Michael Lunt

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Independent investigation into
the death of Mr Michael Lunt,
a prisoner at HMP Liverpool,
on 17 July 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Michael Lunt died on 17 July 2023, having been found hanged in his cell at HMP
Liverpool. He was 40 years old. I offer my condolences to Mr Lunt’s family and friends.
Mr Lunt’s presentation throughout his time at Liverpool was unusual and complex, leading
mental health professionals to question whether he was suffering from an acute mental
illness. However, his presentation fluctuated meaning that staff faced obstacles and delays
when deciding how best to diagnose and treat him. Sadly, this also meant prison staff
were unable to gain an accurate picture of the risk that he posed to himself.
I am satisfied that overall, Liverpool took appropriate measures to manage the risks
associated with Mr Lunt’s presentation. However, there were missed opportunities to
assess whether Mr Lunt was fit for court and share information about his mental health
with court staff.
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 January 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 15
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Summary
Events
1. On 16 January 2023, Mr Michael Lunt was charged with robbery and was
remanded to prison and taken to HMP Altcourse. It was his first time in prison. On
13 February, Mr Lunt transferred to HMP Liverpool.
2. On 17 March, Mr Lunt spoke to a nurse about his anxiety who advised him to make
an appointment with the GP. Over the next few months, Mr Lunt asked to talk to
someone about his mental health on several occasions and each time, he was seen
promptly by the duty worker. Concerns were also raised by prison staff and his
family during this time and again, Mr Lunt was seen promptly, and appropriate
action was taken. Records show that Mr Lunt’s mental health fluctuated, and it was
therefore difficult for healthcare staff to accurately assess his mental state. On
some days he was rational and coherent but on others he was suspicious, paranoid
and showing symptoms associated with psychosis. The mental health team
arranged for Mr Lunt to be assessed by a psychiatrist.
3. On 25 May, a psychiatrist assessed Mr Lunt. He concluded that although Mr Lunt
had disordered speaking and appeared suspicious and guarded, he had no obvious
symptoms of psychosis. The psychiatrist saw Mr Lunt for a follow up appointment
two weeks later at which he found Mr Lunt’s presentation to be more concerning.
4. On 2 July, Mr Lunt’s mother telephoned the prison, concerned about her son. An
officer spoke to Mr Lunt who said he had no thoughts of suicide or self-harm, and
that he was just having a difficult day and missing his daughter. Over the next few
days, Mr Lunt’s mother contacted the prison’s welfare line twice more with further
concerns for her son’s mental wellbeing. Mr Lunt was seen by both mental health
and prison staff but was adamant that he was fine and did not want any additional
support.
5. On 10 July, Mr Lunt attended court for the first day of his trial. There is no record of
him being seen by healthcare staff or his medical record being reviewed to ensure
he was fit to attend court. Mr Lunt returned to Liverpool that day.
6. On the morning of 11 July, Mr Lunt went to court. Again, there is no record that Mr
Lunt was seen by healthcare staff prior to attending court and there is no reference
to his ongoing mental health concerns in the digital prison escort record (dPER).
That same morning, unaware that Mr Lunt had again attended court, the
psychiatrist telephoned Mr Lunt’s mother. It was at this point that the psychiatrist
realised that Mr Lunt was showing clear signs of psychotic mental illness and
needed further assessment and treatment.
7. After the phone call, the psychiatrist wrote a letter to the Judge stating that he did
not feel Mr Lunt was fit to plead at his trial and requested that Mr Lunt be detained
in an acute mental health facility for further assessment. However, Mr Lunt had
already pleaded guilty in court and had been convicted of the offence. The
psychiatrist arranged for Mr Lunt to be assessed for detainment under the Mental
Health Act. The assessment was arranged for 17 July.
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8. Mr Lunt returned from court later that day with a suicide and self-harm warning form
noting that he was withdrawn, tearful, disorientated and was refusing to speak to
court staff. Reception staff started prison suicide and self-harm procedures, known
as ACCT. On 12 July, Mr Lunt was guarded, suspicious, and paranoid but said he
had no thoughts of suicide or self-harm. Staff decided that Mr Lunt would be moved
to the prison healthcare unit once a space was available.
9. On 17 July at approximately 5.12am, an officer found Mr Lunt in his cell in a seated
position with a ligature tied around his neck. She immediately radioed a code blue
(a medical emergency code used when a prisoner is unconscious or having
breathing difficulties). Moments later, three prison officers responded, cut through
the ligature, lowered Mr Lunt to the floor and started chest compressions.
Healthcare staff arrived and continued CPR. At approximately 5.26am, paramedics
arrived at Mr Lunt’s cell and, at 5.36am, pronounced that Mr Lunt had died.
Findings
10. Whilst at Liverpool, staff were concerned about Mr Lunt’s mental wellbeing. His
presentation was complex, unusual and it fluctuated daily. This made it difficult for
staff to accurately assess the risk he posed to himself. We are satisfied that this
was managed well by prison staff and mental health professionals.
11. In the week before he died, staff identified that Mr Lunt may be at risk of suicide and
correctly started ACCT monitoring procedures. Mr Lunt repeatedly said that he did
not want help from the mental health team and had no thoughts of suicide or self-
harm but, despite this, staff made the decision to monitor him on an hourly basis.
We are satisfied that, given the limited information staff had available to them to
accurately assess the risk Mr Lunt posed to himself, this frequency of observations
was proportionate. Staff did not record any checks in the two hours before Mr Lunt
was found unresponsive and CCTV footage did not conclusively show whether the
checks were undertaken. The staff involved told police that they had conducted
these checks. The Governor will want to assure himself that ACCT checks are
being done as required.
