Melvin Grant

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Melvin Grant,
a prisoner at HMP Bedford,
on 21 November 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 Melvin Grant died in hospital from hypoxic brain injury (lack of oxygen to the brain) on
21 November 2023, one week after he was found unresponsive with a ligature around his
neck in his cell at HMP Bedford. Mr Grant was 42 years old. I offer my condolences to his
family and friends.
Mr Grant was being monitored using suicide and self-harm prevention procedures when
he was found unresponsive in his cell. Staff had stopped constant supervision around
seven hours before. The investigation concluded that the decision to stop constant
supervision was a reasonable one in the circumstances.
When staff found Mr Grant unresponsive, there was a delay in entering the cell and
starting CPR. We cannot say whether the delay made a difference to the outcome for Mr
Grant, but we know that in a medical emergency, any delay could be critical.
The clinical reviewer found that the standard of care provided by the nurses during the
emergency response was poor. The Head of Healthcare commissioned an investigation
which is ongoing.
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 November 2024
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 29 August 2023, Mr Melvin Grant was remanded to HMP Thameside charged
with robbery. On 27 September, he was moved to HMP Bedford.
2. On 10 October, Mr Grant told an officer that he was frustrated that he was at
Bedford and wanted to be moved back to a London prison.
3. On 5 November, Mr Grant refused to leave his cell to collect his medication and
meals. He told an officer that he did not feel well.
4. On 9 November, Mr Grant pressed his emergency cell bell and asked staff when he
would get his canteen (items purchased from the prison shop). When an officer told
him that it would not be until the next day, Mr Grant became angry and swallowed
two razor blades. The officer started suicide and self-harm monitoring (known as
ACCT). Mr Grant was later taken to hospital but was discharged in the early hours
of 10 November.
5. When Mr Grant returned to Bedford, he refused to go into his cell and said that if he
was made to go into the cell, he would assault his cellmate. Staff took Mr Grant to
the segregation unit. They continued ACCT monitoring.
6. At around 12.30am on 13 November, Mr Grant started a fire in his cell. The fire
service was called to assist officers in putting out the fire and Mr Grant was taken to
hospital for smoke inhalation.
7. Later that day, Mr Grant returned from hospital. Staff placed him under constant
supervision. Mr Grant told a nurse that he heard voices telling him not to eat or
drink and to be violent. He said that the only way he could stop the voices would be
to end his life.
8. On 14 November, a psychiatrist saw Mr Grant. He prescribed antipsychotic
medication and noted that he should continue to be supported using ACCT.
9. At an ACCT review that afternoon, staff assessed that Mr Grant’s risk of self-harm
had reduced and they stopped constant supervision. They set observations at four
an hour and agreed that Mr Grant should be moved to the prison’s healthcare
inpatient unit so that the mental health team could observe him more closely and
ensure that he took his medication. Staff moved Mr Grant to the inpatient unit that
afternoon and he was checked four times an hour in line with his ACCT plan.
10. During an ACCT check at 9.38pm, an officer saw Mr Grant lying face down on the
floor with a ligature tied around his neck. She called a medical emergency code
blue on her radio.
11. Two nurses and an officer responded and arrived at Mr Grant’s cell. However, the
first officer said that she needed to wait for a third officer to arrive before opening
the cell. Nearly two minutes after calling the code blue, a third officer arrived and
then staff entered the cell and cut the ligature from Mr Grant’s neck.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
12. Staff in the control room called for an ambulance at 9.44pm. At 9.46pm, an officer
started CPR. At 9.51pm, paramedics arrived and took over the management of Mr
Grant’s resuscitation. The paramedics managed to regain a pulse and took Mr
Grant to hospital where he was put on a life support machine.
13. On 18 November, a decision was made to end life support. Mr Grant died on 21
November.
14. The post-mortem report concluded that Mr Grant died from hypoxic brain injury
(lack of oxygen to the brain) and pulmonary oedema (fluid in the lungs) caused by
ligature strangulation injury.
