Mehdi Ghorbani

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Mehdi Ghorbani,
a prisoner at HMP Leeds,
on 11 May 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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 Medhi Ghorbani was found hanged in his cell on 11 May 2023 at HMP Leeds. He was
44 years old. I offer my condolences to Mr Ghorbani’s family and friends.
Mr Ghorbani was the fourteenth prisoner to die by suicide at Leeds in three years. Up to
the end of 2023, there had been one self-inflicted death since Mr Ghorbani’s death.
Mr Ghorbani was a vulnerable prisoner who preferred to spend time alone. While he spoke
good English, his first language was Arabic, and he had very little family support during his
time at Leeds.
When he arrived at Leeds in January 2023, staff recognised that Mr Ghorbani was at risk
of suicide and self-harm and supported him using suicide and self-harm prevention
procedures (known as ACCT). We found that staff managed the ACCT procedures well.
Mr Ghorbani’s behaviour deteriorated from March. My investigation found that staff did not
fully explore the change in Mr Ghorbani’s behaviour. However, in the weeks before his
death, Mr Ghorbani’s behaviour improved and there was no indication that he was at
imminent risk of suicide when he died.
The clinical reviewer concluded that the care Mr Ghorbani received at Leeds was of a
good standard and 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
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. In 2017, Mr Medhi Ghorbani was convicted of rape and sentenced to ten years in
prison. He was released in December 2022. In January 2023, Mr Ghorbani was
recalled to HMP Leeds after he failed to comply with the conditions of his licence.
2. Mr Ghorbani was Iranian and while he preferred to speak Arabic, he spoke good
English. He was a vulnerable prisoner due to the nature of his offence. His family
lived in Iran, and he had no family support in the UK. He made no phone calls and
received no visits while in prison. Due to his history of racist behaviour, staff
decided that Mr Ghorbani could only share a cell with a prisoner of the same
ethnicity.
3. Prison staff managed Mr Ghorbani under Prison Service suicide and self-harm
prevention measures (known as ACCT) when he arrived at Leeds after he told staff
he intended to self-harm in prison.
4. From 1 March, Mr Ghorbani’s behaviour deteriorated. He accessed the safety
netting that separated the wing landings, received conduct warnings for failing to
attend work and was downgraded to a basic regime (meaning certain privileges
were removed) after he damaged prison property. Staff referred Mr Ghorbani for a
challenge, support and intervention plan (CSIP – a process used to manage difficult
prisoners and victims of violence or threat) and provided regular keywork sessions
to support him.
5. On 4 May, a custodial manager decided that Mr Ghorbani was suitable for the
standard regime. His behaviour had improved, he appeared well presented and
said he intended to apply for another job.
6. At 9.45am on 10 May, Mr Ghorbani left his cell for association (social time). At
11.52am, he told a prison officer that he was not hungry and did not want his lunch.
Mr Ghorbani refused his dinner at 4.45pm.
7. An operational support grade (OSG) completed the evening routine check at
8.08pm. Mr Ghorbani was watching television in his cell. This was the last time Mr
Ghorbani was seen alive.
8. At 5.25am on 11 May, the OSG went to Mr Ghorbani’s cell to complete the morning
routine check. He saw Mr Ghorbani had ligatured from his cell window. The OSG
immediately called a medical emergency code, went into the cell and cut the
ligature. Staff decided not to start cardiopulmonary resuscitation (CPR) because it
was clear that Mr Ghorbani had died. Healthcare staff arrived shortly after and
agreed that CPR was not appropriate. Ambulance staff arrived at 5.32am and
confirmed that Mr Ghorbani had died.
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Findings
9. ACCT procedures provided good support to Mr Ghorbani. Case reviews were multi-
disciplinary and care map actions reflected his mental health needs, his concerns
about medication and the need to gain suitable employment.
10. After his behaviour deteriorated, Mr Ghorbani received conduct warnings. While
staff made CSIP referrals and held regular keyworker sessions, they did not fully
explore the change in Mr Ghorbani’s behaviour, consider if he should be referred to
the safety intervention meeting and the mental health team or offered additional
support on the wing.
11. There was no indication that Mr Ghorbani was at imminent risk of suicide in the
days leading to his death. His behaviour had improved, and he had returned to the
standard regime. While Mr Ghorbani refused his meals on 10 May, staff did not
consider that this was unusual behaviour.
