Luke Ashcroft

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Independent investigation into
the death of Mr Luke Ashcroft,
a prisoner at HMP Lincoln,
on 1 July 2020
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Luke Ashcroft died in hospital on 1 July 2020 after being found with a ligature around
his neck in the segregation unit at HMP Lincoln on 24 June. He was 33 years old. I offer
my condolences to Mr Ashcroft’s family and friends.
Mr Ashcroft had only been at Lincoln for five weeks when he was found unresponsive in
his cell with the ligature. He had schizophrenia and bipolar disorder and was suffering from
delusions that he had spiders living inside him. The day before he was found unresponsive
with a ligature around his neck, a psychiatrist had assessed that he was suffering an acute
psychotic episode and a nurse started suicide and self-harm monitoring (known as ACCT)
after Mr Ashcroft said he had had enough of the spiders and was ready to die.
My investigation found that healthcare staff did not properly assess whether Mr Ashcroft
was fit to be segregated. It appears there were healthcare reasons not to segregate Mr
Ashcroft from 23 June, but this was not highlighted to prison managers.
Mr Ashcroft should have been checked five times an hour overnight on 23/24 June. CCTV
shows that many of these checks were not carried out and records were falsified to show
they had. Following a trial, the officer was convicted of misconduct in a public office.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister, CB
Prisons and Probation Ombudsman February 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
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Summary
Events
1. Mr Luke Ashcroft was recalled to prison on 23 May 2020 and sent to HMP Lincoln.
2. Mr Ashcroft had a long history of substance misuse and tested positive for opiates
and cocaine when he arrived at Lincoln. He was already on a methadone (heroin
substitute) programme, which was continued at Lincoln.
3. Mr Ashcroft had schizophrenia and bipolar disorder. Shortly after arriving at Lincoln,
he told healthcare staff that he had spiders living inside his body. He was
prescribed antidepressant and antipsychotic medication but continued to have
delusions.
4. On 22 June, Mr Ashcroft became more distressed about the spiders and barricaded
himself in his cell. He was subsequently moved to the segregation unit (known as
the Care and Separation Unit (CSU)). A nurse assessed that he was medically fit to
be segregated.
5. On 23 June, a psychiatrist assessed Mr Ashcroft and diagnosed delusional
parasitosis (a fixed but false belief that the body is infested with insects). He found
that Mr Ashcroft was having ‘an acute psychotic episode’. He wanted to run some
tests to ensure there was no physical cause, but he considered it likely that Mr
Ashcroft would require further assessment and treatment in a secure psychiatric
hospital.
6. Later that day, a nurse started suicide and self-harm procedures (known as ACCT)
after Mr Ashcroft told her that he had spiders in his body and was ready to kill
himself. He remained in the CSU.
7. Mr Ashcroft was on five checks an hour. The officer responsible for the checks
during the night of 23 June into the early hours of 24 June, failed to carry out
numerous checks and falsified the ACCT log to say he had. His last entry in the
ACCT log was at 6.50am which said that Mr Ashcroft was pacing in his cell.
However, CCTV shows that his last check was at 6.36am.
8. At 6.54am, the day shift officer checked Mr Ashcroft. He saw him lying on the cell
floor and thought he saw a ligature around his neck. The officer called for
assistance. As soon as he heard colleagues arrive on the unit, he entered the cell
and cut the ligature from Mr Ashcroft’s neck. Another member of staff called a
medical emergency code and healthcare staff arrived quickly.
9. Mr Ashcroft was taken to hospital, but he died on 1 July.
Findings
10. Healthcare staff did not make it sufficiently clear to prison staff that Mr Ashcroft was
acutely mentally unwell.
11. Nurses did not complete the Initial Segregation Health Screens correctly. The nurse
who completed the second health screen on 23 June, wrongly concluded that Mr
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Ashcroft was medically fit to be segregated, when in fact she should have
concluded that there were healthcare reasons not to segregate him.
12. We question whether Mr Ashcroft should have been located in the segregation unit
given he was so mentally unwell and was being managed under ACCT procedures.
13. Mr Ashcroft was on five ACCT checks an hour on the night of 23/24 June. An officer
falsified the ACCT record to show that he had completed checks when he had not.
The officer was charged and convicted of misconduct in a public office.
14. The officer who found Mr Ashcroft unresponsive did not call a medical emergency
code.
15. The clinical reviewer found that the healthcare Mr Ashcroft received at Lincoln was
equivalent to that he could have expected to receive in the community.
16. The prison completed a fact-finding report after Mr Ashcroft’s death which noted
that Mr Ashcroft was suspected of taking illicit substances on 18 June. There is
nothing about this in the records provided to the PPO and no intelligence report.
Recommendations
• The Head of Healthcare should ensure that healthcare staff share information about
a prisoner’s mental or physical health with prison staff where this is necessary to
keep a prisoner safe.
• The Governor and Head of Healthcare should ensure that:
• healthcare staff are trained in the completion and importance of Initial
Segregation Health Screens;
• staff complete Initial Segregation Health Screens fully and accurately and arrive
at a clear conclusion; and
• authorising managers understand how the Initial Segregation Health Screen
should be completed and query it if it appears incorrect or incomplete.