Findings
15. Due to its intrusive nature, constant supervision should be used only when a
prisoner is at imminent risk of self-harm and should be used for the minimum time
possible. We consider that the decision to end constant supervision on 14
November was a reasonable one. Staff assessed that Mr Grant was no longer in
crisis and tried to mitigate the risk of harm by maintaining a high level of
observations and moving Mr Grant to the inpatient unit.
16. We consider that there was an unnecessary delay in entering Mr Grant’s cell. There
was no need to wait for a third officer to arrive when there were already two officers
and two nurses present. This resulted in a delay in starting CPR. We cannot say
whether the delay affected the outcome, but we know that in a medical emergency
any delay could be critical. We are aware that HMPPS is updating national
guidance to staff on entering cells in medical emergencies.
17. We found some issues with the management of the ACCT process. We are
concerned that there were missing supervisor checks, suggesting a lack of
management commitment to the ACCT process.
18. The clinical reviewer found that the nurses who attended the emergency response
displayed a clear lack of awareness of basic resuscitation practice. They also failed
to lead the resuscitation process as they should have done. He escalated his
concerns to the Head of Healthcare who has commissioned an investigation into
the actions of the nurses involved.
19. The clinical reviewer found that the care Mr Grant received for his mental health
was only partially equivalent to that which he could have expected to receive in the
community. When the mental health team assessed Mr Grant, they did not use
standardised assessment tools as recommended by NICE guidelines.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Recommendations
• The Head of Healthcare should review:
• the training arrangements in place to support effective delivery of resuscitation;
and
• the capability of the healthcare workforce as this relates to emergency
response.
• The Head of Healthcare should review the arrangements in place for carrying out
assessments of mental health needs to ensure that these are consistent with NICE
guidelines.
• The Governor should carry out an audit to identify whether ACCT supervisor checks
are being completed and address any failings.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
20. HMPPS notified us of Mr Grant’s death on 21 November 2023.
21. The investigator issued notices to staff and prisoners at HMP Bedford informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
22. The investigator visited HMP Bedford on 30 November. She obtained copies of
relevant extracts from Mr Grant’s prison and medical records.
23. NHS England commissioned a clinical reviewer to review Mr Grant’s clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews with
seven members of staff. In addition, the investigator interviewed one member of
staff by telephone.
24. We informed HM Coroner for Bedfordshire and Luton of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
25. The Ombudsman’s office contacted Mr Grant’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. The family asked
(via their legal representative):
• how the prison managed Mr Grant’s risk of self-harm.
• whether staff were appropriately trained.
• why there was a delay in staff adding Mr Grant’s requested phone numbers to
his account.
• why they were unable to get through to the visits booking line to book a visit.
• whether adequate physical and mental health care was provided to Mr Grant.
26. These issues have been addressed in the report and in the clinical review.
27. The legal representative also asked various other questions about prison
procedures, and whether racism played any part in the treatment and care that Mr
Grant received. We have addressed some of the issues raised in the report, and
issues that are not covered in the report have been addressed in separate
correspondence.
28. We shared our initial report with HMPPS. They found no factual inaccuracies.
29. Mr Grant’s family received a copy of the initial report. The solicitor representing Mr
Grant’s family wrote to us pointing out some factual inaccuracies. The report has
been amended accordingly. They also raised a number of questions that do not
impact on the factual accuracy of this report. We have provided clarification by way
of separate correspondence to the solicitor.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Bedford
30. HMP Bedford is a category B male adult prison. There is a healthcare unit with ten
single cells.
HM Inspectorate of Prisons
31. The most recent full inspection of HMP Bedford was in October to November 2023.
Inspectors reported that standards had fallen badly since the last full inspection in
2022. HM Chief Inspector of Prisons issued an Urgent Notification to the Secretary
of State for Justice because Bedford was failing to provide good outcomes for
prisoners.
32. Three of the four areas inspected were rated as poor. Inspectors noted standards of
cleanliness on wings and in cells had worsened considerably since the last
inspection. They considered that it was some of the worst accommodation that the
inspectorate had ever seen, and they deemed the segregation unit was a disgrace
and not fit for purpose.