12. The clinical reviewer concluded that Mr Ghorbani’s mental health care was
equivalent to what he could have expected to receive in the community. Mental
health nurses attended ACCT reviews and completed a mental health assessment
when Mr Ghorbani asked for support.
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The Investigation Process
13. HMPPS notified us of Mr Ghorbani’s death on 11 May 2023.
14. The investigator issued notices to staff and prisoners at HMP Leeds informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
15. The investigator visited Leeds on 8 June. She obtained copies of relevant extracts
from Mr Ghorbani’s prison and medical records and spoke to three prisoners.
16. The investigator interviewed two members of staff at Leeds between August and
September 2023
17. NHS England commissioned a clinical reviewer to review Mr Ghorbani’s clinical
care at the prison.
18. We informed HM Coroner for West Yorkshire of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
19. We wrote to Mr Ghorbani’s family to explain the investigation and to ask if they had
any matters they wanted us to consider. Mr Ghorbani’s family did not ask any
questions but asked for a copy of our report.
20. Mr Ghorbani’s family received a copy of the initial report. The solicitor representing
the family did not raise any further issues, or comment on the factual accuracy of
the report.
21. 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 Leeds
22. HMP Leeds is a local prison holding up to 1,100 men who are on remand, convicted
or sentenced. The prison serves the courts of West Yorkshire. Practice Plus Group
provides healthcare services, including mental health services. Midlands
Partnership Trust provides psychosocial substance misuse services.
HM Inspectorate of Prisons
23. The most recent full inspection of HMP Leeds was in June 2022. Inspectors found
that Leeds was a well-led prison where leaders and managers were visible about
the wings and supportive staff-prisoner relationships were observed. Although
levels of self-harm were falling, there had been eight self-inflicted deaths since the
last inspection in 2019, but inspectors acknowledged the work that the prison had
done to address this major issue. Inspectors reported reduced levels of violence
since the last inspection with significantly fewer prisoners saying that they felt
unsafe.
24. Inspectors reported that mental health services were good, although there were
gaps in non-urgent care. They reported that a 40% staff vacancy rate had affected
the ability to deliver services in 2022, but all vacancies had since been filled.
Pharmacy services were safe and effective, but risk assessments were not always
followed adequately including prisoners who had daily in-possession medication.
Inspectors found that prisoners who were not collecting their medication were
usually followed up robustly.
25. Inspectors reported that the availability of key work sessions was better than at
other local prisons, with 69% of prisoners saying they had a keyworker and 61%
saying the sessions were helpful. Inspectors found that the same person delivered
most key work sessions.
Independent Monitoring Board
26. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 December 2022, the IMB
reported that they considered the prison to be a safe place for prisoners. However,
the number of self-inflicted deaths was a concern.
Previous deaths at HMP Leeds
27. Mr Ghorbani was the thirty third prisoner to die at Leeds since May 2020. Of the
previous deaths, 18 were due to natural causes, 13 were self-inflicted and one is
awaiting classification. Up to the end of 2023, there had been one self-inflicted
death since Mr Ghorbani’s death.
28. As a result of the number of self-inflicted deaths, Leeds is receiving support and
monitoring from HMPPS headquarters.
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Assessment, Care in Custody and Teamwork
29. 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.
Incentives and Earned Privileges (IEP) Scheme
30. Each prison has an Incentives and Earned Privileges scheme which aims to
encourage and reward responsible behaviour, encourage sentenced prisoners to
engage in activities designed to reduce the risk of re-offending and to help create a
disciplined and safer environment for prisoners and staff. Under the scheme,
prisoners can earn additional privileges such as extra visits, more time out of cell,
the ability to earn more money in prison jobs and to wear their own clothes. There
are three levels: basic, standard and enhanced.
Challenge, Support and Intervention Plan
31. A challenge, support and intervention plan (CSIP) is the national case management
model for managing those who are violent or pose raised risk of harming others
through violent behaviour.
32. It works alongside the zero-tolerance approach by challenging violent behaviours
and setting clear expectations on what behaviours are not acceptable and making
sure that punitive measures are not applied in isolation, placing equal focus on
ensuring individuals with challenging behaviours, so they can progress towards a
more positive outlook where they choose not to reoffend.
33. CSIP should be targeted at those individuals who display more challenging violent
behaviours or those who show signs they are highly likely to display this behaviour.