• The Governor should ensure staff record incidents of suspected substance misuse
and submit intelligence reports.
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The Investigation Process
17. The investigator issued notices to staff and prisoners at HMP Lincoln informing
them of the investigation and asking anyone with relevant information to contact
her.
18. The investigator obtained copies of relevant extracts from Mr Ashcroft’s prison and
medical records.
19. NHS England commissioned a clinical reviewer to review Mr Ashcroft’s clinical care
at the prison.
20. We suspended our investigation in July 2020 at the request of the police while they
carried out a criminal investigation. We were able to reactivate our investigation in
July 2021.
21. The investigator interviewed four members of staff in September 2021. She and the
clinical reviewer jointly interviewed healthcare staff. All the interviews were
conducted remotely because of the COVID-19 restrictions.
22. We informed HM Coroner for Lincolnshire of the investigation. He gave us the
results of the post-mortem examination. We have sent the coroner a copy of this
report.
23. The Ombudsman’s family liaison officer contacted Mr Ashcroft’s mother to explain
the investigation and to ask if she had any matters she wanted the investigation to
consider. She had no questions, but she asked to see our report.
24. The family received our initial report, and their solicitor raised a number of queries.
We have made some amendments to this report and answered their other
questions via separate correspondence. The clinical review has also been slightly
amended. However, at the police’s request, we delayed finalising this report while
they pursued criminal charges against an officer.
25. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Lincoln
26. HMP Lincoln holds up to 729 remanded and convicted men. It serves the courts of
Lincolnshire, Nottinghamshire and Humberside. It has four residential wings,
including a Vulnerable Prisoners Unit. Nottinghamshire Healthcare NHS Foundation
Trust provides health services and there is 24-hour nursing cover. ‘We are with you’
provide substance misuse services.
HM Inspectorate of Prisons
27. The most recent inspection of HMP Lincoln was in December 2019/January 2020.
Inspectors reported that Lincoln was a much safer prison since their last inspection
in 2017, though there had been two self-inflicted deaths since then. Inspectors said
that the prison’s approach to prisoners in crisis was good, and they had
implemented previous PPO recommendations. The inspectors found that prisoners
and staff had a good relationship, which was a real strength.
28. Inspectors reported that health services were generally good. Despite a high level
of need, the integrated mental health team provided a very good and
accessible service, which delivered a wide range of evidence-based therapies.
Drug- and alcohol-dependent prisoners were very positive about the care they
received. Their treatment was prompt and met individual need.
29. The level of target searching following the receipt of drugs intelligence had
increased substantially since the previous inspection, but nearly a third of requested
suspicion drugs tests were not carried out. Work to reduce the supply of drugs into
the prison was considered good. In the six months before the inspection, 10% of
mandatory drug tests had been positive, which was low compared with other local
prisons.
Independent Monitoring Board
30. 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 January 2021, the IMB
reported that self-harm and drug use had decreased but that despite best local
efforts, prisoners in need of transfer to a mental health setting sometimes waited far
too long for an appropriate placement. On balance, they considered the CSU to be
well run.
Previous deaths at HMP Lincoln
31. Mr Ashcroft was the fifth prisoner to die at Lincoln since July 2018. Two of the
previous deaths were self-inflicted and two were from natural causes. We have
previously made recommendations about the use of medical emergency codes. The
prison told us that a notice to staff was reissued in May 2020, setting out the
expectations around calling medical emergency codes, and staff had been issued
with code red and blue prompt cards between May and July 2020.
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Assessment, Care in Custody and Teamwork
32. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses to support prisoners at risk of suicide or self-harm. The
purpose of the ACCT is to try to determine the level of risk posed, the steps that
staff might take to reduce this and the extent to which staff need to monitor and
supervise the prisoner. Checks should be at irregular intervals to prevent the
prisoner anticipating when they will occur. Part of the ACCT process involves
assessing immediate needs and drawing up a caremap to identify the prisoner’s
most urgent issues and how they will be met. Staff should hold regular
multidisciplinary reviews and should not close the ACCT until all the actions are
completed.
Segregation units
33. Segregation units (sometimes called Care and Separation Units) are used to keep
prisoners apart from other prisoners. This can be because they feel vulnerable or
under threat from other prisoners or if they behave in a way that prison staff think
would put people in danger or cause problems for the rest of the prison. They also
hold prisoners serving punishments of cellular confinement after disciplinary
hearings. Segregation is authorised by an operational manager at the prison who
must be satisfied that the prisoner is fit for segregation after an assessment by a
member of healthcare staff.
34. Segregation unit regimes are usually restricted, and prisoners are permitted to
leave their cells only to collect meals, shower, make phone calls and have a daily
period in the open air. A manager, a member of the chaplaincy team and a member
of the healthcare team should visit the segregation unit daily and speak to each
segregated prisoner to check their welfare. A doctor should visit at least every three
days and a registered nurse on the other days to assess the physical, emotional
and mental wellbeing of the prisoners and whether there are any apparent clinical
reasons to advise against continuing segregation.
