Mani Kurian Kattampakkal

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Independent investigation
into the death of
Mr Mani Kurian Kattampakkal,
a prisoner at HMP Littlehey,
on 9 February 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, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Mani Kurian Kattampakkal was found unresponsive in his cell with a ligature around his
neck on 9 February 2024 at HMP Littlehey. Staff and paramedics tried to resuscitate him
but were unsuccessful. He was 58 years old. I offer my condolences to Mr Kurian
Kattampakkal’s family and friends.
Mr Kurian Kattampakkal was the fourth self-inflicted death at Littlehey in three years. He
had given no indication to staff that he was at risk of suicide in the lead up to his death and
I am satisfied that staff could not have foreseen his actions.
There was a delay in staff starting CPR when they found Mr Kurian Kattampakkal
unresponsive. Neither of the two staff who found him were trained in first aid. Despite
Littlehey’s health and safety risk assessment saying that 80% of staff on duty at night
should be first aid trained, only 14% were on the night Mr Kurian Kattampakkal died. The
prison has since introduced mandatory first aid training for all staff.
I make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman August 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 6 September 2022, Mr Mani Kurian Kattampakkal was recalled to prison for
breaching his licence conditions. On 25 November, he was moved to HMP
Littlehey.
2. A nurse completed Mr Kurian Kattampakkal’s initial health screen and noted that he
had mental health issues and a history of suicide attempts. A psychiatrist saw Mr
Kurian Kattampakkal and prescribed him antipsychotic medication.
3. Mr Kurian Kattampakkal continued to take his medication and was seen regularly by
the mental health team.
4. On 23 January, Mr Kurian Kattampakkal told prison staff that other prisoners
thought he had been giving information to staff about prisoners taking drugs on D
Wing and he therefore felt under threat. Staff moved Mr Kurian Kattampakkal to the
segregation unit for his own protection.
5. On the evening of 8 February, Mr Kurian Kattampakkal spoke to his son. The
conversation was strained and difficult. Staff were unaware of the nature of the call.
6. At around 5.15am on 9 February, while conducting the early morning routine roll
count, an operational support grade (OSG) looked into Mr Kurian Kattampakkal’s
cell and noticed that the shape in the bed did not match his size. Another officer
happened to be walking past, so the OSG called him over and asked him to have a
look in the cell.
7. The officer turned on the night light and could see Mr Kurian Kattampakkal’s feet
under the shower curtain. He knocked on the cell door, but Mr Kurian Kattampakkal
did not respond.
8. The OSG called a code blue at 5.16am and they both entered the cell. They saw
that Mr Kurian Kattampakkal was lying on the floor unresponsive with a ligature tied
around his neck. The officer used his anti-ligature knife to cut the ligature from Mr
Kurian Kattampakkal’s neck. The OSG fetched a defibrillator and both he and the
officer tried to attach the defibrillator pads to Mr Kurian Kattampakkal’s chest, but
the pads would not stick. The night custodial manager responded to the code blue
and at 5.23am, he arrived and started CPR.
9. Ambulance paramedics arrived at 5.35am, and continued CPR. They were not able
to regain a pulse and at 6.11am, they declared that Mr Kurian Kattampakkal had
died.
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Findings
10. Mr Kurian Kattampakkal had given no indication to staff at Littlehey that he was at
risk of suicide. He was taking his antipsychotic medication and had told staff that he
had no thoughts of suicide or self-harm. We are satisfied that staff could not have
foreseen his actions.
11. Due to the OSG’s sharp observation skills, staff identified that Mr Kurian
Kattampakkal was unresponsive and called a code blue. However, they did not start
CPR. Neither the OSG nor the officer who found Mr Kurian Kattampakkal were first
aid trained.
12. We found that insufficient staff on duty that night were first aid trained, despite a
local policy that 80% of staff on duty at night should be first aid trained. There were
no contingencies in place to address the shortage of first aid trained staff on duty.
The prison has since introduced mandatory first aid training for all staff, starting in
November 2024.
13. The clinical reviewer concluded that overall, the care that Mr Kurian Kattampakkal
received was equivalent to that which he could have expected to receive in the
community.