These challenging behaviours could be identified by the nature or frequency of their
violence, or the extent to which their behaviour strongly indicates that they are likely
to display more challenging violent behaviours. It is important that CSIP is never
used in place of an ACCT plan.
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Key Events
34. On 11 August 2017, Mr Medhi Ghorbani was convicted of rape and sentenced to
eight years in prison. He was sent to HMP Leeds. He spent time in several prisons
before he was released on licence from Leeds on 13 December 2022. Mr Ghorbani
was recalled to prison on 28 January 2023 after he failed to comply with the
conditions of his licence.
35. Mr Ghorbani arrived in England in 2006 from Iran. He was confirmed as a British
citizen in 2017. While Mr Ghorbani’s preferred spoken language was Arabic, he
spoke good English. Mr Ghorbani did not make any telephone calls or receive any
visits during his time in prison.
HMP Leeds
36. When Mr Ghorbani arrived at Leeds on 28 January, prison staff completed a cell
sharing risk assessment (CRSA). This recorded that Mr Ghorbani was a high risk
for sharing a cell because he had demonstrated racist behaviour towards other
prisoners. The CRSA said that Mr Ghorbani could share a cell with a prisoner who
shared the same ethnicity. A prison officer completed Mr Ghorbani’s first night
induction interview. He noted that Mr Ghorbani was known to prison staff at Leeds,
he engaged well and was aware of the support available to him. He did not express
any thoughts of suicide and self-harm. Mr Ghorbani was allocated a keyworker who
completed regular welfare checks.
37. A nurse completed Mr Ghorbani’s initial health assessment and noted his history of
depression and anxiety. Mr Ghorbani said he also suffered from epilepsy. He was
prescribed antidepressant medication and medication to treat his epilepsy which he
was not allowed to keep in his cell. The nurse made a referral to the mental health
team. Mr Ghorbani said that he had attempted suicide by ligature two months
previously and intended to self-harm in prison.
ACCT: 28 January- 20 February
38. At 6.00pm on 28 January, an officer started ACCT monitoring and decided that staff
should monitor Mr Ghorbani twice an hour, have three quality conversations during
the day and monitor him five times during the night.
39. Mr Ghorbani told the officer at his ACCT assessment that he had attempted to hang
himself two weeks before he came into prison and had not yet received his
antidepressant medication from healthcare.
40. On 29 January, a Senior Officer (SO) held an ACCT case review with a mental
health nurse and Mr Ghorbani. The SO noted that Mr Ghorbani’s parents lived in
Iran, and he had no family in this country. He preferred to be in a cell on his own
and asked to move to F wing, the vulnerable prisoners’ wing. Mr Ghorbani said he
was Muslim and wanted to see the Imam. The SO noted that Mr Ghorbani was
unable to do some jobs due to his epilepsy and he should ask staff about suitable
roles. She added four actions to Mr Ghorbani’s caremap (designed to identify the
main areas of concern and the actions required to reduce risk): staff should contact
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healthcare about Mr Ghorbani’s prescribed medication, Mr Ghorbani should engage
with the mental health team, see the Imam and gain suitable employment. She
assessed Mr Ghorbani’s risk as medium and decided that his observations would
remain unchanged.
41. On 30 January, a Custodial Manager (CM) held an interim case review after a self-
inflicted death in the prison. Mr Ghorbani asked when he would move to F wing but
did not have any other concerns. The CM explained that he would move when a
place became available.
42. On 2 February, a nurse completed a mental health assessment. She noted that Mr
Ghorbani did not have any mental health concerns or issues related to his diet,
sleep, self-care, substance misuse or bullying. Mr Ghorbani was aware of the
support available to him and declined further input from the mental health team.
That day, Mr Ghorbani moved to a shared cell on F wing, with a prisoner of the
same ethnicity. An officer was appointed as his keyworker. The officer retired from
HMPPS shortly after Mr Ghorbani’s death and did not respond to our request for an
interview.
43. During a case review with a SO and a nurse on 7 February, Mr Ghorbani said that
he felt settled on F wing and was receiving his prescribed medication. He was
taking part in wing activities and had no current thoughts of suicide and self-harm.
Mr Ghorbani said he did not have anything in common with his cellmate, and the
SO said she would make wing staff aware, which she did. She assessed Mr
Ghorbani’s risk as low and reduced his observations to one irregular observation
every two hours. The frequency of conversations remained unchanged.
