Lee Jackson

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Lee Jackson,
a prisoner at HMP Bristol,
on 1 September 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, 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 Lee Jackson was found hanged in his cell on 1 September 2023 at HMP Bristol. He
was 50 years old. I offer my condolences to Mr Jackson’s family and friends.
Mr Jackson had been at Bristol for less than 24 hours when he died. His alleged offence
was against his partner, he was withdrawing from alcohol, and while in police custody, he
had said that he would not live. These factors increased his risk of suicide. Mr Jackson
was not managed under Prison Service suicide and self-harm monitoring procedures
(known as ACCT) and we consider that more should have been done to support him and
manage his risks.
The clinical reviewer concluded that the care Mr Jackson received at Bristol was not
equivalent to what he could have expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
name of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 31 August 2023, Mr Lee Jackson was remanded to HMP Bristol, charged with
actual bodily harm against his partner. This was not his first time in prison. Mr
Jackson was alcohol dependant and had a history of poor mental health.
2. Mr Jackson arrived at Bristol with a Person Escort Record (PER, a document that
accompanies prisoners between police custody, court and prisons, which sets out
the risks they pose). He had a suicide and self-harm (SASH) warning recorded in
the PER (although the SASH risk marker was ticked as ‘no’ and the risk information
was recorded in the wrong section). It said that while in police custody, Mr Jackson
said that he was ‘a psycho’, had depression and was not going to live anymore.
3. A prison officer conducted Mr Jackson’s reception and first night induction but did
not review all of the information contained in the PER so missed the comments Mr
Jackson had made in police custody. Mr Jackson told the officer that he had no
thoughts of suicide or self-harm. The officer did not consider starting suicide and
self-harm monitoring procedures (ACCT).
4. A reception nurse completed Mr Jackson’s reception health screen and reviewed
the paper copy of the PER. The nurse saw that Mr Jackson had a suicide and self-
harm (SASH) warning and asked him about the comments he had made. Mr
Jackson told the nurse that he did not have any thoughts of suicide or self-harm.
The nurse recorded that there was no visible evidence of self-harm, he was
emotional and feeling down, which is how he had presented on a previous sentence
at Bristol, and considered he did not need to be monitored ACCT.
5. A GP at the prison saw Mr Jackson and noted that he had severe symptoms of
alcohol withdrawal. The GP prescribed appropriate medications and referred him
the substance misuse team.
6. At around 8.45am on 1 September, a substance misuse worker saw Mr Jackson.
He said that he had anxiety and depression but did not have any active thoughts of
suicide or self-harm. The substance misuse worker told Mr Jackson how to contact
the Integrated Mental Health Team.
7. At around 10.00am, Mr Jackson collected his medication from the medications
hatch and saw the nurse who had completed his reception screen. He said that he
was hearing things and had not slept much. The nurse attributed this to Mr
Jackson’s severe withdrawal symptoms.
8. At around 11.30am, a prison officer unlocked Mr Jackson’s cell for lunch. They saw
Mr Jackson suspended from his toilet window by a ligature made of bedsheets.
Prison and healthcare staff and paramedics delivered CPR. Mr Jackson regained a
pulse and was taken to hospital.
9. In hospital. Mr Jackson suffered a cardiac arrest and at 7.54pm, it was confirmed
that he had died.
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Findings
10. Mr Jackson had been at Bristol for less than 24 hours when he was found hanged
in his cell. He had several risk factors for suicide and self-harm. We found that staff
did not read all of the information in the PER that detailed his risk, were too quick to
conclude that he was not at risk, essentially based on how he had presented on
previous occasions at Bristol and so did not initiate ACCT procedures.
11. Staff did not follow the correct reception and first night induction process.
12. We have raised concerns about ACCT management at Bristol before. In August
2023, we sought assurance from the Prison Group Director (PGD) for Avon and
South Dorset that the issues identified were being addressed. We are satisfied that
the PGD has taken necessary steps to improve the management of ACCT
procedures.
13. The clinical reviewer concluded that Mr Jackson’s clinical care at Bristol was not
equivalent to what he could have expected to receive in the community. She found
that healthcare staff did not fully consider Mr Jackson’s risk factors when assessing
him in reception.
Recommendations
• The Governor and the Head of Healthcare should ensure that all healthcare staff
(including GPs who work in the reception area) have regular ACCT training.
• The Head of Healthcare should ensure all GPs in reception have access to
prisoners’ Person Escort Records including SASH warnings forms.