Psychoactive substances (PS)
35. Psychoactive substances (PS), formerly known as ‘new psychoactive substances’
or ‘legal highs’, are a serious problem across the prison estate. They are difficult to
detect and can affect people in many ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of PS can present with marked levels of disinhibition, heightened
energy levels, a high tolerance of pain and a potential for violence. There is
emerging evidence to link PS use to endangering physical health, precipitating or
exacerbating the deterioration of mental health and the risk of suicide or self-harm.
36. In July 2015, we published a Learning Lessons Bulletin about the use of PS and its
dangers, including its close association with debt, bullying and violence. The bulletin
identified the need for staff and prisoners to be more aware of the dangers of PS,
the need for more effective drug supply reduction strategies, better monitoring by
drug treatment services and effective violence reduction strategies.
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Key Events
37. On 20 December 2018, Mr Luke Ashcroft was sentenced to 40 months in prison for
burglary. On 21 May 2020, he was released on licence, but was recalled on 23 May
after taking drugs. He was sent to HMP Lincoln.
38. When he arrived at Lincoln, Mr Ashcroft’s urine tested positive for opiates, cocaine
and methadone (used to treat heroin addiction). Mr Ashcroft said he was on a
methadone prescription of 62mls a day but had recently been told to reduce his
dose. The nurse noted that Mr Ashcroft had epilepsy, schizophrenia and bipolar
disorder. She referred him for a mental health assessment. A prison GP saw Mr
Ashcroft and prescribed medication including methadone. The GP noted that Mr
Ashcroft had issues with his heart rate and would need to have an
electrocardiogram (ECG) to check whether his methadone should be reduced.
39. Mr Ashcroft was located in a single cell as he was assessed as high risk for cell
sharing because of his mental health issues and because he had taken a cellmate
hostage in 2016.
40. That evening, officers asked a nurse to see Mr Ashcroft as he appeared to be under
the influence of illicit substances. He let the nurse start to take his observations but
objected part way through and refused to continue. On 24 May, staff carried out a
cell search but found nothing.
41. On 27 May, a nurse carried out Mr Ashcroft’s mental health assessment. Mr
Ashcroft told him he had been diagnosed with bipolar disorder and schizophrenia in
early adulthood and attention deficit hyperactivity disorder (ADHD) as a child. He
said he heard internal voices – one that was derogatory and negative and another
weaker voice which tried to rationalise with the former. Mr Ashcroft also said he
believed there were spiders inside his body which had entered him through an open
wound over a year ago. Mr Ashcroft said he had attempted suicide in October 2019
when he tied a ligature around his neck and cut his inner arm. The nurse assessed
that Mr Ashcroft was not currently at risk of suicide or self-harm and noted he would
be discussed at a multi-disciplinary team (MDT) meeting.
42. On 5 June, Mr Ashcroft was introduced to his offender supervisor. They discussed
his recall and Mr Ashcroft said probation staff had not helped him to get to his
Approved Premises when he was released. He said he was dyslexic and had
needed special directions printed for him, but this was never done. Mr Ashcroft said
he had ended up in Doncaster, when he needed to be in Lincoln and would be
appealing his recall.
43. On 8 June, a nurse noted that Mr Ashcroft had reduced his methadone from 50mls
to 45mls and that this was a big recent reduction. Mr Ashcroft was adamant he
wanted to reduce even further, and she sent a task for a doctor to review him.
44. On 10 June, a substance misuse specialist had a telephone appointment with Mr
Ashcroft. He had the results of an ECG scan, carried out the day before, and he
agreed Mr Ashcroft could continue to reduce his methadone dose. He booked a
further review appointment for two weeks’ time.
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45. On the same day, a nurse saw Mr Ashcroft for a mental health review. He noted
that Mr Ashcroft was stable, orientated to time and place and appropriate. Mr
Ashcroft said he had spoken to his community probation officer about executive
release. The nurse noted that he would follow this up as, if Mr Ashcroft was not
going to be imminently released, he wanted to place him on the mental health
team’s caseload.
46. On 14 June, Mr Ashcroft told nurses at the medication hatch that there were spiders
in his body trying to eat their way out. The nurses noted that he did not seem to be
under the influence of illicit substances.
47. A nurse saw Mr Ashcroft that afternoon. He repeated his belief that there were
spiders living inside of him and said they were becoming more aggressive. He said
he was ‘Spiderman’ and that he believed he was linked to the COVID-19 outbreak
in the UK. She discussed the conversation with another nurse, and they wondered if
the rapid reduction in Mr Ashcroft’s methadone could have caused worsening
delusions. She sent a task for Mr Ashcroft to be reviewed by the MDT, including a
psychiatrist.
48. On 15 June, a Healthcare Assistant (HCA) saw Mr Ashcroft. He asked to switch
from methadone to Espranor (buprenorphine – another opioid drug used as a
heroin substitute). She sent a task to the prison GP.
49. The same day, an officer noted that a nurse had spoken to her and asked her to
book an urgent appointment for Mr Ashcroft with a psychiatrist as he appeared to
be acutely unwell. The entry indicates that the MDT should have happened but did
not. The nurse also saw Mr Ashcroft who again told him about the spiders and said
they were trying to kill him. He said that he was always told this was a mental health
problem, but it was real, and he wanted to go to hospital to verify that the spiders
were in him. She told Mr Ashcroft the team were trying to make a psychiatrist’s
appointment for him.