44. On 8 February, Mr Ghorbani started work in the sewing workshop.
45. On 13 February, the SO held a case review with a nurse and Mr Ghorbani. She
noted that Mr Ghorbani engaged well and was in good spirits. Mr Ghorbani said that
he would now be serving two years until the end of his sentence. He was receiving
good support from prison staff, got on well with his cellmate and had no current
thoughts of suicide and self-harm. Prison staff agreed to stop ACCT monitoring.
Staff assessed Mr Ghorbani’s risk as low and the actions on his caremap were
complete. The post-closure phase would end on 20 February.
46. On 17 February, the results of a routine mandatory drugs test showed that Mr
Ghorbani tested positive for cannabis. A nurse made a referral to the substance
misuse service.
47. During an ACCT post-closure case review on 20 February, prison staff noted that
Mr Ghorbani remained settled on F wing, was attending English classes and
continued to work. He said he had no current thoughts of suicide and self-harm and
was aware of the support systems place.
20 February-10 May
48. During a substance misuse assessment on 22 February, Mr Ghorbani agreed to
attend the drug and alcohol recovery group to offer him support on relapse
prevention strategies.
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49. On 1 March, staff noted that Mr Ghorbani was showing no interest in his job and
spent most of his time reading a book. Staff described Mr Ghorbani as a loner who
rarely spoke to staff or other prisoners.
50. On 9 March, Mr Ghorbani climbed onto the landing safety netting for approximately
20 minutes. Because this is dangerous (and against prison rules), staff gave him an
Incentives and Earned Privileges (IEP) scheme warning (meaning he was at risk of
having reduced access to some in cell items and other privileges) and submitted a
CSIP referral form. An officer from the safer custody team decided that the incident
would not be investigated under the CSIP process. They noted that Mr Ghorbani
was frustrated because he was unable to access the money in his community bank
account. Prison staff said they would send a referral to The Growth Company (a
support service for prisoners who need help with financial issues). Mr Ghorbani also
wanted to be in a single cell because he was not getting on with his cellmate. Prison
staff moved Mr Ghorbani’s cellmate to another cell on 14 March. As Mr Ghorbani’s
CSRA said he could only share a cell with a prisoner of the same ethnicity, he lived
in a cell on his own until his death.
51. On 21 March, Mr Ghorbani asked to see the mental health team to discuss his
anxiety and depression.
52. Mr Ghorbani attended a meeting with an advisor from The Growth Company. Mr
Ghorbani said he was not in debt and was able to budget his money. He asked for
support with managing his community bank account. The advisor wrote to Mr
Ghorbani’s bank on 6 April to enable the prison’s finance department to access his
account.
53. On 31 March and 4 April, prison staff gave Mr Ghorbani an IEP warning for refusing
to attend work. Mr Ghorbani told prison staff that he did not have any issues and felt
tired.
54. On 5 April, a mental health nurse saw Mr Ghorbani. She noted that he engaged well
and did not display any signs of psychosis. Mr Ghorbani was not distressed or
agitated, and his personal hygiene was good. The nurse discharged Mr Ghorbani
from the mental health service.
55. On 13 April, Mr Ghorbani smashed the television in his cell. Prison staff placed Mr
Ghorbani on the basic regime and set him four targets: to comply with all
instructions given by staff, not to receive any negative IEP warnings or
adjudications, to be respectful towards staff and not to damage prison property.
Prison staff gave Mr Ghorbani a radio. An IEP review was arranged for 20 April.
There is no record that the review took place.
56. On 14 April, Mr Ghorbani flooded his cell and damaged his sink. Mr Ghorbani told
staff he wanted to move to another cell on a different landing. Prison staff submitted
another CSIP referral. An officer from Safer Custody saw Mr Ghorbani and noted
that staff had not raised concerns that he was isolated or vulnerable. Mr Ghorbani
was calm and said he did not have any issues. The officer decided that the incident
would not be investigated further under CSIP. Mr Ghorbani moved to another
single cell.
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57. Mr Ghorbani was subsequently found guilty of damaging prison property at a
disciplinary hearing on 17 April and his punishment was loss of access to the prison
shop for 14 days. Mr Ghorbani told prison staff that he had damaged his cell
because he wanted to move upstairs where it was less noisy.
58. On 17 April, a GP at the prison saw Mr Ghorbani after he asked to see the mental
health team because he felt anxious. Mr Ghorbani said he did not have any current
thoughts of suicide and self-harm but was having difficulty sleeping. He said that he
was taking his medication regularly and his last epileptic seizure was a few months
previously. The GP made a referral to the mental health team.