33. Rates of self-harm had increased by 84% since the last inspection and were among
the highest in the prison estate. During the previous 12 months, 52 prisoners had
been under constant supervision.
34. Inspectors reported that ACCT reviews lacked a multi-disciplinary approach, care
plans were frequently incomplete, and issues raised by prisoners were not properly
addressed and actioned. These issues were compounded by a poor mental health
service which was not meeting the needs of prisoners.
Independent Monitoring Board
35. 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 30 June 2023, the IMB reported
that the prison remained overcrowded, the infrastructure was ancient, and the
segregation unit was in a dire underground location. The Board was concerned that
prisoners spent too long in their cells and that self-harm and violence levels were
too high.
36. The Board reported that the mental health team struggled with limited resources to
provide an effective service. Attendance at ACCT reviews was patchy. While there
was a reasonably good attendance at the initial reviews, mental health staff were
not routinely present at subsequent reviews.
Previous deaths at HMP Bedford
37. Mr Grant was the sixth prisoner at Bedford to die since November 2020. Of the
previous deaths, three were from natural causes and two were self-inflicted. There
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
are no similarities between the findings from our investigation into Mr Grant’s death
and the findings from our investigations into the previous deaths.
Assessment, Care in Custody and Teamwork (ACCT)
38. 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.
39. 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
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
ACCT plan should not be closed until all the actions of the caremap have been
completed.
40. All decisions made as part of the ACCT process and any relevant observations
about the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction (PSI) 64/2011.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
41. On 29 August 2023, Mr Melvin Grant was remanded in prison charged with robbery.
He was sent to HMP Thameside. Mr Grant had a long history of substance misuse
and was prescribed methadone (medicine used to treat heroin dependency). He
was also prescribed medication for anxiety and depression. He had no recent
history of attempted suicide or self-harm (the last suicide attempt being in 2014).
42. On 27 September, Mr Grant was moved to HMP Bedford. Staff recorded that he
engaged well during his induction, and they had no concerns.
43. On 8 October, Mr Grant told an officer that he did not want to get his medication. He
said that he was frustrated that he had been moved to Bedford and wanted to be
moved back to a London prison. Mr Grant said that he did not want to stay on the
wing and wanted to move to the segregation unit. The officer told Mr Grant that
there were no spaces in the London prisons. The officer noted that Mr Grant
seemed less frustrated after their conversation, and that he collected his meal and
returned to his cell.
44. On 5 November, Mr Grant refused to leave his cell to collect his medication or to
collect his lunch or dinner. He told an officer that he did not feel very well. The
officer offered to bring his meals to him, but Mr Grant refused.
45. On 9 November, at around 5.00pm, Mr Grant pressed his emergency cell bell and
asked when he would be getting his canteen (items from the prison shop). An
officer answered the cell bell and told Mr Grant that he would receive his canteen
the next day. Mr Grant was unhappy with this and became loud and aggressive,
and demanded to see a senior officer. When the officer told Mr Grant that this would
not be possible, Mr Grant picked up two razor blades and swallowed them. The
officer started suicide and self-harm monitoring (known as ACCT). A Supervising
Officer (SO) completed the Immediate Action Plan and set observations at two an
hour.
46. Later that evening, Mr Grant pressed his emergency cell bell and asked to see a
nurse because his throat was hurting from swallowing the razor blades. A nurse
saw Mr Grant and assessed that he needed to go to hospital. He was taken to
hospital by ambulance and was escorted by two prison officers.
47. Following an X-ray, hospital staff assessed that Mr Grant did not need to be
admitted to hospital but would need to return on Monday for a repeat X-ray, or
sooner if he had any further issues.
48. Mr Grant returned to Bedford at around 1.20am on 10 November. Officers took Mr
Grant back to the wing, but he refused to go in his cell. He said that he did not want
to share a cell with his cellmate and that if he was put in that cell, he would assault
his cellmate. Staff took him to the segregation unit and continued ACCT monitoring.