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The Investigation Process
14. HMPPS notified us of Mr Jackson’s death on 2 September 2023.
15. The investigator issued notices to staff and prisoners at HMP Bristol informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
16. The investigator obtained copies of relevant extracts from Mr Jackson’s prison and
medical records, viewed CCTV and body worn video camera (BWVC) footage. She
also obtained the HMPPS Early Learning Review and HMPPS internal investigation
report.
17. NHS England commissioned a clinical reviewer to review Mr Jackson’s clinical care
at the prison.
18. The investigator interviewed three members of staff at Bristol and spoke to Mr
Jackson’s cellmate in February 2024. She and the clinical reviewer jointly
interviewed healthcare staff. The investigation was transferred to another
investigator.
19. We informed HM Coroner for Avon 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 spoke to Mr Jackson’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Jackson’s family
did not raise any specific concerns.
21. Mr Jackson’s family received a copy of the draft report. They did not make any
comments.
22. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Bristol
23. HMP Bristol is a category B reception and resettlement prison for adult men. Oxleas
NHS Foundation Trust provides physical and mental health services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Bristol was in July 2023. Following the
inspection, HM Chief Inspector of Prisons invoked the Urgent Notification (UN)
process because he was so concerned about conditions there. (The Urgent
Notification process allows HM Chief Inspector of Prisons to directly alert the Lord
Chancellor and Secretary of State for Justice if he has an urgent and significant
concern about the performance of a prison.) He noted that the UN process had
been invoked after the last inspection in 2019 and many of the failings highlighted
then were also observed during the 2023 inspection. Despite this, there were many
excellent, dedicated staff in the prison who were doing their best to support the
prisoners in their care. The issues highlighted included:
• Staffing across the prison was insufficient to ensure the delivery of a safe and
purposeful regime.
• The number of self-inflicted deaths and reported levels of self-harm were much
too high.
• Most prisoners spent 22 hours a day locked in their cells, with half of them
sharing cramped cells designed for one.
• Wing staff did not develop effective relationships with prisoners. The prison was
not delivering key work, wing staff had little time to advocate for prisoners who
needed their help, and they lacked the capability and confidence to manage
behaviour more effectively.
• Work to help prisoners rebuild ties with their families and significant others was
too limited and poorly resourced.
25. A high number of prisoners at risk of self-harm were supported by Assessment,
Care in Custody and Teamwork (ACCT) case management, reflecting the high
levels of self-harm and reported mental health issues in the population. Care plans
for these prisoners were reasonably good and informed by sufficient exploration of
the risks and triggers for each individual. Staff made efforts to engage them in
purposeful activity, and some had involved their families where appropriate. They
also sought input from the mental health team, substance misuse service or other
relevant departments. Oversight of ACCT case management had improved since
the last inspection, and robust quality assurance and a programme of staff training
were driving improvement.
26. Inspectors reported that there were staff shortages on the mental health team,
which was struggling to meet increased demand. Referrals to the team had doubled
in the previous six months with patients in crisis prioritised.
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Independent Monitoring Board
27. 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 July 2023, the IMB reported
that there had been an increase in deaths, self-harm and violence and more
prisoners than the previous year were on ACCT monitoring and constant
supervision. There had been high levels of overcrowding (over 50% all year) with
two prisoners in cells built for one person, and staffing was below the required
levels, which affected the consistent delivery of a full daily regime, resulting in more
prisoners spending time in their cells. Activities were often cancelled on the day and
key working had not yet been re-established. The Board reported that there were
insufficient staff in the mental health team to support the mental health needs of all
prisoners. Priority was given to the most unwell.
Previous deaths at HMP Bristol
28. Mr Jackson was the 12th prisoner to die at Bristol since September 2020, and the
eighth self-inflicted death. By the end of July 2024, there had been one self-inflicted
death at Bristol since Mr Jackson’s death.
29. As a result of these self-inflicted deaths and the Urgent Notification issued by HMIP
Bristol is receiving additional support and monitoring from HMPPS regional and
national safety teams.
30. In previous investigations, we raised concerns about the quality of ACCT
management at Bristol, in particular the premature closure of ACCTs and staff’s
reliance on what the prisoner told them rather than an objective assessment of the
prisoner’s risk of suicide and self-harm. Despite Bristol having introduced measures
in 2020 to improve ACCT procedures, we continued to raise the same concerns
and recommended that the Prison Group Director for Avon and South Dorset
should write to the Ombudsman setting out what was being done to improve ACCT
management at Bristol. He responded in January 2023 and set out a range of
measures including training and quality assurance.