59. An officer held a keyworker session with Mr Ghorbani on 21 April. He noted that the
cell was untidy with a strong odour. Mr Ghorbani said he understood that his
behaviour was unacceptable and told the officer that he was listening to music on
his radio and felt well. He agreed to clean his cell and open the windows.
60. On 24 April, a mental health nurse completed a mental health assessment. Mr
Ghorbani said he had no current thoughts of suicide and self-harm. He was well
presented, calm and appeared to concentrate well. She noted that there was no
evidence of a low mood or anxiety. Mr Ghorbani was discharged from the mental
health service.
61. On 1 May, an officer held a keyworker session. Mr Ghorbani said that he was
getting on well and did not have any issues. The officer noted that Mr Ghorbani was
still on the basic regime and encouraged him to continue to behave well.
62. On 4 May, a CM held an IEP review. She noted that Mr Ghorbani’s behaviour had
improved. He had not received any IEP warnings and he engaged well with staff. Mr
Ghorbani said he wanted to work, and he intended to apply for a new job. She
decided that Mr Ghorbani should be returned to a standard regime.
63. Over the next few days, prison staff completed routine welfare checks on Mr
Ghorbani and did not note any concerns.
Events of 10 and 11 March
64. At 9.45am on 10 May, CCTV showed Mr Ghorbani returning to his cell from the
exercise yard. At 11.52am, Officer A unlocked Mr Ghorbani’s cell for lunch. Mr
Ghorbani told him that he was not hungry and pushed his cell door shut from the
inside. Mr Ghorbani left his cell shortly after and asked to borrow a vape from
another prisoner. The investigator spoke to that prisoner, who said that Mr Ghorbani
did not have friends on the wing and spent most of his days reading in his cell. The
prisoner said that Mr Ghorbani’s request for a vape was their only interaction.
65. Mr Ghorbani returned to his cell where he remained until 4.36pm, when Officer A
unlocked his cell for dinner. Mr Ghorbani refused his meal and again shut his cell
door from the inside. The officer returned to Mr Ghorbani’s cell at 4.45pm, but Mr
Ghorbani said that he was not hungry. An Operational Support Grade (OSG) made
an entry in the wing observation book that Mr Ghorbani had refused his meals. Mr
Ghorbani remained in his cell and staff did not note any concerns.
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66. Officer A told the investigator that it was not unusual for Mr Ghorbani to refuse his
meals. He described Mr Ghorbani as a quiet man who preferred to remain in his cell
alone. He did not consider that Mr Ghorbani should be managed under the food
refusal policy.
67. At 8.08pm, the OSG completed the evening routine check. In a written police
statement, he said that Mr Ghorbani was in his cell watching television and did not
raise any concerns. This was the last time Mr Ghorbani was seen alive. Mr
Ghorbani did not ring his cell bell during the night.
68. At 5.25am on 11 May, the OSG went to Mr Ghorbani’s cell to complete the morning
routine check. He looked through the observation panel and saw Mr Ghorbani
ligatured from his cell window. He radioed an emergency code blue (indicating a
prisoner is unconscious or has breathing difficulties). Control room staff called an
ambulance immediately.
69. Staff immediately responded and arrived at 5.27am. A CM opened the cell door and
entered the cell. An officer cut the ligature from Mr Ghorbani’s neck. In a statement,
the CM said that Mr Ghorbani was rigid, his skin was grey, he felt cold, and he
could not find a pulse. He believed that rigor mortis was present. A nurse arrived
and agreed that staff should not start CPR. Paramedics arrived at 5.32am and
confirmed that Mr Ghorbani had died.
Contact with Mr Ghorbani’s family
70. On 11 May, the prison appointed a family liaison officer (FLO). He identified Mr
Ghorbani’s father as his next of kin. As Mr Ghorbani’s father did not speak English,
Mr Ghorbani’s family asked a family friend to act as the family contact.
71. The FLO arranged for Mr Ghorbani to be repatriated to Iran. The prison contributed
towards the cost of Mr Ghorbani’s funeral in line with national policy.
Support for prisoners and staff
72. 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.
73. After Mr Ghorbani’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.
74. The prison posted notices informing other prisoners of Mr Ghorbani’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 Ghorbani’s death.
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75. Safer custody staff gave prison listeners and the wing manager postvention leaflets
to share with prisoners and staff.