49. Later that day, at around 11.15am, a SO held a multidisciplinary ACCT review. A
nurse from the mental health team attended. The SO recorded that Mr Grant
engaged well in conversation and appeared calm and polite. Mr Grant said that he
did not know why he had self-harmed the previous day and that he did not
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
remember swallowing razor blades. It was also recorded in the ACCT review that
Mr Grant was struggling to recall his date of birth, and that he said he was avoiding
prison food because he thought that something was being put in it. The case review
team decided that Mr Grant should remain on ACCT monitoring and set
observations at one an hour.
50. At around 12.30am on 13 November, Mr Grant started a fire in his cell. The fire
service was called to assist officers in putting out the fire. Paramedics also attended
and said that because Mr Grant had inhaled a considerable amount of smoke he
needed to go to hospital. While being seen by the paramedics Mr Grant became
agitated and started to hit his head on the wall. Staff restrained him to prevent him
injuring himself.
51. At 2.20am, Mr Grant was taken to hospital by ambulance. While at hospital, Mr
Grant was given oxygen but, after around 30 minutes, he became agitated and
started pulling off the oxygen mask. Staff restrained him. Mr Grant discharged
himself from hospital. When he returned to Bedford, staff placed him under constant
supervision.
52. Later that day, a nurse assessed Mr Grant. He said that he thought his food and
medication were laced with substances that would harm him and that he was
hearing voices that were telling him not to eat or drink and at times to be violent
towards others. He said that the voices had become such a nuisance that the only
way he could stop them was to end his life. He said he had no plans and would
await instructions from the voices. The nurse noted that Mr Grant had been seen
banging his head and punching the walls in an effort to deal with the voices. The
nurse recommended that Mr Grant should be reviewed by a psychiatrist.
53. At around 5.30pm, a prison manager held a multidisciplinary ACCT review with Mr
Grant. A nurse from the mental health team attended. The manager noted that Mr
Grant seemed depressed and said that he had had enough. When she asked him
about the cell fire, he said that he did not know why he had started it. She told Mr
Grant that a psychiatrist would see him the next morning.
54. The prison manager assessed that the risk of Mr Grant harming himself had
increased and that he should remain under constant supervision. She set a review
for the next day.
Events of 14 November
55. At around 10.30am on 14 November, a psychiatrist saw Mr Grant. He noted that Mr
Grant had drug induced psychosis (due to his past drug use) and prescribed him
with antipsychotic medication (olanzapine). He noted that Mr Grant should remain
on ACCT monitoring and would be reviewed in two weeks.
56. At around 2.00pm, a prison manager chaired a multidisciplinary ACCT review. She
recorded that Mr Grant engaged well, maintained eye contact, and told her that he
had no thoughts of suicide or self-harm. The case review team assessed that Mr
Grant’s risk of self-harm had reduced, that he was not in crisis and that he no longer
needed to be under constant supervision. They agreed that Mr Grant needed
support and high observations and that he should move to the prison’s healthcare
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
inpatient unit so that the mental health team could observe him and ensure that he
took his medication. They set observations at four an hour and scheduled the next
review for 21 November.
57. Shortly after the ACCT review, staff moved Mr Grant to the healthcare inpatient unit.
58. At around 8.40pm, Officer A started her night shift in the healthcare unit. In her
statement she said that she received a full handover at the beginning of her shift,
which included information about Mr Grant. She said that during a routine check of
prisoners, she saw Mr Grant sitting up in bed.
59. Officer A completed ACCT checks at 9.02pm, 9.16pm and 9.28pm. At the 9.28pm
check, she recorded that Mr Grant was looking out of the observation panel of his
cell door, and that when she asked him if he was okay, he nodded.
60. At 9.38pm, Officer A checked Mr Grant again. When she looked through the
observation panel, she could see that he was lying face down on the floor and had
a ligature tied round his neck. She called his name, but he did not respond. She
immediately shouted for healthcare staff and radioed a code blue (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).
61. Two nurses and Officer B, who were all working in the healthcare unit, responded
quickly and arrived at Mr Grant’s cell. However, Officer A said that she needed to
wait for another officer to arrive before opening the cell door. Another officer arrived
after around two minutes. Officer A opened the cell door and used her anti-ligature
knife to cut the ligature, made from bedsheets, from Mr Grant’s neck.