14. We commend the OSG for the diligence he showed when conducting his roll count.
We also note the good practice showed by the night custodial manager when he
arranged for all the prison gates to be opened to enable quick access for the
ambulance.
15. We make no recommendations.
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The Investigation Process
16. HMPPS notified us of Mr Kurian Kattampakkal’s death on 9 February 2024.
17. The investigator issued notices to staff and prisoners at HMP Littlehey informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
18. The investigator visited Littlehey on 21 February. She obtained copies of relevant
extracts from Mr Kurian Kattampakkal’s prison and medical records.
19. The investigator interviewed two members of staff by video call.
20. NHS England commissioned a clinical reviewer to review Mr Kurian Kattampakkal’s
clinical care at the prison. The investigator and clinical reviewer interviewed one
member of staff by video call.
21. We informed HM Coroner for Cambridgeshire and Peterborough of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
22. The Ombudsman’s office contacted Mr Kurian Kattampakkal’s wife to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Kurian Kattampakkal’s wife did not respond.
23. The initial report was shared with HMPPS. HMPPS pointed out some factual
inaccuracies, and this report has been amended accordingly.
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Background Information
HMP Littlehey
24. HMP Littlehey is a category C training prison for men convicted of sexual offences.
Northamptonshire NHS Foundation Trust provides healthcare services at the
prison. The prison healthcare centre is open from Monday to Thursday from 7.30am
to 7.30pm, on Fridays from 7.30am to 5.20pm and at weekends from 8.00am to
5.50pm. A local practice provides GP services, and there is a range of nurse-led
clinics. There are no inpatient beds at the prison.
HM Inspectorate of Prisons
25. The most recent inspection of HMP Littlehey was in September 2023. Inspectors
reported that Littlehey continued to be an overwhelmingly safe prison, with little
violence. They found that referrals for the mental health team were mainly received
from staff in reception, but also from other prison staff, and prisoners could self-
refer. All new and ongoing patients were discussed at the weekly multidisciplinary
team meeting. The service also provided a twice-weekly drop-in clinic, where
prisoners could receive basic advice and signposting.
26. They also noted that levels of self-harm, which were low at the time of the previous
inspection, had decreased by about 30% and were well below the average among
similar prisons. Only a minority of self-harm incidents were serious, and reviews
were conducted on these to try to identify any lessons to be learnt.
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 annual report for the year to 31 January 2023, the IMB reported that
the prison continued to be generally safe and secure and that prisoners were
treated with respect and decency. They reported that previous PPO
recommendations had been accepted and implemented.
28. The Board also noted the introduction of mental health drop-in clinics on a Friday
afternoon which had helped prisoners manage their mental health and seek ad hoc
support as they needed it.
Previous deaths at HMP Littlehey
29. Mr Kurian Kattampakkal was the fourth prisoner to take his life at Littlehey since
February 2021. There were 38 deaths from natural causes at Littlehey between
February 2021 and 2024. There were no similarities between the findings from our
investigation into Mr Kurian Kattampakkal’s death and the findings from our
investigations into the previous deaths at the prison.
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Key Events
30. On 6 September 2022, Mr Mani Kurian Kattampakkal was recalled to prison for
breaching his licence conditions in relation to a conviction for sexual offences. He
was sent to HMP Wandsworth. (He had no release date as this had to be agreed by
the Parole Board at an oral hearing. This had not happened by the time he died.)
31. On 25 November, Mr Kurian Kattampakkal was moved to HMP Littlehey. A nurse
completed Mr Kurian Kattampakkal’s initial health screen at Littlehey and noted that
he had several long-term health issues, including diabetes and bipolar disorder for
which he received regular medication.
32. On 10 January 2023, a nurse saw Mr Kurian Kattampakkal to complete a mental
health assessment. Mr Kurian Kattampakkal told the nurse that he had previously
tried to take his life by jumping in front of a bus and had tied a noose in his attic with
the intention to take his life. Mr Kurian Kattampakkal said he had no current
thoughts of suicide or self-harm. She recorded that Mr Kurian Kattampakkal had a
high assessment score that indicated he was suffering with severe depression. She
referred him to the mental health team.