12. The clinical reviewer found that most of the mental health care Mr Lunt received at
Liverpool was equivalent to that which he could have expected to receive in the
community. However, healthcare staff did not assess Mr Lunt before he went to
court or after he came back, and opportunities were missed to share information
with court staff about his mental health.
13. We make no recommendations.
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The Investigation Process
14. HMPPS notified us of Mr Michael Lunt’s death on 17 July 2023.
15. The investigator issued notices to staff and prisoners at HMP Liverpool informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
16. The investigator obtained copies of relevant extracts from Mr Lunt’s prison and
medical records. The disc the prison provided of Mr Lunt’s telephone calls did not
work and the prison had no other recordings, so we were unable to listen to them.
17. NHS England commissioned a clinical reviewer to review Mr Lunt’s clinical care at
the prison. The investigator and clinical reviewer conducted six joint interviews with
members of staff at Liverpool in August and November 2023. They also interviewed
two mental health practitioners from the Liaison and Diversion Team at Liverpool
Crown Court in November and December. In April 2024, the investigation was
reallocated to another investigator.
18. We informed HM Coroner for Liverpool and Wirral 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. The Ombudsman’s office contacted Mr Lunt’s next of kin, his mother, to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked how Mr Lunt was able to attend his court trial after he had been assessed as
being unfit for trial by a prison psychiatrist. Mr Lunt’s friend also wrote to us with
some concerns about Mr Lunt’s mental ill health and the treatment he received for
this at Liverpool. These concerns have been addressed within our report and the
clinical review.
20. Mr Lunt’s mother received a copy of the initial report. She did not make any
comments.
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 Liverpool
22. HMP Liverpool is a category B local reception and resettlement prison for adult
males. There is a healthcare inpatient facility. Primary healthcare services are
provided by Spectrum Healthcare UK Limited. Mersey Care National Health Service
Foundation Trust provides mental health services.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Liverpool was in July 2022. Inspectors reported
that it was an encouraging inspection and that there was a positive and caring
culture at the prison. Recorded levels of self-harm had fallen by 60% since the last
inspection and were now lower than most comparator prisons. Prisoners in crisis
were supported through the ACCT process, and those inspectors spoke to were
positive about the care they had received from staff. Staff had a good
understanding of individuals’ risks and triggers, and daily entries by wing staff
indicated that they built constructive and supportive relationships with the prisoners
in their care.
24. Inspectors reported that the mental health provider, Mersey Care NHS Foundation
Trust, delivered a seven-day mental health service, including assessment, low
intensity psychological interventions and trauma-informed support. Nurses
screened all prisoners on arrival at the prison and a duty nurse reviewed any new
referrals each day, responding to acute concerns and prioritising clinical need and
risk. Nurses referred patients, including those with complex needs, for further
assessment or specialist mental health input through a regular single point referral
meeting. The service worked well with safer custody and attended all ACCT
meetings. The care programme approach was used consistently for patients with
complex or severe and enduring mental health conditions and involved a range of
professionals, including independent advocates.
Independent Monitoring Board
25. 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 2022 to 2023, the IMB reported that
healthcare staff generally responded quickly to concerns raised and that the
prisoner was often seen on the same day or within 24 hours. The healthcare team
and the safer custody team worked collaboratively, and lessons had been learned
following recent self-inflicted deaths. The IMB found that some prisoners housed in
the segregation unit had serious mental health issues and considered that they
should be accommodated in more suitable conditions or mental health facilities.
Previous deaths at HMP Liverpool
26. Mr Lunt was the nineteenth prisoner to die at Liverpool since August 2020. Of the
previous deaths, 12 were from natural causes, three were drug-related, one was
unascertained, and two were self-inflicted. None of these investigations raised
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issues relevant to the death of Mr Lunt. Since the death of Mr Lunt up until the end
of September 2024, there have been seven further deaths at Liverpool. Two of
these were self-inflicted, four were from natural causes, and one is awaiting
classification.
Assessment, Care in Custody and Teamwork
27. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and 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
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
28. As part of the process, staff put in place a care plan (plan of care, support, and
intervention). The ACCT plan should not be closed until all the actions of the care
map have been completed. 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
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Key Events
Background
29. Mr Michael Lunt did not have a significant history of mental ill health. However,
during the year before being remanded to prison, Mr Lunt experienced major life
changes which included the breakdown of his marriage and the closure of his
business. This caused Mr Lunt a significant amount of distress and marked the
beginning of a rapid deterioration in his mental health.
30. On 14 January 2023, Mr Lunt attempted to steal a bike from a member of the
public. He was quickly apprehended by police and arrested. At the police station, he
told police that he had tried to steal the bike to get away from the people who were
chasing him. He said that people had been following him and were trying to steal
his identity. Mr Lunt was seen by a mental health nurse in police custody, but Mr
Lunt denied any issues with his mental health and said he did not want any help
from their services.
31. On 16 January 2023, Mr Lunt was charged with robbery. Crown Prosecution
Service (CPS) records note that Mr Lunt was of no fixed abode, had a history of
failing to comply with bail conditions, and was evidently experiencing a decline in
his mental health. It was deemed that if bailed, Mr Lunt could become transient and
commit further offences. He was denied bail and taken to HMP Altcourse. This was
Mr Lunt’s first time in prison.