62. At 9.44pm, an Operational Support Grade (OSG), who was working in the control
room, called an ambulance. Body worn camera footage shows that at 9.46pm,
Officer B started CPR, which was then continued by a Custodial Manager (CM). At
9.51pm, paramedics arrived and took over the management of Mr Grant’s care.
63. The paramedics managed to regain a pulse and took Mr Grant to hospital where he
remained in a coma in the critical care unit. Doctors said that no brain activity could
be found, and on 18 November a decision was made to end life support. Mr Grant
died on 21 November.
Contact with Mr Grant’s family
64. The duty governor at Bedford on the evening of 14 November told us that Mr
Grant’s prison record had no address or telephone number recorded for his next of
kin (his grandmother). She was therefore unable to contact Mr Grant’s grandmother
as soon as Mr Grant was taken to hospital. The next morning, she went to the
prison’s business hub and obtained Mr Grant’s grandmother’s address. As HMP
Belmarsh was much closer to the address than Bedford, she asked Belmarsh to
send one of their family liaison officers to visit Mr Grant’s grandmother to break the
news.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
65. At around 12.15pm on 15 November, a prison chaplain, a family liaison officer and
an officer, both from Belmarsh, went to Mr Grant’s grandmother’s home to tell her
that her grandson was in hospital.
66. On 17 November, a prison chaplain from Bedford took over the role of the family
liaison officer and went to the hospital to support Mr Grant’s family. Throughout the
time that Mr Grant was in hospital, the family liaison officer maintained contact with
Mr Grant’s family and went to the hospital on several occasions.
67. The Prison Service contributed to the funeral expenses in line with national
instructions.
Support for prisoners and staff
68. After Mr Grant’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.
69. The prison posted notices informing other prisoners of Mr Grant’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 Grant’s death.
Post-mortem report
70. The post-mortem report concluded that Mr Grant died from hypoxic brain injury
(lack of oxygen to the brain) and pulmonary oedema (fluid in the lungs) caused by
ligature strangulation injury.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment and management of risk
71. Prison service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the processes (known as
ACCT) that staff should follow when they identify that a prisoner is at risk of suicide
and self-harm. The PSI provides a list of risk factors and triggers that may increase
the risk of suicide and self-harm. These include violent offences against another
person and a mental illness diagnosis, both of which applied to Mr Grant.
72. Staff correctly started ACCT procedures for Mr Grant on 9 November when he
swallowed razor blades. On 13 November, after Mr Grant had started a cell fire,
staff considered that his risk of self-harm had increased so decided that he should
be under constant supervision.
73. Following a multidisciplinary ACCT review chaired by a prison manager on 14
November, staff stopped constant supervision and set observations at four an hour.
They also agreed that Mr Grant would be moved to the healthcare inpatient unit
where he could be closely monitored by the mental health team.
74. Constant supervision is intrusive and can have potentially negative impacts. It must
therefore be used only where a prisoner is at imminent risk and used for the
minimum amount of time necessary. We consider that the decision to stop constant
supervision for Mr Grant on 14 November was a reasonable one in the
circumstances. Staff took appropriate actions to minimise his risk by setting a high
level of observations and placing Mr Grant in the inpatient unit so he could be
monitored by mental health staff.
75. We found some issues with the management of the ACCT process. The care plan
had minimal actions, the ongoing record lacked detail and there was no record of
any meaningful conversations. In addition, there were missing supervisor checks
which suggests a lack of commitment to quality assuring the ACCT process. While
we do not consider that these issues impacted on the care provided to Mr Grant, we
are concerned that there were no supervisor checks throughout the time that he
was under ACCT monitoring and that should have highlighted the other issues we
identified. We make the following recommendation:
The Governor should carry out an audit to identify whether ACCT supervisor
checks are being completed and address any failings.
Emergency response
Delay entering the cell
76. PSI 24/2011 on the management and security of nights says that under normal
circumstances, authority to unlock a cell at night must be given by the Night Orderly
Officer (NOO) and no cell will be opened unless a minimum of two/three (subject to
local risk assessment procedures) members of staff are present one of whom
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
should be the NOO. However, the PSI also says that staff have a duty of care to
prisoners, themselves and other staff, and that the preservation of life must take
precedence over usual arrangements for opening cells. It 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, if safe to do so.