Assessment, Care in Custody and Teamwork
31. 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 carried out at
irregular intervals to prevent the prisoner anticipating when they will occur. Regular
multidisciplinary review meetings involving the prisoner should be held.
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Key Events
32. On 31 August 2023, Mr Lee Jackson was remanded to HMP Bristol charged with
actual bodily harm against his partner. It was not his first time in prison, and he was
known by staff at Bristol.
33. Mr Jackson had a history of alcohol dependency and diabetes and was prescribed
medication for this condition in the community. He also had a history of anxiety and
depression and had attempted suicide in 2019. He had never been subject to ACCT
monitoring before.
34. On arrival at Bristol, just after 7.00pm, escort staff took Mr Jackson to the reception
area and handed Officer A a box containing four paper Prisoner Escort Records
(PER), one of which belonged to Mr Jackson. On the second page of Mr Jackson’s
PER, under the heading ‘self-harm’, it said that Mr Jackson was not at risk of
suicide or self-harm and did not need any additional observations. However, on the
fourth page, under the heading ‘medical care’ it noted that Mr Jackson had previous
brief contact with mental health services (prior to remand), his concerns were
primarily related to alcohol dependence, and he said that he was ‘a psycho’, had
depression and was not going to live anymore. The officer placed the box of PERs
on the reception desk and carried on with processing other prisoners who had
arrived at reception.
35. Mr Jackson made a phone call to someone but there is no record of who he called.
36. Mr Jackson was taken to see Officer B (a relative of Officer A) for his reception and
first night induction. The officer noted that Mr Jackson engaged well, said that he
did not have any thoughts of suicide or self-harm and had not self-harmed before.
He accessed the electronic PER but did not have the paper copy. He did not read
the all the information about Mr Jackson in the PER. At interview, he said that when
he checked the digital PER, he looked at Mr Jackson’s offence and his level of risk.
He said he did not usually check the medical section of the PER because
healthcare staff in reception would deal with the healthcare issues. He said that he
saw that the self-harm risk marker was ticked as ‘no’ and therefore, did not read the
document any further because it was related to healthcare concerns.
37. Mr Jackson told Officer B that he was aware of the support available from Listeners
and knew he could speak to staff if needed. The officer completed Mr Jackson’s cell
sharing risk assessment and recorded that Mr Jackson had no markers for suicide
and self-harm.
38. An OSG collected Mr Jackson’s paper PER from the reception desk, placed it in a
file and handed it to the reception nurse.
39. The reception nurse completed Mr Jackson’s reception health screen. She
completed a Clinical Institute Withdrawal Assessment for Alcohol and the results
indicated severe withdrawal from alcohol. She referred Mr Jackson to the
Psychosocial Substance Misuse Team (PSMT). She arranged for Mr Jackson to
see a GP because she was concerned about his withdrawal symptoms.
40. Mr Jackson said that he did not have any thoughts of suicide or self-harm. The
reception nurse noted there was no visible evidence of self-harm. She noted the
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information in the medical section of the PER and asked Mr Jackson about his
comments. Mr Jackson said that he made them out of anger and that he would not
kill himself. She noted that Mr Jackson was emotional and feeling down. At
interview, she said that Mr Jackson had presented as emotional and low in mood at
Bristol in the past, so she did not think he needed to be monitored under ACCT.
41. A GP at the prison saw Mr Jackson in reception and noted that he was presenting
with marked alcohol withdrawal symptoms and prescribed withdrawal medication.
Mr Jackson told him that his mood was low, and he had fleeting suicidal thoughts,
but did not intend to attempt suicide or self-harm. He said his community GP had
prescribed thiamine (a vitamin B1 supplement), ramipril (blood pressure
medication), citalopram and mirtazapine (antidepressants). The GP increased his
mirtazapine dose and prescribed the usual dose of ramipril and citalopram. At
interview, he said that he was not aware that Mr Jackson had a SASH warning, but
did not consider ACCT procedures were necessary.
42. Mr Jackson was located in a shared cell on the first night wing. Mr Jackson’s
cellmate said that Mr Jackson was chatty and appeared happy that evening. Mr
Jackson knew other prisoners on the wing and intended to talk to them over the
next few days. He said that Mr Jackson did not express any thoughts of suicide or
self-harm. They both went to bed at around 10.00pm and did not speak again as
the cellmate went to court early the next day.