50. On 17 June, the substance misuse specialist noted that his plan was to reduce Mr
Ashcroft’s methadone one final time to 30mls and then he would switch him to
Espranor on 20 June with a review in nine days’ time.
51. On 18 June, the MDT discussed Mr Ashcroft. They agreed that an urgent
appointment should be made for him to be assessed by a consultant psychiatrist.
An appointment was arranged for 23 June.
52. The same day, prison staff thought Mr Ashcroft was under the influence of illicit
substances. (This information was recorded in a fact-finding document the prison
completed after Mr Ashcroft’s death, but we have found no evidence that any record
was made at the time.)
53. On 19 June, an officer noted that another prisoner had threatened Mr Ashcroft
through his door, calling him a liar and saying that he would see him at dinner. Staff
understood this was over a debt that Mr Ashcroft owed for vapes. The two were
unlocked separately for dinner. The next day another officer noted that the situation
between the two had calmed down.
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22 June
54. At around lunchtime on 22 June, Mr Ashcroft’s mother telephoned the prison
because she was worried about Mr Ashcroft and thought he was having a psychotic
episode. In response, an officer went to see Mr Ashcroft and he said he was okay.
She said she would speak to him again after lunch. When she returned, Mr Ashcroft
told her he had been bitten by a spider 20 months before and that spiders were
growing inside him, and he feared he would die. He said that healthcare staff knew
about this, but no one had taken him for a scan to have the spiders removed. He
said he had had enough and wanted to go to hospital. She noted that she had
contacted healthcare staff who told her that Mr Ashcroft would not be going to
hospital that day, but they knew about his issues. There is no record that anyone
contacted Mr Ashcroft’s mother.
55. At around 2.10pm, an officer noted Mr Ashcroft had used his emergency cell bell
and demanded he [the officer] turn on his body-worn camera to record him
demanding to be taken to hospital. The officer told Mr Ashcroft that he could not
demand to be recorded or to be taken to hospital. He noted that Mr Ashcroft was
trying to manipulate staff into getting him to hospital for an unknown reason. (The
officer did not make her entry on Mr Ashcroft’s prison record until 3.25pm, so
another officer did not know what Mr Ashcroft and healthcare had told her.)
56. An hour later, Mr Ashcroft barricaded himself in his cell and covered his observation
panel. After staff gained access, they restrained Mr Ashcroft and took him to the
Care and Separation Unit (CSU – the segregation unit) at around 3.00pm.
57. At 5.10pm, a nurse noted he had seen Mr Ashcroft in the CSU and considered him
medically fit to be held there. The nurse completed the Initial Segregation Health
Screen, which contains a flow chart known as the Health Algorithm. In answer to
Question 3, ‘Does the prisoner show signs of being acutely unwell?’, the nurse
ticked ‘Yes’, which then led to the outcome ‘There are healthcare reasons not to
segregate at this time’. In answer to the final question on the flow chart, ‘Do you
think that the prisoner will be able to ‘cope’ with a period of segregation?’, the nurse
ringed both ‘Yes’ and ‘No’. An answer of ‘Yes’ leads to a box that says, ‘No
healthcare intervention at this time’ and ‘No’ leads to a box that says, ‘There are
reasons not to segregate at this time – discuss with healthcare.’ The nurse did not
select either conclusion.
58. At 6.00pm, the Head of Security signed the form to say she had seen the Initial
Segregation Health Screen. She did not query the lack of conclusion on the Health
Algorithm.
23 June
59. On the morning of 23 June, a nurse took Mr Ashcroft’s medication to him in the
CSU. Mr Ashcroft spat out the water as he thought spiders’ webs had fallen into the
cup but still took the medication.
60. At midday, the consultant psychologist, who was escorted by a nurse, assessed Mr
Ashcroft in the CSU. At interview he said he had not met Mr Ashcroft before and it
was a difficult assessment as Mr Ashcroft refused to leave his cell and it had to be
conducted at the open cell door with two prison officers in attendance.
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61. The consultant psychiatrist noted that Mr Ashcroft was preoccupied, staring at the
prison wall and then pointing at his cheek. Mr Ashcroft told them that there was a
spider on his cheek, and he believed that there were several spiders in his body
which were moving. He lifted his t-shirt and showed some old, healed marks on his
chest which he attributed to spiders. He told them that he had first started to worry
about spiders after lying down in the loading bay area of a local shop. He woke up
feeling that a spider had entered his body. Mr Ashcroft said that he had been taken
to Watford Infirmary but rather than investigating him they had sectioned him under
the Mental Health Act. He became very agitated when talking about this.
62. Mr Ashcroft offered to show the doctor and nurse the spiders but when the
consultant psychiatrist said he could not see anything, Mr Ashcroft became very
agitated and started to shout loudly. He became more hostile, and the interview was
suspended and continued through the observation panel with the cell door closed.