33. On 13 January, a psychiatrist saw Mr Kurian Kattampakkal and prescribed
quetiapine (an antipsychotic medication that can be used as a mood stabiliser). He
recorded that that he would be reviewed again in three months’ time.
34. Over the next 12 months, a mental health nurse regularly saw Mr Kurian
Kattampakkal. She noted that he was taking his medication and reported no
thoughts of suicide or self-harm.
35. On 23 January, Mr Kurian Kattampakkal told prison staff that other prisoners
thought he had been giving information to staff about prisoners taking drugs on D
Wing and he therefore felt under threat. Staff moved Mr Kurian Kattampakkal to the
segregation unit for his own protection.
36. A mental health nurse saw Mr Kurian Kattampakkal in the segregation unit and
noted that he had no thoughts of self-harm and was fit for segregation.
37. Prison security staff looked at where in the prison Mr Kurian Kattampakkal could be
safely located and on 26 January, he was moved from the segregation unit to L
Wing.
38. Mr Kurian Kattampakkal had regular key work sessions with his allocated key
worker who had no concerns. Staff recorded no concerns about him on L Wing.
39. Mr Kurian Kattampakkal made frequent calls to his son and ex-wife. All calls are
recorded. The investigator listened to the calls Mr Kurian Kattampakkal made in the
months leading up to his death. The conversations were strained as it was clear
that the family struggled to come to terms with his offences, but Mr Kurian
Kattampakkal did not say that he was feeling low or suicidal.
40. On the evening of 8 February, Mr Kurian Kattampakkal spoke to his son. It was a
difficult conversation and Mr Kurian Kattampakkal’s son implied that his father
would be better off dead. Staff were not aware of the call or its nature.
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Events of 9 February
41. On 9 February at around 5.15am, an operational support grade (OSG) started his
early morning routine check. When he got to Mr Kurian Kattampakkal’s cell, he
looked through the observation panel and noticed that the shape in the bed did not
match the size of Mr Kurian Kattampakkal. He said that from his prison picture
displayed on the card outside the cell, Mr Kurian Kattampakkal looked like a larger
man and the shape in the bed was of a small frame.
42. At the same time, an officer was walking through L Wing. The OSG called the
officer to the cell to have a look. The officer knocked on the cell door and called Mr
Kurian Kattampakkal’s name, but he did not respond. He turned on the night light
and they could see Mr Kurian Kattampakkal’s feet on the floor at the bottom of the
shower curtain in the toilet area.
43. At 5.16am, the OSG called a code blue over the radio (a medical emergency code
used when a prisoner is unconscious or having breathing difficulties that alerts
healthcare staff and tells the control room to call an ambulance immediately). The
officer opened the cell door and saw that Mr Kurian Kattampakkal was lying
unresponsive on the floor with a ligature tied around his neck.
44. The officer used his anti-ligature knife to cut the ligature from Mr Kurian
Kattampakkal’s neck. The control log shows that at 5.18am, the OSG in the control
room called an ambulance.
45. The officer told the OSG to fetch a defibrillator (an electronic device that gives an
electric shock to try to restart the heart) while he checked for signs of life. It was
clear that Mr Kurian Kattampakkal was not breathing. Both the officer and the OSG
tried to attach the defibrillator pads to Mr Kurian Kattampakkal’s chest, but they
were unable to do so because the pads would not stick. Body worn camera footage
shows that at 5.23am, a custodial manager (CM), the night orderly officer (the
senior officer in charge of the prison at night), arrived and immediately started CPR.
46. At 5.35am, paramedics arrived and continued resuscitation. The paramedics were
not able to regain a pulse and at 6.11am, they declared that Mr Kurian
Kattampakkal had died.
Contact with Mr Kurian Kattampakkal’s family
47. At around 12.30pm on 9 February, a family liaison officer (FLO) at HMP Lewes
went to Mr Kurian Kattampakkal’s wife’s home to tell her of her husband’s death
(having first visited the old address on Mr Kurian Kattampakkal’s prison record).