Post-mortem report
76. The pathologist gave Mr Ghorbani’s cause of death as hanging. A toxicological
analysis did not detect any illicit substances in Mr Ghorbani’s blood.
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Findings
Assessment of Mr Ghorbani’s risk
77. Mr Ghorbani had a number of risk factors that increased his risk of suicide and self-
harm. He had been recalled to prison within the last four months. He was a
vulnerable prisoner both due his offence and because English was not his first
language, and he had no contact with friends or family. He made no phone calls
and received no visits. Despite being able to share a cell with a prisoner of the
same ethnicity, he preferred to be in a cell alone. Mr Ghorbani was often
disconnected from other prisoners with little social support.
78. Mr Ghorbani was supported by ACCT procedures when he arrived at Leeds, after
he told staff he had attempted suicide in the community and intended to self-harm in
prison. We consider that the ACCT procedures provided good support to Mr
Ghorbani. Staff held regular multidisciplinary case reviews which appropriately
assessed his risk. They added actions to Mr Ghorbani’s caremap which reflected
his mental health needs, medication and the need to gain suitable employment. The
ACCT was closed when staff assessed that Mr Ghorbani’s risk had reduced and the
caremap actions had been completed.
79. From 1 March, Mr Ghorbani’s behaviour deteriorated. He refused to attend work,
accessed the safety netting and there were two incidents of damaging prison
property, which resulted in a downgrade to the basic regime. As Mr Ghorbani’s
behaviour was not violent, staff decided that he did not meet the criteria for CSIP
However, they did not consider alternative supportive interventions, such as referral
to the safety intervention meeting and the mental health team, additional keyworker
sessions, purposeful activity or a wing buddy. This was a missed opportunity to fully
explore the change in Mr Ghorbani’s behaviour.
80. However, in the weeks leading up to his death, Mr Ghorbani’s behaviour improved.
He engaged well with staff, appeared well presented and he had been upgraded to
standard regime. Staff did not consider that the decision to refuse his meals on 10
May was unusual behaviour for Mr Ghorbani and there was no indication that he
was at imminent risk of suicide.
81. Since Mr Ghorbani’s death, Leeds has introduced various measures to improve the
quality of CSIP management, including a written summary to justify why a CSIP
investigation is not appropriate. Staff also need to demonstrate that they have fully
considered other supportive actions and how these could have a positive impact on
a prisoner’s behaviour. We make no recommendation.
Mental and clinical healthcare
82. The clinical reviewer concluded that Mr Ghorbani’s mental and clinical healthcare
was equivalent to what he could have expected to receive in the community.
83. Mr Ghorbani had a diagnosis of epilepsy. He was fully compliant with taking his
medication and he did not have any seizures during his time at Leeds.
12 Prisons and Probation Ombudsman
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84. Mental health nurses attended Mr Ghorbani’s ACCT case reviews. When Mr
Ghorbani asked to see the mental health team, nurses saw him promptly and
completed a mental health assessment.
85. The clinical reviewer considered that, overall, Mr Ghorbani received a good
standard of care.
Governor to note
IEP reviews
86. Mr Ghorbani’s IEP level was reduced to basic on 13 April after he smashed the
television in his cell. Leeds’ local IEP policy states that prisoners who are
downgraded to basic after a serious single incident will have an IEP review after
seven days to monitor their progress. This did not happen, and Mr Ghorbani
remained on basic regime until 4 May. This was a missed opportunity to assess
how Mr Ghorbani was coping on the basic regime and whether he was suitable to
return to the standard IEP level. We bring this to the Governor’s attention.
Good practice
87. The decision of prison and healthcare staff not to attempt cardiopulmonary
resuscitation was appropriate and demonstrated that they were aware of the
Resuscitation Council’s guidelines on when resuscitation was likely to be futile and
ensured that Mr Ghorbani’s dignity was preserved.
Inquest
88. At the inquest held on 25 June 2024, the Coroner concluded that Mr Ghorbani died
from hanging. The conclusion reached by the jury was that Mr Ghorbani committed
suicide.
89. The Coroner concluded that the support Mr Ghorbani received from the prison
service was appropriate and the healthcare provided was equivalent, however it
was not clear if inadequate keyworker programme management, the discharge
process from the mental health in-reach service, or insufficient communication
between healthcare staff and prison staff contributed to Mr Ghorbani’s death.
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