63. The consultant psychiatrist assessed that Mr Ashcroft knew he was in prison, but he
appeared to be paranoid and revealed persecutory delusions and delusional
misinterpretation. He recorded that Mr Ashcroft was ‘vividly hallucinating’, his
concentration was poor and his insight very poor. He concluded that Mr Ashcroft
was experiencing an acute psychotic episode with a diagnosis of delusional
parasitosis (a rare mental health condition in which a person has an unshakable,
false belief that they are infested with insects) which required further assessment
and treatment in a secure psychiatric hospital. He did not want to prescribe any
medication until any physical causes had been eliminated and he ordered blood
tests and an ECG.
64. The consultant psychiatrist also noted he asked the nurse for an urgent ‘IMPACT’
referral form to be completed with a view to further assessment and possible
transfer to a medium secure mental health unit, and for psychiatric observation and
regular follow up from the mental health team to review risk issues. He noted that if
baseline observations were normal, then oral antipsychotic medication should be
considered.
65. At interview, the consultant psychiatrist said his SystmOne entry made at the time
did not save and it was entered again just after 9.00am on 24 June (after Mr
Ashcroft had been taken to hospital).
66. The nurse said at interview that her role was to escort the consultant psychiatrist
and she took no part in the assessment and made no notes of her own. She said
she could not remember the details of the assessment, although she remembered
that Mr Ashcroft had been ‘very distressed’.
67. At 1.47pm, a nurse noted she had carried out Mr Ashcroft’s CSU assessment. She
noted he was calm and relaxed and did not express any thoughts of self-harm or
suicide and she had no concerns for his health at that time. There is no paperwork
to suggest she completed a Segregation Assessment Screen.
68. At 2.45pm, an unknown staff member made an entry in the CSU wing observation
book that Mr Ashcroft had to be moved to another cell after damaging the one he
was in.
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69. At about 3.30pm, the Head of Residence emailed a member of the prison’s
psychology department, the Clinical Matron for Mental Health and the Head of
Healthcare to ask for information to assist CSU staff in supporting Mr Ashcroft’s
mental health and understanding the best way to communicate and engage with
him. She said she understood that the psychiatrist had been to see him and that it
would be helpful for prison staff to receive feedback from him.
70. The Clinical Matron for Mental Health responded and said Mr Ashcroft’s mental
health worker would be visiting him the next day to get a better understanding of his
needs.
ACCT Opened
71. At around 4.00pm, a nurse started suicide and self-harm procedures (known as
ACCT) after Mr Ashcroft told her that there were spiders in his body, and he was
ready to kill himself. At interview she described Mr Ashcroft as ‘acutely unwell’ and
said she ‘100% believed he would make an attempt [to kill himself]’.
72. An officer completed the Immediate ACCT Action Plan and set observations at five
an hour.
73. As an ACCT had been opened, a nurse completed another Initial Segregation
Health Screen and Health Algorithm. In answer to the question, ‘Does the prisoner
show signs of being acutely unwell … at the present time?’, she circled ‘Yes’. This
leads to the box that says, ‘There are healthcare reasons not to segregate at this
time – discuss with health team.’ Despite this, the nurse marked the other box that
says, ‘No healthcare intervention at this time’. She also answered both ‘Yes’ and
‘No’ to the question, ‘Do you think that the prisoner will be able to ‘cope’ with a
period of segregation?’ (as a previous nurse had done). At interview she told us she
felt Mr Ashcroft would be better off in the CSU ‘due to the quieter environment and
… more engagement from staff’.
74. The Head of Security and Intelligence signed the form to say he had read the Initial
Segregation Health Screen. There is no evidence he queried the nurse’s
conclusion. He authorised the decision to segregate. He recorded that he had read
the ACCT plan and considered other options to segregation.
75. The Head of Security also completed a defensible decision log. He noted he had
spoken to Mr Ashcroft at length that day and considered his needs could be met in
the CSU, and that he would be vulnerable on the wings. The nurse had agreed with
him. He did not consider Mr Ashcroft needed distraction material or anti- ligature
clothing and bedding as he was not actively self-harming.
24 June
76. The ACCT observation log shows that Mr Ashcroft was checked five times an hour
during the morning of 24 June. However, the police reviewed the CCTV footage
from midnight to 7.00am and found that many of the recorded checks were not
carried out.
77. Officer A documented five checks between midnight and 1.00am, but only carried
out two of them. Another officer relieved him when he went on his break between
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1.00am and 2.00am and completed four checks (as he had documented that he
had completed one just before 1.00am, although he had not done so).
78. Officer A returned from his break and documented five checks between 2.00am and
3.00am, but CCTV shows he only approached the cell once in that time. From this
point until 6.00am, CCTV shows that he made only one check an hour, but
documented four or five an hour. At 3.53am, Mr Ashcroft pressed his emergency
cell bell and he did not respond until 4.17am.
79. Between 6.00am and 6.50am, Officer A made five log entries compared to two
actual checks (which occurred at 6.06am and 6.36am). At 6.38am, he documented
that Mr Ashcroft was sitting on the floor and making no sense. This was the last
time he checked Mr Ashcroft.
80. At 6.50am, Officer A made his last log entry, which says that Mr Ashcroft was ‘stood
in cell pacing around’. CCTV shows that he did not carry out this check.