43. During the night, a nurse checked on Mr Jackson three times to monitor his
withdrawal symptoms. She did not note any concerns.
Events of 1 September
44. At 5.25am on 1 September, an officer noted that Mr Jackson had settled and slept
well. Mr Jackson said he was okay and needed his night medication.
45. At around 8.45am, a member of the substance misuse team visited Mr Jackson to
complete a substance misuse assessment. Mr Jackson said that he had anxiety
and depression but did not have any thoughts of suicide or self-harm. She did not
note any concerns about Mr Jackson but told him how to contact the Integrated
Mental Health Team if needed.
46. An officer saw Mr Jackson during the morning domestics period, where prisoners
have time out of their cell to shower, make telephone calls and can have outside
exercise. Mr Jackson had a shower; staff gave him clean bedding and clothing and
he spoke with other prisoners on the wing. Mr Jackson did not present any
concerns to staff.
47. At 10.00am, Mr Jackson collected his medication from the medications hatch and
the reception nurse assessed him. His observations (blood pressure, oxygen levels,
etc) were within the normal range. Mr Jackson told her that he was hearing things
such as his girlfriend whispering to him and that he did not sleep well. She
completed a Clinical Institute Withdrawal Assessment for Alcohol and again noted
that Mr Jackson was presenting with severe withdrawal symptoms. She attributed
his hearing of voices to withdrawal, rather than a mental health symptom.
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48. At about 10.40am, the member of the substance misuse team dropped off some art
materials to Mr Jackson to help occupy himself while in his cell. She put them under
his door, and he thanked her.
49. At 11.31am, an officer went to unlock Mr Jackson for lunch. When he opened Mr
Jackson’s cell, he saw that Mr Jackson had hanged himself from the toilet window,
using bedsheets. He called for help and a colleague responded. The colleague
radioed a code blue (indicating a prisoner is unconscious or is having breathing
difficulties). Control room staff called an ambulance immediately. The officer used
his anti-ligature knife to cut the ligature and they started CPR.
50. Healthcare staff arrived at Mr Jackson’s cell at 11.33am and supported staff with
CPR and used a defibrillator. At 11.45am, paramedics arrived and took over Mr
Jackson’s care.
51. At 12.04pm, Mr Jackson regained a pulse and was given oxygen. He was taken to
Bristol Royal Infirmary and was taken into intensive care.
52. Mr Jackson had a cardiac arrest and, at 7.54pm, it was confirmed that he had died.
53. Mr Jackson did not leave a note.
Contact with Mr Jackson’s family
54. Once Mr Jackson had been taken to hospital, the Deputy Governor tried to phone
Mr Jackson’s mother several times but was not able to make contact. At 4.30pm,
she spoke to Mr Jackson’s mother and informed her that Mr Jackson had been
taken to hospital.
55. Mr Jackson’s family attended the hospital to be with him.
56. The prison appointed a family liaison officer, who provided support to Mr Jackson’s
mother and offered advice as to the next steps.
57. The prison contributed towards Mr Jackson’s funeral costs in line with national
policy.
Support for prisoners and staff
58. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners 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.
59. After Mr Jackson’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.
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60. The prison posted notices informing other prisoners of Mr Jackson’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 Jackson’s death.
61. Safer custody staff gave prison listeners and the wing manager postvention leaflets
to share with prisoners and staff.
Post-mortem report
62. The post-mortem report gave Mr Jackson’s cause of death as complications of
prolonged cardiorespiratory arrest, caused by suspension by a ligature. The
toxicology report showed therapeutic ranges of prescribed medication. It did not
detect any illicit substances.
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Findings
Assessment of Mr Jackson’s risk of suicide and self-harm
63. Mr Jackson had been at Bristol for around 16 hours when he was found hanged in
his cell. Prison Service Instruction (PSI) 64/2011 on safer custody, requires all staff
who have contact with prisoners to be aware of the triggers and risk factors that
might increase the risk of suicide and self-harm, and take appropriate action. Mr
Jackson had several of these risks including that he was on remand for a violent
offence against his partner and had a history of relationship instability. Mr Jackson
was also experiencing severe withdrawal from alcohol, was low in mood and was
taking antidepressants and said that he was hearing voices. He had been identified
as a heightened risk of suicide and self-harm while in police custody.