HMP Altcourse, 16 January 2023 – 13 February 2023
32. During his reception screening, a nurse noted that Mr Lunt appeared anxious.
However, he denied having any history of mental health issues and said he did not
have thoughts of suicide or self-harm.
33. The next day, wing staff asked the mental health team to see Mr Lunt as he was
acting in a bizarre and paranoid manner. A mental health nurse completed an initial
assessment and noted that Mr Lunt was unable to hold a conversation, appeared
paranoid and had disordered and delayed responses. His medical records showed
a history of anxiety and depression, and she noted that he required further
assessment from mental health professionals. She referred him to the mental health
team.
34. On 24 January, staff discussed Mr Lunt at the mental health multi-disciplinary
meeting and agreed that he needed to be assessed by the secondary mental health
team (specialists who manage those with severe and enduring mental health
conditions).
35. On 27 January, a mental health nurse completed the secondary assessment in
which she noted that Mr Lunt was coherent, oriented and engaged effectively
throughout. She asked Mr Lunt about the concerns staff had raised and Mr Lunt
said that his behaviour was due to feeling anxious and overwhelmed at being in
prison for the first time. Mr Lunt assured the nurse that he had no thoughts of
suicide or self-harm. The nurse noted that Mr Lunt appeared stable and had no
obvious symptoms of psychosis. (Psychosis is where an individual sees or hears
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things that are not there (hallucinations) or believes things that are not true
(delusions)). The nurse discharged Mr Lunt back to the care of the primary
healthcare team (for those with less complex mental health conditions, managed by
the prison GP).
36. The next day, a nurse saw Mr Lunt for a follow up appointment. She described Mr
Lunt’s presentation as completely different from the first time she had met him on
17 January. She noted that he appeared relaxed and was able to engage in
conversation with her. Mr Lunt said that he was happy on his wing and was feeling
much more settled in prison. The nurse scheduled a follow-up appointment with a
plan to discharge Mr Lunt from mental health services, if appropriate.
HMP Liverpool, 13 February 2023 onwards
37. On 13 February, Mr Lunt transferred to HMP Liverpool. During his reception
screening, Mr Lunt said he had no thoughts of suicide or self-harm. Reception staff
noted that he had a history of anxiety and depression. A few hours later, an officer
noted that Mr Lunt was polite and coherent and said that although he felt a little
vulnerable in custody, he had no thoughts of suicide or self-harm.
38. The next day, a registered mental health nurse (RMN) completed Mr Lunt’s initial
health assessment. Mr Lunt asked if he could be prescribed sertraline, an
antidepressant he had been prescribed while in the community. She said she would
add Mr Lunt to the GP’s waiting list and told Mr Lunt about the mental health
support available to him at Liverpool.
39. On 21 February, Mr Lunt moved from the induction wing to a shared cell on G wing.
40. On 17 March, Mr Lunt asked to speak to healthcare staff. Later that day, a mental
health nurse saw Mr Lunt in his cell. Mr Lunt said that he would like to see a GP to
discuss medication options for anxiety. The nurse advised Mr Lunt to make an
appointment to see the GP (he was unaware that he was already on the GP’s
waiting list).
41. On 23 March, a workshop instructor raised concerns to wing staff about Mr Lunt’s
presentation. He told them that Mr Lunt appeared anxious, stressed, and was
having difficulty following basic instructions. Wing staff contacted the mental health
team who agreed to see Mr Lunt later that day. A few hours later, a mental health
nurse saw Mr Lunt in his cell. Mr Lunt told the nurse that he was feeling low and
anxious but that he had no thoughts of suicide or self-harm. The nurse booked Mr
Lunt an appointment for a depression review with the GP (in addition to the
appointment he was already waiting for) and referred him for psychotherapy.
42. On 7 April, a nurse went to see Mr Lunt after he was brought back early from his
shift in the kitchens. He told her that he was feeling overwhelmed as it was his first
day in the kitchens. He said that he wanted to keep this job and that he felt he
would be able to cope once he was on the right anxiety medication. She noticed
that he was nineteenth on the GP’s waiting list, so she moved him up to be seen as
a priority.
43. On 10 April, a Custodial Manager (CM) requested that Mr Lunt was discussed at
the next Safety Intervention Meeting (SIM), due to him presenting with paranoid and
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bizarre behaviour on the wing. (The SIM is a multi-disciplinary safety risk
management meeting, chaired by a senior manager. It focuses on those who are
deemed to pose a significant risk of harming themselves or others and should
ensure that individuals are managed and supported appropriately.)
44. On 11 April, a psychotherapist completed an initial talking therapies assessment
with Mr Lunt. They agreed that Mr Lunt would benefit from engaging in therapy and
he was added to the waiting list. Mr Lunt also asked to be removed from working in
the kitchens until his anxiety lessened to which staff agreed.
45. The next day, Mr Lunt rang his emergency cell bell and told an officer that he was
having thoughts of harming himself. The officer started suicide and self-harm
prevention procedures (known as ACCT) and Mr Lunt was temporarily monitored on
an hourly basis. Later that day, a multi-disciplinary ACCT review chaired by a CM
was completed in which Mr Lunt denied having any thoughts of suicide or self-harm.
The CM noted that Mr Lunt appeared confused as to why the ACCT had been
opened and presented in a bizarre manner, with delayed responses and intermittent
eye contact. As the CM felt she did not have an accurate picture of the risk Mr Lunt
posed to himself, the ACCT remained open.