48. After Mr Kurian Kattampakkal’s family had been told of his death, a CM and an
officer at Littlehey took over the role of FLOs. The CM met with Mr Kurian
Kattampakkal’s family at the hospital mortuary and maintained contact and offered
support in arranging Mr Kurian Kattampakkal’s repatriation to India.
49. The prison paid the repatriation expenses in line with national instructions.
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Support for prisoners and staff
50. After Mr Kurian Kattampakkal’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.
51. The prison posted notices informing other prisoners of Mr Kurian Kattampakkal’s
death and offered support. Staff reviewed all prisoners assessed as being at risk of
suicide or self-harm in case they had been adversely affected by Mr Kurian
Kattampakkal’s death.
Post-mortem report
52. The post-mortem report concluded that Mr Kurian Kattampakkal died from ligature
strangulation.
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Findings
Assessment of Mr Kurian Kattampakkal’s risk of suicide
53. Mr Kurian Kattampakkal had bipolar disorder and told staff at Littlehey that he had
attempted suicide in the past. However, he took his antipsychotic medication as
prescribed and was seen regularly by the mental health team. He told staff that he
had no thoughts of suicide or self-harm and there were no indications that he was
struggling with his mental health or that he was in crisis in the days before his
death.
54. Mr Kurian Kattampakkal’s final phone call with his son was difficult but staff were
not aware of the nature of the call. We are satisfied that staff could not have
foreseen his actions.
Emergency response
55. When staff found Mr Kurian Kattampakkal unresponsive with a ligature tied around
his neck, they immediately called a code blue and cut the ligature. However, they
did not start CPR as neither the officer nor OSG were first aid trained.
56. Littlehey does not have 24-hour healthcare so there are no healthcare staff in the
prison during the evening and night. If a code blue is called during this time, prison
staff must respond and start emergency first aid.
57. On the night Mr Kurian Kattampakkal died, only three members (14%) of staff on
duty were first aid trained. The night orderly officer was one of them and he started
CPR when he arrived. However, the other two first aid trained members of staff
were in positions they could not leave (one was undertaking constant supervision
and one was opening the prison gates to enable the ambulance to enter), which
meant that the night orderly officer had to continue with CPR, rather than oversee
the management of the incident which should have been his role.
58. Littlehey’s local risk assessment says that 80% of staff on a night shift should be
trained in first aid, and the risk assessment form says that contingencies should be
put in place if the number of first aid trained staff on any night shift falls below 80%.
59. At interview the investigator asked the night orderly officer if any contingencies had
been put in place, given that the percentage of staff trained in first aid on duty on
the night Mr Kurian Kattampakkal died fell well below the requirement. He was not
familiar with the risk assessment document and seemed unaware of the need for
contingencies if the 80% requirement was not met.
60. The training manager told the investigator that only 31% of staff at Littlehey were
trained in first aid and that it had been difficult to increase numbers as the training
was voluntary and many staff did not want to do it. The prison is bringing in a new
policy where first aid training will be mandatory for all staff. However, this training is
not starting until November and will take several months for all staff to be fully
trained.
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61. While we do not make a recommendation, we bring this issue to the Governor’s
attention.
Clinical care
62. The clinical reviewer found that the care that Mr Kurian Kattampakkal received was
of a good standard and equivalent to that which he could have expected to receive
in the community.
63. The clinical reviewer noted that the care that Mr Kurian Kattampakkal received for
his mental health was of a high standard and above expected practice.
Good practice
64. When the OSG completed his morning routine check, he looked through the
observation panel and noticed that the shape in bed did not look like that of Mr
Kurian Kattampakkal. His excellent observation skills meant that staff checked on
Mr Kurian Kattampakkal and identified that he was unresponsive. He should be
commended for showing such professional curiosity and diligence.
65. After responding to the code blue, the night orderly officer directed staff to open all
the entrance gates to the prison, to allow ambulances quick access. He should be
commended for his quick thinking and pragmatic approach.
Inquest
66. At the inquest, held from 6 to 8 August 2025, the jury concluded that Mr Kurian
Kattampakkal died by suicide.
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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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