Emergency response
81. At 6.47am, Officer B came on duty and made his way to the CSU, where he
received a handover from Officer A. Officer B had been detailed to cover video-link
duties, but the rota had changed to put him in the CSU.
82. At 6.54am, Officer B checked on Mr Ashcroft. He described the cell as ‘trashed’ with
items on the floor and the mattress on the floor. Mr Ashcroft was on the floor
between the mattress and his sink. He was on his front with his head turned
towards the sink. The officer said he was confused as, according to the ACCT book,
Mr Ashcroft had been fine only minutes earlier.
83. Officer B thought he could see a small piece of green material above Mr Ashcroft’s
collar, which he thought might be a ligature. He called out to Mr Ashcroft but got no
response. He went to the CSU office to use the radio to call for assistance (as his
own radio was turned off and assigned to him for video-link duties and would take
time to load up). An Operational Support Grade (OSG), who was the duty
communications controller, heard his call, ‘Staff assistance required. Prisoner under
ligature’.
84. The OSG sounded the prison’s emergency alarm, called over the radio for staff
assistance and asked for Oscar 1 (the call sign for the Night Orderly Officer in
charge of the prison overnight) and Hotel 1 (the healthcare first responder) to
acknowledge the message.
85. Officer B said he did not know Mr Ashcroft and so was not comfortable going into
the cell alone. He told the investigator he had also experienced a fake self-harm
incident the day before. Mr Ashcroft’s cell was the furthest from the CSU gate, but
as soon as he heard the gate being unlocked by other staff, he entered the cell, at
6.56am.
86. Officer B cut the ligature from Mr Ashcroft’s neck using his fish knife. The ligature
appeared to have been made from a thin piece of bedding and was not attached to
anything. He told the investigator he was focused on removing the ligature and that
it did not enter his mind to call a medical emergency code. There was blood around
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Mr Ashcroft’s nose and mouth, and he started chest compressions. Officer C
arrived first and helped with cardiopulmonary resuscitation. Other staff also
attended. At 6.58am, a CM called a code blue and confirmed an ambulance was
required. A prison manager also arrived.
87. At 7.00am, two nurses arrived. Prison staff were doing compressions and Mr
Ashcroft was warm to the touch. One nurse applied a defibrillator, but it advised ‘no
shock’. Staff continued with CPR. Two more nurses arrived and assisted with
efforts. Two ambulances arrived at 7.10am, followed by a third at 7.16am and an air
ambulance carrying a doctor at 7.36am.
88. A CM completed the escort risk assessment and decided that Mr Ashcroft should
be escorted to hospital by two officers but with no handcuffs. Paramedics said that
the prognosis was not good. However, they detected a rhythm and took Mr Ashcroft
to hospital at 7.48am.
89. Mr Ashcroft was put on a ventilator, and the prison healthcare team contacted the
hospital regularly about his condition. On 1 July at 7.47am, treatment was
withdrawn, and Mr Ashcroft died at 8.10am.
Contact with Mr Ashcroft’s family
90. On 24 June, the prison appointed a family liaison officer. He contacted Mr
Ashcroft’s mother to tell her Mr Ashcroft had been taken to hospital and maintained
contact with her.
91. Mr Ashcroft’s funeral was on 23 July. The prison contributed to the costs in line with
national policy.
Support for prisoners and staff
92. After Mr Ashcroft was taken to hospital, a prison manager debriefed the staff
involved in the emergency response to signpost staff to support and initiate any
required further actions. On 3 July, the manager held a cold debrief to discuss any
potential learning points.
93. The prison posted notices informing other prisoners of Mr Ashcroft’s death and
offering support. Staff reviewed all CSU prisoners assessed as being at risk of
suicide or self-harm in case they had been adversely affected by the incident.
Post-mortem report
94. The post-mortem report concluded that Mr Ashcroft died of hypoxic brain injury
(lack of oxygen to the brain) consistent with ligature application.
95. Toxicology tests showed therapeutic levels of quetiapine (an anti-psychotic),
mirtazapine (an antidepressant), metoclopramide (an anti-emetic) and methadone
in Mr Ashcroft’s system at the time of his death, together with a high level of
buprenorphine and the presence of psychoactive substances (PS). There has likely
been therapeutic range use of metoclopramide, mirtazapine, methadone and
quetiapine. The mirtazapine and quetiapine may be artefactually raised in post-
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mortem blood due to redistribution. Mr Ashcroft was not prescribed metoclopramide
or methadone at the time of his death. The pathologist said that although the use of
PS and the high level of buprenorphine may have impacted on Mr Ashcroft’s
thought processes and awareness at the time of his death, he did not consider they
contributed to his death in a toxicological sense.
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Findings
Clinical care
96. Mr Ashcroft had been at Lincoln for only five weeks when he died and had received
substantial input from healthcare services during this time. The clinical reviewer
concluded that the clinical care Mr Ashcroft received was of a reasonable standard
and equivalent to that he could have expected to receive in the community, despite
it being during the difficult early days of the COVID-19 pandemic.
97. The clinical reviewer said that Mr Ashcroft was quickly and appropriately referred to
a psychiatrist who diagnosed delusional parasitosis and had planned to refer him
for more specialised assessment by secure mental health services, but he died
before this could be actioned.