46. Following the ACCT review, a nurse reviewed Mr Lunt’s clinical records and found
that in 2018, Mr Lunt was diagnosed with a brain cyst. She questioned whether this
could be causing Mr Lunt’s unusual behaviour and delayed responses, so she
relayed her concerns to the GP.
47. On 14 April, Partners of Prisoners (POP, a scheme which supports the families of
those in prison), contacted the prison after receiving concerns from Mr Lunt’s family
about his welfare. As a result, the duty mental health worker and a GP saw Mr Lunt
to assess his mental and physical wellbeing. Medical records note that Mr Lunt
appeared to be unaware of the concerns raised regarding the cyst and was
confused as to why he was being reviewed. Staff noted that he displayed no
psychotic symptoms, and his clinical observations (including blood pressure and
pulse rate) were all within an acceptable range. Additional observations were
completed a few days later, all of which came back within acceptable ranges.
48. On 18 April, staff discussed Mr Lunt at the SIM. Due to his unusual presentation, it
was agreed that he would be moved to a single cell until the ongoing investigation
into his brain cyst had been concluded.
49. On 19 April, a Supervising Officer (SO) held Mr Lunt’s ACCT review alongside a
nurse from the mental health team. Mr Lunt said he was feeling much more settled
and less anxious now that he was in a single cell. It was noted that Mr Lunt
presented well during the review and that healthcare staff were not concerned
about any potential psychotic symptoms. However, he still appeared to be
distracted at times with delayed responses and a fixed gaze. Mr Lunt said he had
no thoughts of suicide or self-harm, and the only issues he raised were regarding
his physical health. As Mr Lunt was due to see the GP the following day, it was
agreed that Mr Lunt no longer needed to be monitored via the ACCT process. The
ACCT was put into post-closure (a seven day period of review).
50. On 20 April, further concerns regarding Mr Lunt’s mental wellbeing were raised by
his family via the POP scheme. As a result, a mental health nurse visited Mr Lunt in
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his cell. Mr Lunt told her that he had spoken to his mother about his physical health
concerns connected to his digestion which he felt were causing his anxiety to
increase. Mr Lunt said that he did not want to be referred to the GP regarding this.
When asked, Mr Lunt said he had no thoughts of suicide or self-harm and did not
want any further support from the mental health team. She referred Mr Lunt to the
primary healthcare team regarding his physical health concerns and reminded him
how he could access mental health support at Liverpool, should he need it in the
future.
51. The following day, a nurse was carrying out her duties on G wing when wing staff
alerted her to concerns regarding Mr Lunt’s bizarre behaviour. They told her that he
often stood staring blankly at walls and that it was hard to get his attention. They
told her that when they tried to speak to him regarding his wellbeing and personal
life, he became overly suspicious and often spent periods isolating himself in his
cell. She placed Mr Lunt on the duty ledger to have a full mental health assessment
the next day.
52. On 22 April, a nurse attempted to complete a full mental health assessment with Mr
Lunt. However, she was unable to do so due to his increased confusion, paranoia
and unwillingness to engage. She noted that Mr Lunt had no recollection of seeing
her previously and that he became guarded when she tried to speak with him about
the concerns raised by staff and family. Mr Lunt said that he did not want to discuss
these issues with her and asked to return to his cell.
53. The next morning, the Mental Health Team Leader again attempted to complete a
full mental health assessment with Mr Lunt. Mr Lunt did not wish to speak with him
and abruptly ended their appointment. In their discussions at the multi-disciplinary
team meeting the next day, the mental health team agreed that Mr Lunt needed to
have a full psychiatric assessment with a consultant psychiatrist, as well as a CT
scan to look for any changes in his neurological cyst. They booked an appointment
with a psychiatrist for 25 May and referred Mr Lunt to the local neurology hospital.
54. On 25 May, a consultant forensic psychiatrist at Liverpool completed Mr Lunt’s
initial psychiatric assessment. He assessed that although Mr Lunt had disordered
speaking and appeared suspicious and guarded, he had no obvious symptoms of
psychosis. He recommended that Mr Lunt had a CT scan of his brain in case his
symptoms were neurological and related to his previously diagnosed brain cyst. At
interview, he told the investigator that he wanted to review the results of the brain
scan before deciding on a treatment plan in case Mr Lunt’s symptoms were not
related to mental illness. He arranged to see Mr Lunt for a follow up appointment in
two weeks’ time.
55. On 8 June, the psychiatrist completed a follow-up review with Mr Lunt. At interview,
he told us that Mr Lunt was significantly more guarded than in their previous
meeting and was unwilling to answer any direct questions. He told us that Mr Lunt
said that there was nothing wrong with his mental health and that he didn’t need
help from anyone. When he tried to discuss prescribing Mr Lunt antidepressants, he
could not recall ever being prescribed or asking to be re-prescribed them. Mr Lunt
hastily ended the conversation and said he wished to speak with his solicitor before
answering any further questions from him.
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56. Due to his concerns about Mr Lunt’s presentation and his upcoming court case, the
psychiatrist spoke to the Secondary Mental Health Team Lead. He proposed writing
to the Judge and requesting that Mr Lunt had an independent Mental Health Act
assessment to determine if he needed to be admitted to a secure hospital. She said
that she did not think that Mr Lunt was acutely unwell and that he therefore would
not meet the criteria for an urgent hospital admission. They agreed to monitor Mr
Lunt and for the psychiatrist to review him in two weeks’ time (they did not write to
the judge at this point).