64. Despite his risk factors and having a SASH warning, staff did not start ACCT
monitoring procedures when Mr Jackson arrived at Bristol. The reception officers
saw that the information recorded in the risk section reported that Mr Jackson did
not present with any suicide or self-harm risks. They did not read the risk related
information recorded (wrongly by the police) in the medical section of the form. Both
Officers A and B had up-to-date ACCT training.
65. Although the reception nurse saw the SASH warning and noted Mr Jackson was
emotional and feeling low, she considered that he had presented in this way when
he was previously at Bristol and therefore did not consider that ACCT procedures
were necessary. She had not had ACCT training at that time.
66. We found that the combination of incorrect completion of the PER, prison staff not
reading the form in its entirety and the nurse considering that Mr Jackson’s low
mood was normal for him meant that staff did not properly assess his risk and
missed an opportunity to monitor Mr Jackson under ACCT procedures for a period.
67. The Head of Operations at Bristol told the investigator that reception staff at Bristol
were under additional pressures. He said that Bristol received 50-60 new receptions
each week, which was high compared to similar prisons. He said that since January
2024, the prison had introduced a dedicated first night centre (at the time Mr
Jackson was at Bristol, prisoners were put on a wing with prisoners from the main
population). He had also implemented changes to take some pressure off reception
staff. Officers on the first night centre now complete the initial assessments which
allows for greater consistency. We consider this a positive step to easing the
pressures in reception and ensuring better quality and continuity for prisoners in
their first days in custody.
68. The Head also said that in light of Mr Jackson’s death, additional quality assurance
checks are completed to ensure that staff follow the correct procedures including
reviewing all PERs and SASH information in detail so that staff identify those
prisoners who are at increased risk. This includes a first night reception database
and a SASH warning tracker. The prison’s operations team and contracted escort
services provider, Serco, hold a monthly meeting to discuss and share risk
information and work together to improve outcomes.
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69. The Head of Safety said that since Mr Jackson’s death, 84% of prison staff have
had ACCT training and the remaining 16% will complete the training by the end of
September 2024. He said it is not mandatory for healthcare staff to complete annual
ACCT training, however, Oxleas NHS Foundation Trust offer safeguarding training.
He said 15 healthcare staff had attended ACCT training since Mr Jackson’s death,
including the reception nurse, and new healthcare staff are offered the training.
70. The Head of Healthcare told us that the need for regular and consistent ACCT
training for healthcare staff had been identified and escalated to Oxleas NHS
Foundation Trust. While annual ACCT training is not currently available to
healthcare staff, they are expected to be compliant with prison service orders and
frameworks, which include identifying patients at risk of suicide or self-harm.
Therefore, there is a clear expectation that healthcare staff have adequate
knowledge and understanding of the ACCT process.
71. At interview, the prison GP said that he was not aware of the information relating to
Mr Jackson suicide and self-harm risk, and did not know what a PER was as it was
not a document GPs used in their assessment. He had not had or been offered
ACCT training. We question whether GPs covering reception duties are able to
make good quality decisions on a prisoner’s level of risk, and properly contribute to
the safeguarding of all prisoners, if they have not had ACCT training and do not see
relevant risk related information on newly arrived prisoners. We recommend:
The Governor and the Head of Healthcare should ensure that all healthcare
staff (including GPs who work in the reception area) have regular ACCT
training.
The Head of Healthcare should ensure all GPs in reception have access to
prisoners’ Person Escort Records including SASH warnings forms.
72. In our investigation into a self-inflicted death at Bristol in November 2022, we found
that staff placed too much emphasis on what the prisoner said rather than their
objective risk factors. In August 2023, we recommended that the Prison Group
Director for Avon and South Dorset should satisfy himself that meaningful
improvements had been made to the management of ACCT procedures at Bristol.
The PGD has implemented assurance measures to provide additional support to
case managers and to quality assure Bristol’s ACCT procedures. In light of the
changes Bristol has made to both reception procedures and ACCT management,
we make no further recommendation.
Mental and physical healthcare
73. The clinical reviewer concluded that Mr Jackson’s clinical care at Bristol was not
equivalent to what he could have expected to receive in the community because his
risk of suicide and self-harm was not holistically assessed when he arrived. The
care Mr Jackson received in relation to his substance misuse was equivalent.
74. The clinical reviewer made recommendations to the Governor and the Head of
Healthcare which they will wish to consider.
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Inquest
75. At the inquest, held on 11 May 2026, the Coroner concluded that Mr Jackson died
by suicide.
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