98. The clinical reviewer noted that Mr Ashcroft also had a long history of substance
and alcohol misuse and had regularly been under the care of substance misuse
services in the community and in prison. Despite the many courses of treatment
given to him, he had continued to use illicit substances.
99. The clinical reviewer noted that Mr Ashcroft had decided to reduce his methadone
dose rapidly while he was at Lincoln. She asked the substance misuse specialist if
a rapid reduction of methadone may cause an increase in mental health symptoms,
such as Mr Ashcroft’s delusional parasitosis. He said that in his experience it was
very rare for a rapid reduction to trigger psychosis. He also said that Mr Ashcroft
had instigated rapid reductions before with no known mental health impact.
Communication with prison staff
100. Although Mr Ashcroft received a good level of healthcare, we are concerned that
healthcare staff did not make it clear to prison staff that he had serious mental
health problems.
101. For example, although healthcare staff recognised that Mr Ashcroft appeared to be
acutely mentally unwell from at least 15 June (when it was agreed he needed an
urgent appointment with the psychiatrist), the officer who recorded that Mr Ashcroft
appeared to be trying to manipulate a transfer to hospital on 22 June appeared to
be completely unaware of this or of Mr Ashcroft’s delusions about being infested
with spiders.
102. We are also concerned that there is no evidence that healthcare staff made prison
staff aware that the consultant psychiatrist had assessed that Mr Ashcroft was
having an acute psychotic episode on 23 June. When the Head of Residence asked
for feedback on the psychiatrist’s visit later that day, she was simply told that Mr
Ashcroft’s mental health worker would see him the following day.
103. If prison staff had had a better understanding of how unwell Mr Ashcroft was, it is
possible they would have managed him differently and may have concluded that
segregation was inappropriate or that he should be placed on constant watch.
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We recommend:
The Head of Healthcare should ensure that healthcare staff share information
about a prisoner’s mental or physical health with prison staff where this is
necessary to keep a prisoner safe
Fitness for segregation
104. We are concerned that the Initial Segregation Health Screens, which are used to
assess whether a prisoner is medically fit to be segregated, were completed
incorrectly.
105. The first, completed by a nurse on 22 June, answered ‘Yes’ and ‘No’ to the same
question and had no conclusion marked. We consider that the second, completed
by another nurse on 23 June, reached the wrong conclusion as, according to the
answers given, she should have concluded that there were healthcare reasons not
to segregate Mr Ashcroft. We are particularly concerned about this because she
had recorded on the health screen that Mr Ashcroft was ‘acutely unwell’ and
because she told us at interview that she believed Mr Ashcroft was serious about
attempting to kill himself.
106. The nurse told us that she had not been trained in completing the Segregation
Health Screen and she found it confusing. The Clinical Matron for Mental Health
told us that the form is very simple to follow and although healthcare staff are given
no specific training in completing it, they are mentored for four to six weeks before
they attend CSU or ACCT reviews on their own. We consider that the fact that two
nurses made similar errors in completing this very important form suggests that
training is required. In addition, it is important that healthcare staff understand that
they are not simply completing a form for the sake of it – they are contributing to a
key decision about whether a prisoner can be segregated safely.
107. We are also concerned that there is no evidence that another nurse completed a
Segregation Health Screen on 23 June. Her assessment that Mr Ashcroft was calm
and relaxed was completely at odds with his presentation less than two hours
previously when the consultant psychiatrist had concluded he was having an acute
psychotic episode, and with his presentation two hours later when another nurse
opened an ACCT and recorded that he was acutely unwell. Unfortunately, this
nurse was not available for interview to explain her assessment.
108. We are also concerned that despite the managers who authorised segregation both
signing to say they had read the Initial Segregation Health Screen, neither queried
the conclusion, or lack of conclusion, or whether the segregation unit was an
appropriate location for an acutely unwell prisoner.
109. It is well known that segregation can have a detrimental effect on prisoners’ mental
health, and it is important that every prisoner is properly assessed before being held
in segregation. If there are healthcare reasons not to segregate, this needs to be
highlighted and then managers need to assess carefully whether there are
alternatives available.
110. This is particularly important in the case of prisoners who are subject to ACCT
monitoring. Such prisoners are, by definition, particularly vulnerable and locating
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them in segregation units should be avoided wherever possible. Prison Service
Instruction (PSI) 64/2011 on safer custody and Prison Service Order (PSO) 1700 on
segregation both make this clear. PSI 64/2011 says:
‘Prisoners on open ACCT plans must only be located or retained in Segregation
Units only in exceptional circumstances. The reasons must be clearly
documented in the ACCT Plan and include other options that were considered
but discounted.’
111. Given the errors in completing the Segregation Health Screen and the apparent
lack of scrutiny or challenge by the prison managers who authorised Mr Ashcroft’s
segregation, we are not satisfied that the CSU was the most appropriate location for
a man who was described as ‘acutely unwell’.
112. We recommend:
The Governor and Head of Healthcare should ensure that:
• healthcare staff are trained in the completion and importance of Initial
Segregation Health Screens;
• healthcare staff complete Initial Segregation Health Screens fully and
accurately and arrive at a clear conclusion; and
• authorising managers understand how the Initial Segregation Health
Screen should be completed and query it if it appears incorrect or
incomplete.
