified the lack of use of interpreting services in a previous investigation into
the death of a foreign national at Leeds. The Head of Safety and Equalities and the
Head of Healthcare accepted that use of interpretation services could be improved.
They said that work was ongoing to increase the number of telephone handsets
available to staff and to improve guidance on using the telephone interpretation
service.
78. The Head of Safety and Equalities provided an update to the investigator in May
2025. He said that all prisoner facing areas had been issued with handsets to
access the Language Line services. However, the current arrangements for access
were not ideal as there were issues with real-time access, excessive wait times,
frequent disconnections, unavailable languages and no access outside of normal
hours.
79. The issue of staff’s failure to use formal interpreting services is not singular to
Leeds. We have raised our concerns in a number of investigations across a number
of prisons. HMPPS has commissioned a trial of a handheld translation device and
Leeds has requested to be included in the pilot. Leeds has provided confirmation
that they are working to improve staff use of interpreting services. As a result, we do
not make a recommendation on this occasion, but the Governor must maintain
focus on this area and demonstrate progress is being made.
Key worker scheme
80. HMPPS’s Manage the Custodial Sentence Policy Framework requires that all
prisoners should be allocated a prison officer key worker to engage, motivate and
support them throughout their time in custody. Key workers should spend an
average of 45 minutes each week per prisoner on key work duties, including
individual time with each prisoner. This did not happen for Mr Vuong who had only
one ten-minute key worker session during his five months at Leeds.
81. Prison managers at Leeds told us that from 12 May 2024, their focus had been on
ensuring that new arrivals had a key worker session within five days. Mr Vuong had
his session on day 11. Managers said staffing levels had impacted on their ability to
meet the five-day target.
82. Managers said that the intention was for prisoners to have a key worker session
every 28 days. A group of 20 staff were now being utilised as key workers when on
duty and they each had 56 prisoners. The plan was to give them 42 hours a month
to see each prisoner on their caseload. However, staffing levels and redeployments
meant that it was a challenge to consistently deliver key work. The Governor should
be aiming for full delivery as soon as possible so that all prisoners can benefit from
key work.
Governor to Note
83. There was a delay in the prison FLO contacting Mr Vuong’s family in Vietnam. It is
unclear why it took five days to check the number listed on Mr Vuong’s telephone
account. We bring this to the Governor’s attention.
Prisons and Probation Ombudsman 13
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Good practice
84. The two workshop instructors were proactive in trying to help Mr Vuong. They were
the first to identify Mr Vuong’s deteriorating physical and mental health and alerted
staff. They also helped Mr Vuong to complete healthcare applications. We wanted
to highlight the help and support they provided to Mr Vuong.
Inquest
85. At the inquest, held on 14 April 2026, the jury concluded that Mr Vuong died by
suicide.
14 Prisons and Probation Ombudsman
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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