57. On 29 June, the psychiatrist attempted to review Mr Lunt. However, he said he had
not yet spoken to his solicitor and did not want any help from mental health
services. At interview, he told us that despite Mr Lunt’s family continually expressing
their concerns about his mental state, he was unable to speak with them without Mr
Lunt’s consent. As Mr Lunt had no significant history of mental illness, was not
willing to engage, and would not consent to family involvement, he was still unable
to make an accurate assessment of Mr Lunt’s mental state. He told us that, at that
stage, he still did not consider that Mr Lunt would meet the threshold for mental
health detention. He asked Mr Lunt to speak to his solicitor to find out when his
court date was and planned another review for 10 July.
58. On the evening of 2 July, Mr Lunt’s mother telephoned the prison with concerns for
Mr Lunt’s welfare, stating that he had said, “I can’t do this anymore” before hanging
up the telephone. An officer immediately spoke to Mr Lunt about his mother’s
concerns. Mr Lunt assured the officer that he had no thoughts of suicide or self-
harm, and that he was just having a difficult day and missing his daughter. The
officer asked Mr Lunt if he would like to speak to a Listener (trained prisoners who
offer confidential emotional support to their peers). Mr Lunt declined this offer and
said that he was fine. He reminded Mr Lunt to press his cell bell if he needed
anything during the night. He also suggested that Mr Lunt called his mother to
reassure her, which he did.
59. The next day, Mr Lunt’s mother again rang the prison’s welfare line. As a result,
another officer spoke to Mr Lunt, who seemed confused why his mother was
concerned about him. Mr Lunt said he was fine, he had no thoughts of suicide or
self-harm, and would ring his mother that day. The officer reminded Mr Lunt of
support services available to him at Liverpool and Mr Lunt thanked her for checking
on him.
60. On 5 July, a nurse saw Mr Lunt after his family contacted the prison with further
concerns about his mental health. Mr Lunt told her that he just seen his family on a
visit (this was true) and did not understand why they were concerned for his
wellbeing. He said he had no thoughts of suicide or self-harm and was reluctant to
engage in any meaningful conversation. The nurse was not overly concerned with
his presentation and noted that he had an upcoming appointment with the
psychiatrist.
61. On 10 July, Mr Lunt attended court for the first day of his trial. There is no record of
him being seen by healthcare staff or his medical record being reviewed to ensure
he was fit to attend court. The medical section of the digital Person Escort Record
(dPER – a document containing relevant details about a prisoner, including any
risks), completed by a nurse, did not reference any of the concerns regarding his
presentation, or the ongoing intervention from the mental health team. In answer to
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whether Mr Lunt had any mental health issues, the person completing the dPER
clicked “no” from the drop down menu.
62. Before Mr Lunt’s court hearing, Mr Lunt’s mother spoke to a social worker from the
Criminal Justice Liaison and Diversion (CJLD) team at Liverpool Crown Court. The
CJLD team provides early identification, assessment and care for vulnerable people
with mental health problems in the criminal justice system. Mr Lunt’s mother
expressed her concerns regarding her son’s deteriorating mental health including
that he was experiencing paranoid delusions. The social worker shared this
information with Mr Lunt’s solicitor. He also spoke to the Secondary Mental Health
Team Lead, who explained that Liverpool was exploring the possibility of having Mr
Lunt detained under Section 35 of the Mental Health Act. (The purpose of Section
35 is for mental health professionals to establish if an individual with an upcoming
court case has any potential diagnoses and to establish if that individual is fit to
plead at court. Section 35 does not apply to individuals who have already been
convicted.) It seems that neither Mr Lunt’s solicitor, nor the CJLD took any further
action to explore with Mr Lunt whether he was mentally well enough to understand
court proceedings.
63. The same day, the psychiatrist went to review Mr Lunt, but found that he was
already at court. Mr Lunt returned to Liverpool that day.
64. The next morning, Mr Lunt went to court for his trial. Again, there is no record that
Mr Lunt was seen by healthcare staff before going to court and, there was no
reference to his ongoing mental health concerns in the dPER and the medical
section of the form was left blank.
65. The same morning, unaware that Mr Lunt had again attended court, the psychiatrist
telephoned Mr Lunt’s mother. Although the psychiatrist did not have Mr Lunt’s
consent to disclose any details of his current condition, Mr Lunt had consented to
him obtaining information from her about his past medical history. She gave the
psychiatrist a detailed account of the events leading up to his arrest along with
details of her concerns of the preceding 12 months. This included clear examples of
delusions amongst other symptoms associated with psychotic illness. The
psychiatrist told the investigator that it was at this point he realised that Mr Lunt was
showing clear signs of a psychotic mental illness and needed timely further
assessment and treatment. After the phone call, he wrote a letter to the Judge
requesting that Mr Lunt be detained in an acute mental health facility under Section
35 of the Mental Health Act. The letter was forwarded to the Judge later that day.
66. However, unbeknownst to the psychiatrist, Mr Lunt had already pleaded guilty at
court. This meant that Section 35 was no longer applicable, and he would need to
be detained under a different section of the Mental Health Act. As the psychiatrist
was due to go on annual leave, he telephoned another consultant psychiatrist
working at Liverpool. He asked the other psychiatrist to complete a referral to the
Psychiatric Intensive Care Unit, requesting that they assess Mr Lunt’s suitability for
Section 48 of the Mental Health Act (hospital detainment for individuals who have
been convicted but have not yet been sentenced). The other psychiatrist arranged
to see Mr Lunt and complete the referral on 17 July. Mr Lunt was due back in court
for sentencing on 15 August.
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67. Mr Lunt returned from court later that day with a suicide and self-harm warning
form. The form noted that Mr Lunt was withdrawn, tearful, disorientated and had
refused to speak to court staff. Reception staff started ACCT procedures and a
senior prison manager completed the immediate action plan. Staff set Mr Lunt’s
observations at four per hour until his review the following day. Mr Lunt was not
reviewed by healthcare staff as he should have been. When Mr Lunt returned to the
wing, a SO completed a second immediate action plan. He reduced Mr Lunt’s
observations to one per hour and noted his decision for doing so as being ‘due to
having previous knowledge of Mr Lunt and his unusual behaviour’. It is not standard
practice to complete a second immediate action plan without a review taking place.
However, we recognise that this did not make any difference to the care Mr Lunt
received in this instance or affect the outcome for him.
68. On 12 July, a SO chaired Mr Lunt’s first ACCT review with the Secondary Mental
Health Team Lead. The SO noted that Mr Lunt presented as guarded, suspicious,
and paranoid. He was easily startled, unable to converse fluently and was reluctant
to answer questions in any detail. When asked, Mr Lunt was unable to recall the
outcome of his court case and became increasingly agitated and confused by their
questions. The team discussed the psychiatrist’s actions the previous day. Mr Lunt
repeatedly said that he did not want help from the mental health team and had no
thoughts of suicide or self-harm. The Team Lead asked Mr Lunt if he would like to
move to the prison’s healthcare unit where it was quieter, and he said he would.
69. Although there was no obvious indication that Mr Lunt presented a risk to himself,
staff agreed that his presentation was concerning and that ACCT observations
should remain at one per hour until his next review. His next review was set for 17
July.
70. At the Integrated Mental Health Team meeting the following day, staff agreed that
Mr Lunt should be moved to the prison’s healthcare unit where he could be closely
monitored and have access to additional support from mental health staff. As the
healthcare unit was full, he was added to the waiting list.
71. On 14 July, Mr Lunt spoke to his ex-partner and his daughter on the telephone for
just over one minute. The early learning review conducted after Mr Lunt died, noted
that although Mr Lunt spoke about being low in mood, there was nothing that
indicated Mr Lunt was a risk to himself. This was his last recorded prison telephone
call before he died (although he had phone credit remaining at the time). Prison
records also show that Mr Lunt had placed a canteen order on 15 July, to be
delivered the following week.
72. In the early hours of the morning on 16 July, Mr Lunt pressed his emergency cell
bell and said that he was feeling very anxious and was having difficulty breathing.
The Deputy Head of Healthcare spoke with Mr Lunt at his cell door, and, after a few
minutes, Mr Lunt said he was feeling more relaxed. She advised Mr Lunt to try
some deep breathing exercises and to contact staff again if his anxiety worsened.
Prison records note that Mr Lunt slept through the rest of the night with no issues.
Records also show that Mr Lunt raised no concerns throughout the day and
collected both his lunch and dinner from the servery. Officer A documented that he
was watching TV until approximately 9.30pm that evening. She noted that he said
he was feeling better, smiled, and said he was going to get some sleep.
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Events of 17 July
73. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to prison radio communications from 17 July. She also obtained
information from the Northwest Ambulance Service. The following account has
been taken from all sources.
74. At approximately 3.35am, Officer A went to Mr Lunt’s cell to complete an ACCT
observation. She recorded that Mr Lunt was asleep in his bed. This is the last
documented ACCT observation prior to Mr Lunt’s death.
75. At approximately 5.12am, Officer B went to Mr Lunt’s cell to complete an ACCT
observation. Upon opening the observation panel, she saw Mr Lunt in a sitting
position on the floor with a ligature (made from a blanket) around his neck and
attached to the top bunk. She immediately radioed a code blue (a medical
emergency code used when a prisoner is unconscious or having breathing
difficulties). She did not enter the cell straight away as she did not know Mr Lunt
and therefore waited for other staff to attend.
76. CCTV shows Officer A and a CM attending the cell within one minute, followed by a
nurse. As the control room did not acknowledge the initial code blue, the CM
radioed a further code blue, in which he said that he needed an ambulance
immediately. Staff went into the cell and the CM cut the ligature with his anti-ligature
knife. They lowered Mr Lunt onto the floor, laid him on his back, checked for signs
of life and started giving chest compressions. The nurse completed medical
observations, applied a defibrillator (a device that gives shocks to the heart to
restore a normal heartbeat) and continued resuscitation attempts.
77. At approximately 5.14am, control room staff phoned an ambulance. At 5.18am, a
category 2 (for serious but non-life threatening situations) ambulance was
dispatched to the prison with a wait time of 45 minutes. The control room relayed
this information to those with Mr Lunt, who replied stating that they had a possible
self-inflicted death and needed an ambulance immediately. At 5.19am, the control
rang the emergency services and updated them on the condition of Mr Lunt. At
5.21am, a category 1 ambulance (for life-threatening situations) was dispatched to
the prison.
78. At 5.26am, paramedics arrived at Mr Lunt’s cell. Their notes confirm that Mr Lunt
was showing clear signs of death including blood pooling and discolouration of the
skin. At 5.36am, the paramedics pronounced that Mr Lunt had died.
Contact with Mr Lunt’s family
79. At 8.50am, the Governor and a senior prison manager travelled to Mr Lunt’s
mother’s home address and informed her of Mr Lunt’s death and offered their
condolences. The prison appointed a family liaison officer, who kept in touch with
Mr Lunt’s mother. The prison contributed to Mr Lunt’s funeral costs in line with
national guidance.
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Support for prisoners and staff
80. 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.
81. After Mr Lunt’s death, staff held a debrief and those involved in the emergency
response were given the opportunity to discuss any issues arising. They were also
offered support by the staff care team and signposted to support services available
to them. The staff directly involved in the incident were on their last night shift for
that week and were all about to go on their rest week. As a result, their line
managers kept in contact with them during the week to check on their welfare and
offer additional support. Additionally, a member of the care team suggested that
staff swap phone numbers so they could support each other.
82. The prison posted notices informing other prisoners of Mr Lunt’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 Lunt’s death.
Post-mortem report
83. The post-mortem concluded that Mr Lunt died of neck compression as a result of
suspension by ligature (hanging). There were no significant toxicological findings to
report.
84. The pathologist found a small cyst within Mr Lunt’s brain. Although he did not find
this to have directly contributed to Mr Lunt’s death, he noted the potential for cysts
to cause neurological symptoms and to contribute to psychiatric problems.
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Findings
Assessment of risk of suicide and self-harm
85. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of suicide or self-harm posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under ACCT procedures. PSI 64/2011
also states that any information that becomes available which may affect a
prisoner’s risk of harm to self must be recorded and shared, to inform proper
decision making. Mr Lunt had several risk factors, including that it was his first time
in prison, he had undiagnosed mental health issues, and he was awaiting
sentencing. However, he had no recorded history of suicidal thoughts or attempts,
or self-harm.
86. Mr Lunt was monitored under ACCT procedures on two occasions while at
Liverpool. Firstly, for a week in mid-April, when he had expressed thoughts of self-
harm. Secondly, when Mr Lunt returned from court on 11 July until he died. Overall,
we are satisfied that the ACCT process was managed well. Mr Lunt was allocated
an ACCT case co-ordinator in a timely manner, and his ACCT reviews were
attended by a multi-disciplinary team, including those from the mental health
department.
87. However, Mr Lunt’s fluctuating complex mental presentation made it difficult for staff
to accurately assess when this risk increased. Mr Lunt repeatedly said that he did
not want help from the mental health team and had no thoughts of suicide or self-
harm but, despite this, staff made the decision to monitor him on an hourly basis.
We are satisfied that, given the limited information staff had available to them to
accurately assess the risk Mr Lunt posed to himself, these observations were
proportionate. We do not believe that staff could have foreseen his actions or
should have assessed him as an imminent risk of suicide when he died.
ACCT observations
88. PSI 64/2011 states that ACCT observations and conversations must be
documented immediately after they take place. On the morning of Mr Lunt’s death,
CCTV shows that ACCT observations took place hourly as required up until 2am,
and these observations were correctly recorded in the ACCT document. We found
that the next observation at 3.35am was conducted outside of the 60-minute period,
and we found no record of an hourly observation being completed between 4.00am
and 5.00am.
89. CCTV does not cover Mr Lunt’s cell door. There are two cameras covering parts of
the landing outside Mr Lunt’s cell, with views in both directions, but the landing
outside his cell door is a CCTV blind spot. In addition, at the time that these checks
were supposed to take place, the wing was extremely dark and CCTV footage is
therefore not clear.
90. The night patrol officers, Officers A and B told the police that they had carried out
Mr Lunt’s hourly ACCT checks as required, but had not yet documented them in the
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ACCT. Neither the investigator nor the police were able to verify if an hourly
observation was indeed completed between 4.00am and 5.00am.
91. We spoke to the Head of Safety to ask why there was no internal investigation into
this matter after Mr Lunt’s death. She told us that she would have expected a local
investigation to have been commissioned but, as she was not in post at the time,
she was unsure why this was missed. We are satisfied that she has now highlighted
this matter to the Governor at Liverpool, who is considering further action.
Additionally, she explained that measures have been taken to ensure that ACCT
procedures are completed to a high standard in line with national policy. This
includes monthly upskilling days and ACCT refresher training for both operational
and civilian staff. They have also introduced a process whereby wing supervising
officers complete daily checks on all open ACCTS to ensure they are up-to-date,
accurate, and to minimise the likelihood of anything being missed. Finally, Liverpool
have introduced a robust ACCT quality assurance process whereby 100% of open
ACCTS and 50% of ACCTS in post-closure are reviewed on a weekly basis. On
that basis, we make no recommendation.
Clinical care
92. The clinical reviewer concluded that much of the physical healthcare that Mr Lunt
received was of a reasonable standard and equivalent to that he could have
received in the community although she did find some exceptions to this which the
Head of Healthcare will wish to address.
Mental healthcare
93. The clinical reviewer also concluded that the mental healthcare Mr Lunt received
was equivalent to that which he could have expected to receive in the wider
community, although again she found some exceptions to this.
94. Mr Lunt first came to the attention of the mental health team at Liverpool on 17
March when he applied to speak to someone about his anxiety. Mr Lunt asked to
see or talk to someone on several occasions after this and each time, he was seen
promptly (usually the same day) by the duty mental health worker. When concerns
were raised by prison staff and his family, Mr Lunt was seen promptly, and
appropriate action was taken.
95. Healthcare staff faced difficulties in accurately assessing Mr Lunt’s mental state due
to fluctuations in his presentation, him consistently denying thoughts of suicide or
self-harm, denying disordered thinking, and being adamant that he did not want any
help from the mental health team. Despite this, healthcare staff were evidently
concerned about Mr Lunt and identified that his reluctance to engage may be
attributable to a deterioration in his mental state. As a result, they continued to take
measures to identify the cause of his unusual presentation, and he was
appropriately assessed and reviewed regularly by mental health professionals, with
serious mental illness being considered on multiple occasions.
96. A psychiatrist was responsible for Mr Lunt’s mental healthcare at the time of his
death. He told us that before Mr Lunt’s court hearing, he did not have the evidence
to conclusively diagnose Mr Lunt with an acute mental illness and therefore Mr Lunt
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would not have met the criteria for detainment in a secure hospital. He said that it
only became clear to him that Mr Lunt was likely to be experiencing a significant
psychotic illness on 11 July, when he obtained a detailed account of Mr Lunt’s
mental health history from his mother. He made timely arrangements for Mr Lunt to
be assessed for detainment in a secure psychiatric hospital. Sadly, the
assessments were not completed before Mr Lunt’s death six days later.
Transfer to/from court
97. Completion of medical and health risk information within the dPER is an essential
requirement to ensure the safe movement and risk management of prisoners. It
includes any relevant mental health concerns, current or historic. Prison healthcare
staff are responsible for completing the health information section of the dPER
when someone leaves prison. If healthcare staff decide that a prisoner is not fit to
travel, then they must communicate this to prison staff and the move should be
cancelled. It is not mandatory for the prisoner to be seen by healthcare staff before
leaving the prison. However, it is recommended that the healthcare section is
completed as close as possible to when the prisoner leaves to ensure it is accurate.
98. Mr Lunt attended court on 10 July and 11 July. Neither dPER contained any
reference to the ongoing concerns regarding his behaviour, presentation, or mental
health. We spoke to the Head of Healthcare, who told us that, typically, the nurse
who completes the dPER consults the patient summary record which provides a list
of established diagnoses and all current medications. This summary does not
contain information about any ongoing assessments or concerns. As Mr Lunt had
no formal mental health diagnosis and assessments were ongoing, this would not
have been captured in the patient summary. He said that Mr Lunt’s ongoing mental
health concerns may not therefore have been obvious to the nurse filling in the
dPER, especially if that nurse had no prior knowledge of him.
99. Since the death of Mr Lunt, there is now an allocated nurse in reception who is
present from 6.30am to 9pm, to ensure that every prisoner who passes through
reception has an appropriate assessment, and that this is documented on the
prisoner’s record. These screenings have also been reviewed to ensure they are
completed comprehensively and include physical observations and a rapid review
of any recent entries on the prisoner’s record. We are satisfied that Liverpool has
taken appropriate measures to ensure that all prisoners are assessed by a
healthcare professional before leaving the prison. We therefore make no
recommendation.
100. Prison Service Order (PSO) 3050, Continuity of healthcare for prisoners, says that
events that require a prisoner to leave the prison and pass back through prison
reception can have a significant impact on the prisoner: a court appearance is an
example of such an event. The PSO says that prisons must have protocols in place
for screening prisoners for any potential health or suicide/self-harm risks following
such events.
101. Mr Lunt attended court and pleaded guilty on 11 July. His upcoming sentencing was
likely to have caused additional worry, distress and anxiety. It also meant that the
psychiatrist had to start a separate referral for him to be transferred to a mental
health unit, so delaying this process further. Mr Lunt returned with a suicide and
self-harm warning form and staff appropriately opened an ACCT. He should have
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been seen by healthcare staff in reception, but this did not happen. However, we
are satisfied that Mr Lunt was appropriately assessed by healthcare staff after this
as part of the ACCT process. In addition, as already identified, the prison now has a
nurse present in reception to screen those returning. We therefore make no
recommendation.
102. The clinical reviewer has also identified several other issues relating to recording
information, completing a mental capacity assessment and communication between
staff which the Head of Healthcare will wish to consider.
Emergency response
103. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
states that when a member of staff finds a prisoner unresponsive, they should alert
the control room of this using a medical emergency code, without delay. The
member of staff using the medical emergency code must also provide relevant
information about the condition of the prisoner to the control room staff, so that they
can pass it on to the ambulance service for use in the triage process. This is to
ensure a timely, appropriate, and effective response to medical emergencies and to
maximise the likelihood of a positive outcome for the prisoner.
104. There was a delay of approximately two minutes between the code blue being
called and the control room ringing the emergency services. The first code blue was
not acknowledged by the control room. That morning, there were some signal
issues and disruption on the prison’s radio network. This meant that some vital
radio transmissions were inaudible. This issue has been resolved since that time.
The CM then radioed a second code blue (in which he requested an ambulance but
did not provide details of Mr Lunt’s condition) and, having repeated the transmission
as the control room could not hear it, they immediately rang an ambulance.
105. However, control room staff were unable to provide any information about the
nature of the emergency or Mr Lunt’s condition. As a result, the 999 call handler did
not despatch a priority ambulance until they were provided further information in a
second call from the control room a few minutes later.
106. We acknowledge that these issues did not affect the outcome for Mr Lunt given that
when he was found he was showing clear, irreversible signs of death. However,
such a delay could be critical for somebody in a life-threatening condition in a future
medical emergency. We are aware that HMPPS and NHSE are currently
considering further national guidance in relation to medical emergencies, so we
make no recommendation.
Inquest
107. Mr Lunt’s inquest concluded on 5 March 2026 and found that he died as a result of
suicide.
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