ACCT observations
113. Mr Ashcroft should have been checked five times an hour on the night of 23/24
June. We are very concerned that Officer A failed to carry out many of the checks
and falsified the ACCT log to make it look as though they had been completed
when they had not, and that Mr Ashcroft was not observed at all for the 18 minutes
before he was found unresponsive.
114. When he was interviewed by the police, Officer A said that as long as he could hear
Mr Ashcroft shouting or banging, he knew he was still alive, and he did not therefore
always need to check him visually. This displays a worrying misunderstanding of
the purpose of the ACCT observations. Mr Ashcroft was on five observations an
hour and the officer should have realised this meant he was considered to be at
high risk of suicide or self-harm. If he had checked him frequently, the officer might
have noticed signs that Mr Ashcroft was preparing to self-harm or use a ligature, or
signs that he was becoming increasingly distressed.
115. Officer A has since been convicted of misconduct in a public office.
116. It is not uncommon for our investigations into deaths in prisons to reveal that ACCT
checks have not been completed as they should have been. In such cases, it is
always difficult for us to know whether what we are seeing are the failures of a
single officer, or whether there is a general culture among staff at the prison that
ACCT checks do not need to be done. We are pleased to see that managers at
Lincoln have introduced an additional assurance process using CCTV to check if
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recorded ACCT observations have actually been carried out. We, therefore, make
no recommendation.
Emergency response
117. Prison Service Instruction (PSI) 24/2011 on the management of prisons at night
says that staff should not normally enter a cell at night unless there are at least two
or three staff present and entry has been authorised by the Night Orderly Officer
(NOO). However, it also says that where there is, or appears to be, immediate
danger to life, then cells may be unlocked without the authority of the
NOO and an individual member of staff may enter the cell on their own after first
conducting a dynamic risk assessment. However, night staff should not take action
that they feel would put themselves or others in unnecessary danger.
118. PSI 3/2013 says that prisons must have a medical emergency response code
protocol in place to ensure a timely, appropriate and effective response to medical
emergencies. A code blue is called when a prisoner is unconscious or having
breathing difficulties and a code red is called for serious blood loss or burns. When
a medical emergency code is called it should automatically trigger the prison’s
communications room to call an ambulance and prison healthcare staff to attend the
emergency immediately with the appropriate equipment.
119. In a medical emergency minutes may make the difference between life and death.
The PSI says that if staff are in any doubt about the nature of the situation, they
must call a code and that ‘it is better to act with caution and request an ambulance
that can be cancelled if it is later assessed as not required’.
120. When Officer B saw Mr Ashcroft lying on his cell floor with what looked like a
ligature around his neck, he called for staff assistance. He then waited at the cell
door until he heard other officers arriving on the unit, and then he went into the cell
and cut the ligature around Mr Ashcroft’s neck. It was not until two minutes later -
four minutes after he saw Mr Ashcroft unresponsive on the floor - that a CM called a
code blue. The officer said he was focused on cutting the ligature rather than calling
a code, which did not enter his mind.
121. We understand why Officer A considered it may not be safe to go into the cell alone
and we recognise that he went in as soon as he heard other staff arriving. We do
not criticise him for this.
122. However, we are concerned that he did not call an emergency medical code
straightaway, given that Mr Ashcroft was not responding, and he thought he could
see a ligature. He subsequently radioed, ‘Staff assistance required. Prisoner under
ligature’ but did not call a code.
123. Officer A has since been reminded about the use of medical emergency codes and
he showed a good understanding when interviewed by the PPO investigator. We do
not therefore make a recommendation.
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Illicit substances at Lincoln
124. Toxicology tests showed that Mr Ashcroft had taken psychoactive substances (PS)
shortly before he was found unresponsive. We know that PS can have a detrimental
effect on mental health and can increase the risk of suicide and self-harm.
However, we cannot say how much impact the use of PS had on Mr Ashcroft’s
death.
125. He had also used methadone and metoclopramide (prescription-only drugs that he
had not been prescribed). He had presumably obtained these drugs and the PS
illicitly within the prison.
126. The most recent HMIP inspection in 2020 found that work done to limit the supply of
substances into the prison was good, as was the prison’s drug strategy. In terms of
target searching following receipt of intelligence, it said searches had increased
substantially, but nearly a third of suspicion drug tests were not carried out.
127. We are concerned that the post-mortem toxicology tests suggest that Mr Ashcroft
had been using illicit substances more than staff were aware of. We are also
concerned that although a fact-finding report conducted by the prison after Mr
Ashcroft’s death said that he was suspected of being under the influence of illicit
substances on 18 June, we have seen no evidence that staff recorded this at the
time or that they submitted an intelligence report. It is important that incidents of
suspected drug use are recorded and acted upon. We recommend:
The Governor should ensure staff record incidents of suspected substance
misuse and submit intelligence reports.
Inquest
128. At the inquest, held from 2 to 17 March 2026, the jury concluded that based on the
evidence they heard, they were satisfied that Mr Ashcroft did not intend to take his
life and died by misadventure.
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