77. When Officer A saw Mr Grant lying on the floor with a ligature around his neck and
he failed to respond to her, she immediately called a code blue. She did not enter
the cell. We can understand why she did not feel safe to enter the cell alone.
However, Officer B and two nurses arrived quickly. Officer A still did not open the
cell door and can be heard saying on the body worn camera that she needed to
wait for another officer to attend before opening the cell door.
78. In their statements, both Officers A and B said that Mr Grant had a history of
assaulting staff and prisoners, so they were wary of opening the cell door. The
investigator could not find a record of Mr Grant assaulting any prisoners or staff
while at Bedford or at any prison since 2016.
79. The investigator interviewed the custodial manager in charge of the prison on the
night of 14 November and asked him about the protocol on opening cell doors at
night in a medical emergency. He said that it was a difficult choice and a judgement
call. He said that the expectation was that if it was safe to do so, staff should enter
the cell.
80. We consider that as there were two officers at the cell, along with two nurses, it was
safe for them to enter the cell. There was an unnecessary delay in entering Mr
Grant’s cell and providing emergency care.
81. While we did not find any direct evidence of racial discrimination in the course of the
investigation, it has been well documented that due to racial stereotyping, black
prisoners are assumed to have a history of violence when it is not the case. We
cannot say whether this was a factor in this case.
82. It is not possible to say whether the delay impacted on the outcome for Mr Grant,
but we know that in a medical emergency, any delay could be critical. Staff
uncertainty about entering cells in an emergency has been a recurring issue in PPO
investigations. As a result of a recent national recommendation, HMPPS begun a
programme to update national guidance for staff on entering cells in an emergency
to preserve life. We therefore make no recommendation.
Delay in calling the ambulance
83. The code blue was called at 9.38pm but an ambulance was not called until 9.44pm.
When we asked the OSG in the control room about this delay, he said that he did
not realise that there had been a delay, and his only possible explanation was that
he was trying to obtain as much information as possible to relay to the 999 operator.
84. We are aware of ongoing work, commissioned by the Director General of HMPPS
and in collaboration with health partners, to address this issue so we make no
recommendation.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Nurses’ role in resuscitation
85. The clinical reviewer considered that the two nurses involved in the emergency
response showed a clear lack of awareness of basic resuscitation practice. Both
nurses also failed to display the leadership expected in an emergency.
86. We escalated these concerns to the Head of Healthcare at Bedford who has
commenced an investigation into the nurses involved. We recommend:
The Head of Healthcare should review:
• the training arrangements in place to support effective delivery of
resuscitation; and
• the capability of the healthcare workforce as this relates to emergency
response.
Clinical care
87. The clinical reviewer concluded that the care Mr Grant received for his mental
health was partially equivalent to that which he could have expected to receive in
the community. The clinical reviewer found that when the mental health team
assessed Mr Grant, they did not use standardised assessment tools as
recommended by NICE guidelines. We recommend:
The Head of Healthcare should review the arrangements in place for carrying
out assessments of mental health needs to ensure that these are consistent
with NICE guidelines.
Informing next of kin
88. Mr Grant was taken to hospital at around 11.00pm on 14 November and placed in
an induced coma. His family were not notified until 13 hours later, when staff in the
business hub were able to search Mr Grant’s prison file for next of kin details. Given
the seriousness of Mr Grant’s condition, we consider that this was too long.
89. While we do not make a recommendation, we bring this issue to the Governor’s
attention so that she can consider what measures could be put in place to avoid
such delays in future.
Inquest
90. At the inquest, held from 6 to 20 October 2025, the jury reached a narrative
conclusion as follows: “We, the jury, agree that on a balance of probabilities in
taking such action that night, Melvin Grant intended his life to end. We also believe
that the decision to downgrade Melvin's observation, due to a serious failure in
sharing relevant information regarding his mental health, probably made more than
a minimal contribution to Melvin's death.”
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE