Michael Marsh

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Independent investigation into
the death of Mr Michael Marsh,
a prisoner at HMP Exeter,
on 23 November 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Michael Marsh died in hospital of a hypoxic brain injury (when the brain does not get
enough oxygen) caused by a cardiac arrest, on 23 November 2021, after he was found
hanging in his cell at HMP Exeter five days earlier. He was 33 years old. I offer my
condolences to his family and friends.
Mr Marsh was a troubled man who appeared to struggle in prison. He isolated himself in
his cell and staff started suicide and self-harm monitoring, known as ACCT, a few days
after he arrived at Exeter. I am concerned that some aspects of the ACCT procedures
were not correctly implemented, including that they were closed at a case review that did
not have proper healthcare input.
I am concerned that the control room did not effectively communicate the nature of the
emergency, which meant that not all staff were immediately aware of the seriousness of
the situation.
I am concerned that the keywork process was not as effective as it should have been in
offering additional support to Mr Marsh, which the Governor will need to address. Staff
also did not undertake regular wellbeing checks, in line with national instructions.
It is also concerning that prison staff initially notified the next of kin of a different prisoner
who had the same name as Mr Marsh.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman June 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 4 October 2021, Mr Michael Marsh was convicted of sending digital
communications causing fear or anxiety. He was remanded to HMP Exeter. He
had a history of substance misuse and mental health difficulties but declined
medication.
2. On 8 October, prison staff intercepted a letter of suicidal intent from Mr Marsh to his
mother and started suicide and self-harm prevention procedures (known as ACCT).
Over the next three weeks, Mr Marsh self-isolated and barely left his cell. He told
staff that he had received threats from other prisoners for being in a relationship
with an ex-sex offender. On 31 October, an officer conducted a wellbeing check
and recorded that Mr Marsh appeared well and did not report any concerns.
3. On 2 November, a supervising officer (SO) chaired an ACCT review. Healthcare
staff did not attend but before the meeting, they told the SO that Mr Marsh refused
to take his medication that morning. However, the information related to another
prisoner with the same name. The SO recorded that Mr Marsh continued to self-
isolate but engaged well and did not report any thoughts of suicide or self-harm.
Attendees stopped ACCT monitoring and made a Challenge Support Intervention
Plan (CSIP) referral.
4. At 8.20pm on 18 November, an officer conducting a roll check found Mr Marsh
hanging by a ligature. He radioed a medical emergency code and entered the cell.
Staff attended, cut the ligature and started cardiopulmonary resuscitation (CPR). In
the meantime, a control room operative requested that all available staff attend but
did not specify that it was an emergency code. At 8.21pm, healthcare staff arrived
and assisted officers. At 8.28pm, paramedics arrived and took over resuscitation.
At 8.56pm, they took Mr Marsh to hospital by ambulance.
5. At 3.41am on 23 November, a hospital doctor pronounced that Mr Marsh had died.
Findings
6. Some mandatory requirements of ACCT procedures were not completed in line with
national instructions. The assessment and first case review were not completed
within expected timescales. The ACCT procedures were closed at a case review
which was not multidisciplinary and before all of the issues raised in the support
plan had achieved their intended outcome.
7. Prison and healthcare staff responded promptly to the emergency. However, we
are concerned that the control room did not effectively communicate the severity of
the situation.
8. The clinical reviewer considered that the care Mr Marsh received at HMP Exeter
was equivalent to that which he could have expected to receive in the community.
However, he found that healthcare staff had mistakenly made entries for another
prisoner of the same name in Mr Marsh’s medical record. This impacted on the
quality of information provided to ACCT case reviews.
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9. We are concerned that the next of kin identified by the prison was incorrect and that
the Governor initially broke the news to the wrong person.
10. We are also concerned that prison staff did not undertake regular wellbeing checks,
in line with local and national instructions.
Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide and self-harm in line with national instructions, including that:
• ACCT assessments and first case reviews are completed within expected
timescales;
• a case co-ordinator is appointed at the first case review, who should lead all
subsequent case reviews whenever possible;
• healthcare staff are invited and contribute to all case reviews where their
support is relevant;
• ACCT monitoring does not stop until all support actions have been completed
and risk is no longer considered raised; and
• staff record, share and consider all relevant information about risk, and start
ACCT procedures when indicated.
• The Governor should ensure that control room staff are made aware of and
understand their responsibilities during medical emergencies, including that staff
correctly communicate the nature of an emergency.
• The Head of Healthcare ensure that healthcare staff record actions and decisions
about a prisoner’s care in the correct medical record.
• The Governor should ensure that prison staff correctly identify and inform the
appropriate next of kin as soon as possible when a prisoner dies or becomes
seriously ill.
• The Governor should ensure that staff conduct wellbeing checks and keywork
sessions for all prisoners identified as vulnerable, in line with national and local
policy.
• The Governor and Head of Healthcare should ensure that a copy of this report is
shared with the staff named in this report and that a senior manager discusses the
findings with them.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Exeter, informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Marsh’s prison and
medical records.
13. The investigator interviewed six members of staff between 26 and 27 January.
NHS England commissioned a clinical reviewer to review Mr Marsh’s clinical care at
the prison. They jointly interviewed healthcare staff. All the interviews were
conducted remotely because of the restrictions in place during the COVID-19
pandemic.
14. We informed HM Coroner for Exeter and Greater Devon of the investigation. He
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
15. The Ombudsman’s family liaison officer contacted Mr Marsh’s family to explain the
investigation and to ask if they had any matters that they wanted us to consider.
They asked the following questions:
• Were there any issues with Mr Marsh receiving letters from his family?
• How often was he supposed to be checked and were these checks carried out?
• Did Mr Marsh have a mental health assessment and what support, including
medication, did he get for his mental health?
• Did paramedics experience a delay getting to Mr Marsh?
We have addressed these concerns in the report and in separate correspondence.
16. Mr Marsh’s family received a copy of the initial report. They did not raise any
further issues, or comment on the factual accuracy of the report.
17. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out a factual inaccuracy and this report has been amended
accordingly. The action plan has been annexed to this report.
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Background Information
HMP Exeter
18. HMP Exeter holds up to 561 adult men and young offenders, and serves the courts
of Devon, Cornwall and Somerset. Practice Plus Group provides primary health
services and Devon Partnership NHS Trust provide mental health care.
HM Inspectorate of Prisons
19. In March 2021, HMIP carried out a Scrutiny Visit at HMP Exeter. Inspectors
reported that levels of self-harm had increased during the COVID-19 pandemic and
that the quality of many ACCT documents was poor. They found that although
most prisoners did not have meaningful contact with staff and that keywork
sessions occurred infrequently, daily wellbeing checks for prisoners assessed as
vulnerable generally took place.
20. The most recent full inspection of Exeter was in November 2022. Following the
inspection, HM Chief Inspector of Prisons invoked the Urgent Notification protocol
and wrote to the Secretary of State setting out significant concerns. The Chief
Inspector’s letter highlighted that levels of self-harm were higher than at any
comparable prison and 44 per cent higher than the year before their previous
inspection. The Chief Inspector also found that the provision of mental healthcare
was not good enough, with too few staff to provide adequate support.
Independent Monitoring Board
21. 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 2021, the IMB reported that a high number
of ACCTs had been started during the reporting year. They found that most ACCT
reviews took place on time and that there had been strenuous efforts to ensure that
they are multi-disciplinary.
22. The IMB also reported that there had been a steady increase in violent incidents
that tended to coincide with the relaxation of COVID-19 restrictions.
Previous deaths at HMP Exeter
23. Mr Marsh was the tenth prisoner to die at Exeter since November 2019, and the fifth
to take his own life since then. We have previously made recommendations about
the medical record keeping and communicating medical emergencies.
Assessment, Care in Custody and Teamwork
24. 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
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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.
25. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the support actions 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 on safer custody.
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Key Events
26. On 4 October 2021, Mr Michael Marsh was convicted of sending digital
communications causing fear or anxiety and remanded to HMP Exeter. Before he
arrived at the prison, a member of staff from the police, court liaison and diversion
service (PCLDS) contacted the mental health team and requested a mental health
assessment for Mr Marsh.
27. A nurse conducted an initial health screen and noted that Mr Marsh reported a
history of substance misuse, a previous admission to a psychiatric hospital and a
diagnosis of personality disorder. He also noted that Mr Marsh did not report any
thoughts of suicide or self-harm and that he had made a mental health referral.
28. Shortly afterwards, Mr Marsh refused to leave the Reception area unless staff
located him under Prison Rule 45. (If staff think a prisoner would be in danger, for
example, because of the offence they committed such as sexual offence, they can
allocate them a place on a separate wing away from the main population for their
own safety.) Mr Marsh said he needed protecting as his partner was a convicted
sex offender. However, staff did not deem his offence as suitable for Prison Rule
45 and they had to forcibly escort him from Reception. They located him in a safer
cell (a cell specifically designed to minimise ligature points) and charged him with
breaching prison rules.
29. On 5 October, a mental health nurse, conducted an assessment through Mr
Marsh’s cell door due to his aggressive behaviour the previous day. He told her
that he was worried about people putting something in his food or assaulting him for
being in a relationship with an ex-sex offender. He also said that he was prescribed
olanzapine (an antipsychotic) in the community but felt that there was “no point” in
taking it as it “did not make a difference”. She concluded that he displayed no
evidence of a psychotic illness.
30. A substance misuse worker visited Mr Marsh to provide harm reduction advice, as
part of the induction process. However, he was lying on his bed, with his head
covered and refused to engage.
31. On 6 October, a substance misuse worker, visited Mr Marsh and made a further
attempt to have a harm reduction conversation with him, but he said he was not
interested.
32. On 8 October, staff in the correspondence offices submitted a security intelligence
report (SIR) stating that they had intercepted what looked like a letter of suicidal
intent from Mr Marsh to his mother. In the letter, Mr Marsh said that he had had no
electricity (in his cell) for two days, no money for the prison shop, that staff would
not let him move wing and that he would “rot away from starvation”. At 2.10pm,
prison staff started ACCT procedures and set his observation requirement at one an
hour.
33. At around 9.20am on 10 October, an officer visited Mr Marsh to conduct an ACCT
assessment, but he refused to engage. She reviewed his prison record and
completed the ‘key information’ part of the ACCT. She did not record why the
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assessment did not take place within 24 hours of the ACCT starting, as required by
national policy.
34. At 2.45pm, a Supervising Officer (SO) was named as the case co-ordinator and
chaired a first ACCT case review, which several members of staff, including a nurse
and, a substance misuse worker, attended. The SO noted that Mr Marsh was self-
isolating in his cell due to a concern that other prisoners knew about his “messed up
sexual thoughts” and that he had barely eaten anything for two days. The nurse
recorded that Mr Marsh became upset when discussing his intrusive thoughts and
agreed to see a psychiatrist. Attendees set his observation requirement at two
conversations a day with hourly checks at night. They also agreed several care
support actions, which included mental health intervention and for Mr Marsh to
apply for a place on the Vulnerable Prisoners’ Unit under Prison Rule 45.
35. On 11 October, a mental health nurse recorded that staff discussed Mr Marsh at a
multidisciplinary team meeting (MDT) and concluded that he did not require
secondary mental health support as he had no formal diagnosis of mental illness
and denied any thoughts of suicide and self-harm.
36. On 13 October, a prison GP reviewed Mr Marsh’s community medical summary and
sent a task to the mental health team, saying that Mr Marsh was prescribed
olanzapine (although it was possible that he had not been taking it) and asked if
they would like the prescription to continue. A consultant psychiatrist replied
directly to the prison GP asking her to prescribe olanzapine for paranoid disorder.
However, she did not see the task for two weeks due to a period of annual leave.
37. On 15 October, a SO chaired an ACCT case review which several members of staff
attended, including a nurse. He noted that the review took place in Mr Marsh’s cell
and that he said, “I will smother myself with a pillow tonight” but did not give a
reason. Attendees increased his observation requirement to four an hour and
agreed to review him again the next day. There is, however, no record that this
took place.
38. On 17 October, a SO chaired an ACCT case review which a nurse attended. He
noted that Mr Marsh did not engage well but did open up slightly after
encouragement. He recorded that Mr Marsh said he would continue to stay in his
cell as he had intrusive thoughts about children and that other prisoners knew about
them. Mr Marsh also said that he had thoughts about hanging or suffocating
himself. Attendees decided to keep his observation requirement unchanged.
39. On 20 October, a SO chaired an ACCT case review which a member of prison staff
and a nurse attended. She recorded that although Mr Marsh was forward thinking
and said he had no plans to end his life, he continued to report intrusive thoughts.
She noted that he had had another Rule 45 application declined and remained in
self-isolation. Attendees agreed that ACCT monitoring should continue, but
reduced his observation requirement to once every two hours, with two quality
conversations a day.
40. On 21 October, the consultant psychiatrist visited the wing to review Mr Marsh, but
he refused to attend. She recorded that wing staff said his door had a sign on it,
saying “in- isolation”, so she requested for the appointment to be re-scheduled. At
interview, she told us that at first, she thought that Mr Marsh may have been
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isolating due to COVID-19, but subsequently, she became aware that he was
isolating out of choice.
41. On 26 October, a Custodial Manager (CM) chaired an ACCT case review and noted
that he was the only member of staff able to attend due to low staffing levels. He
noted that healthcare staff offered a verbal contribution, but there is no written
record of the information provided. Mr Marsh told the CM that he did not feel that
he needed to be on an ACCT. The CM recorded that he would keep the ACCT in
place so that a multidisciplinary discussion could take place first.
42. On 29 October, prison staff moved Mr Marsh to standard cell on the same wing.
Prison location records show that it was classified as a “general move”.
43. On 31 October, an officer conducted a wellbeing check and recorded that Mr Marsh
appeared well and did not report any concerns. The next day, an officer saw Mr
Marsh for a keywork session but he did not want to engage.
44. On 2 November, a SO chaired an ACCT case review which a prison chaplain,
attended. Healthcare staff did not participate, but a clinical administrator, reviewed
Mr Marsh’s medical record and told the SO that he had refused his medication that
morning. However, at interview, the Head of Healthcare told us that the entry was
made in error and related to a different prisoner, also called Mr Marsh. The SO
recorded that Mr Marsh continued to self-isolate but did not report any thoughts of
suicide or self-harm. Attendees agreed to stop ACCT monitoring and to make a
Challenge Support Intervention Plan (CSIP) referral. (CSIP is a national case
management model for managing prisoners who are violent or pose a risk of being
violent. It can also be used to support victims or potential victims of violence.)
Later that morning, the SO made a CSIP referral.
45. On 6 November, the Acting Head of Residence, asked Mr Marsh why he had closed
his door shortly after it was opened for a domestic period. He said that he wanted
to leave his cell but did not provide a reason. Later that day, a CM reviewed Mr
Marsh’s CSIP referral and concluded that the case should progress to CSIP as it
would provide more appropriate support.
46. On 10 November, a SO conducted an ACCT post-closure review and noted that
although Mr Marsh did not report any thoughts of suicide and self-harm, he
continued to isolate. Later that day, the consultant psychiatrist recorded that Mr
Marsh failed to attend a review for a second time and discharged him from her
psychiatry clinic.
47. On 15 November, a prison offender manager visited Mr Marsh to conduct a CSIP
review. He recorded that he explained his reason for wanting to talk to Mr Marsh,
but that Mr Marsh declined to engage. He added that Mr Marsh did not raise any
concerns and that he re-scheduled the review for 19 November.
Events of 18 November
48. At 9.30am on 18 November, an officer conducted a wellbeing check and recorded
that Mr Marsh gave him a ‘thumbs up’ but declined to engage further.
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49. At 5.07pm, staff moved Mr Marsh to a cell on A Wing after an intelligence report
indicated that two prisoners had allegedly assaulted him in the shower on C Wing.
There is, however, no record that staff conducted a wellbeing check or spoke to Mr
Marsh about the alleged assault.
50. Prison records indicate that Mr Marsh’s cell bell was activated and reset twice
between 6.58pm and 7.35pm. An officer told the investigator that he was the only
officer on the wing and remembered giving Mr Marsh a toilet roll. He said that Mr
Marsh thanked him and that he carried on with his duties.
51. At 7.45pm, CCTV footage shows that the officer approached Mr Marsh’s cell door to
conduct a roll check but it is not clear whether he opened the cell door observation
panel due to the obscure camera angle. At interview, he told us that he saw Mr
Marsh standing in his cell and that he was moving.
52. At 8.20pm, the night patrol officer looked through Mr Marsh’s cell door observation
panel to conduct a roll check and saw him hanging by a ligature made from bed
linen and attached to the cell window. He radioed a medical emergency code blue
(which indicates that a prisoner is unconscious or has breathing difficulties) and
entered the cell. Around 10 seconds later, the officer arrived with several members
of staff and cut the ligature. The officers laid Mr Marsh on the floor and started
cardiopulmonary resuscitation (CPR). In the meantime, an officer in the control
room radioed for “staff assistance” to A Wing.
53. At 8.21pm, a nurse arrived on the wing with a Healthcare Assistant (HCA) and
asked her to collect an emergency medical bag in case it was needed. She then
went into the cell, saw staff conducting CPR and shouted “code blue” to HCA, who
handed her the bag and went to collect an oxygen cylinder. The nurse requested
that staff move Mr Marsh out on the wing landing for easier access and assisted
with the resuscitation effort.
54. At 8.24pm, an ambulance arrived at the prison. At 8.28pm, the first paramedics
arrived at Mr Marsh’s cell. Paramedics took over the resuscitation effort and, at
8.34pm, established that Mr Marsh had a pulse. At 8.56pm, paramedics transferred
Mr Marsh by ambulance to the Royal Devon and Exeter Hospital. Two officers
escorted Mr Marsh to hospital, without using restraints.
55. On 19 November, a nurse spoke to hospital staff who informed her that Mr Marsh
had brain damage and was unlikely to survive. Healthcare staff remained in daily
contact with the hospital for updates on Mr Marsh’s condition.
56. At 3.41am on 23 November, a doctor pronounced that Mr Marsh had died.
Contact with Mr Marsh’s family
57. On 18 November, the governor attended the prison in response to the incident and
requested contact details for Mr Marsh’s next of kin. Mr Marsh had not named a
next of kin so staff looked through his prison record and found a letter from a Mrs
Marsh, who appeared to be his mother. Later that night, a SO and the governor
visited her address to break the news, but it quickly became apparent that she was
the mother of the other Mr Michael Marsh who was in prison at Exeter. The
governor subsequently contacted the prison and asked staff to check Mr Marsh’s
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phone records. They found a contact number, which was for the correct Mr Marsh’s
mother, and the governor broke the news to her by phone.
58. At 9.40am on 19 November, the prison appointed an officer as the family liaison
officer (FLO) and a second officer as his deputy. The FLO recorded that the
governor offered to arrange for Mr Marsh’s mother’s transport to the hospital, but
she said she would prefer to make her own way there. He also noted that the
governor asked if she would like a member of staff to meet her at the hospital, but
she was unsure.
59. At 7.45am on 22 November, a prison manager asked a SO, if she could attend the
hospital to offer support to Mr Marsh’s family as it was likely that his life support
equipment would be turned off and the allocated family liaison officers were off duty.
However, when she arrived at around 8.30pm, the nurses looking after Mr Marsh
said that his family visited yesterday and said they would not return. At 11.22am,
the SO phoned Mr Marsh’s mother and she confirmed that the family had said their
goodbyes and would not be returning.
60. On 23 November at 10.55am, the SO phoned Mr Marsh’s mother to offer her
condolences and an officer provided ongoing support. Mr Marsh’s funeral took
place on 20 December and the prison contributed towards the cost, in line with
national instructions.
Support for prisoners and staff
61. On 19 November, 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. On 23 December, the prison manager spoke to the officers present
at the hospital when Mr Marsh died to offer support.
62. The prison posted notices informing other prisoners of Mr Marsh’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 Marsh’s death.
Post-mortem report
63. The post-mortem examination found that Mr Marsh died of a hypoxic brain injury
(when the brain does not get enough oxygen), caused by a cardiac arrest that was
caused by hanging. Post-mortem toxicology analysis found low levels of
tetrahydrocannabinol (from cannabis). The pathologist was unable to conclude if
Mr Marsh had used cannabis before or after he was sent to prison. No other illicit
medications were detected. However, the pathologist noted that the interval of time
of nearly 81 hours between staff finding Mr Marsh hanged and the blood sample
being taken meant that many drugs, including psychoactive substances, might have
already been eliminated from his body.
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Findings
Assessment of the risk of suicide and self-harm
64. Prison Service Instruction (PSI) 64/2011 on safer custody requires all staff who
have contact with prisoners to be aware of the risk factors and triggers that might
increase prisoners’ risk of suicide and self-harm, and to take appropriate action.
Any prisoner identified as at risk of suicide and self-harm must be managed under
ACCT procedures.
ACCT procedures
65. Mr Marsh was monitored under ACCT procedures on one occasion at Exeter.
While there were some positive aspects in the way staff operated ACCT
procedures, we are concerned that some aspects were poorly managed. PSI
64/2011 requires the ACCT assessment to be completed within 24 hours of the
start of ACCT procedures and the first case review to be held within 25 hours. Mr
Marsh’s assessment took place around 43 hours after the procedures were
initiated, and the first case review was over two days after they were started.
66. PSI 64/2011 also instructs that a case co-ordinator must be appointed at the first
case review. The case co-ordinator should lead all case reviews, where possible,
to promote consistency in managing the ACCT plan, assessing risk and care
planning. Case co-ordinators should therefore try to plan ACCT case reviews for
times when they are working. A SO was named as case co-ordinator but attended
only half of the ACCT case reviews.
67. PSI 64/2011 states that the case co-ordinator must ensure that healthcare staff are
always invited to attend all case reviews where they are relevant to supporting the
prisoner (or provide a written contribution if attendance is not possible).
68. While there were healthcare staff at most of Mr Marsh’s case reviews, there was no
one present at his closing case review. A healthcare administrator provided an
update based on a review of the medical record, but she mistakenly provided
information about another prisoner who shared the same name. (The update
provided also stated that the prisoner had not taken his medication that morning,
which if it was correct would not indicate progress or a reduction in risk.) One of Mr
Marsh’s support plan issues related to his mental health and he had recently
refused a psychiatrist assessment. Our view is that it would have been appropriate
for a healthcare member of staff to attend the case review to provide input about
these issues.
69. PSI 64/2011 also states that ACCT procedures can be closed when the risk of harm
has reduced to a level where it is no longer considered raised, and all support
actions have been completed with their intended outcome achieved.
70. One of Mr Marsh’s support actions was to apply for protection under Prison Rule
45. This had been marked as completed in his ACCT document and an application
had been submitted. However, prison staff refused Mr Marsh’s application and he
continued to live on a standard residential wing. While the support action (to submit
an application) had been completed, its intended outcome (for Mr Marsh to feel
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safe, stop isolating and begin to associate with his peers and engage in prison life)
had not as he continued to isolate in his cell due to fears for his safety. We
appreciate that CSIP procedures were initiated with the aim of addressing Mr
Marsh’s isolation issues and agree that this is an important document that was valid
in the circumstances. However, CSIP should not be used to replace the risk
assessment, care planning and monitoring that ACCT procedures provide for
prisoners at risk of suicide and self-harm.
Events of March 2022
71. Mr Marsh had some continuing risk factors for suicide and self-harm in the time
after the ACCT procedures were stopped. He continued to self-isolate and declined
to engage in a CSIP assessment. He again declined a review with the psychiatrist.
An intelligence report indicated that Mr Marsh had been assaulted by two prisoners
and he moved wings as a result. There is no evidence that anyone checked on Mr
Marsh’s wellbeing after the wing move or spoke to him about the alleged assault.
72. We are concerned that each of these factors were treated in isolation. There is no
evidence that anyone considered whether, either individually or together, they might
increase Mr Marsh’s risk of suicide and self-harm or considered restarting ACCT
procedures. We make the following recommendation:
The Governor and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide and self-harm in line with national instructions,
including that:
• ACCT assessments and first case reviews are completed within expected
timescales;
• a case co-ordinator is appointed at the first case review, who should lead
all subsequent case reviews whenever possible;
• healthcare staff are invited and contribute to all case reviews where their
support is relevant;
• ACCT monitoring does not stop until all support actions have been
completed and risk is no longer considered raised; and
• staff record, share and consider all relevant information about risk, and
start ACCT procedures when indicated.
Emergency response
73. Exeter’s local policy instructs staff to use a code blue to indicate an emergency
when a prisoner is unconscious or having breathing difficulties. Calling an
emergency medical code should automatically trigger the control room to call an
ambulance, and for all healthcare staff to attend with the appropriate medical
equipment.
74. An officer responded quickly when he found Mr Marsh hanging. He used an
appropriate medical code and entered the cell without delay. Additional staff arrived
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swiftly and the control room called an ambulance immediately, in line with Prison
Service instructions. However, we are concerned that attending staff were not fully
aware of the seriousness of the situation.
75. At interview, an officer told the investigator that upon receiving the code blue, he
raised a general alarm on the radio network and broadcast “code blue alpha
landing”. However, prison radio records show that he did not confirm it was a code
blue. An officer told us that he responded to a code blue, but statements from
healthcare staff say they responded to a general alarm and were not aware of the
seriousness of the situation until they entered the cell and saw officers doing CPR.
While we consider that the apparent miscommunication did not affect the outcome
for Mr Marsh, it is crucial that staff understand their roles in a medical emergency.
We therefore make the following recommendation:
The Governor should ensure that control room staff are made aware of and
understand their responsibilities during medical emergencies, including that
staff correctly communicate the nature of the emergency.
Clinical care
76. The clinical reviewer concluded that the clinical care that Mr Marsh received at HMP
Exeter was equivalent to that which he could have expected in the community.
Healthcare staff reviewed him frequently, his care was discussed at MDT meetings
and a psychiatrist attempted to review him on two occasions. Substance misuse
staff also offered him support and attended the first ACCT case review. However,
the clinical reviewer did identify one area for improvement, namely clinical record
keeping.
77. The clinical reviewer found that two case notes entered on Mr Marsh’s medical
record related to a different Mr Marsh. This meant that healthcare staff provided
incorrect clinical information to prison staff prior to the closing ACCT case review.
We therefore make the following recommendation:
The Head of Healthcare should ensure that healthcare staff record actions
and decisions about a prisoner’s care in the correct medical record.
Family contact
78. Prison Rule 22 requires that when a prisoner dies or becomes seriously ill, the
Governor should tell their next of kin “at once”. Although we are satisfied that the
Governor contacted Mr Marsh’s mother once he realised that they had gone to the
wrong address, we are concerned that he informed the wrong person in the first
instance. We consider that it is likely to have caused unnecessary distress.
79. Prison records show that a letter for the other Mr Marsh had been incorrectly put in
Mr Marsh’s file. While we appreciate that it is crucial to act quickly when identifying
a prisoner’s next of kin, it is vital that staff cross reference information such as a
prison number to ensure as far as reasonably possible that the information is
correct. We therefore make the following recommendation:
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The Governor should ensure that prison staff correctly identify and inform the
appropriate next of kin as soon as possible when a prisoner dies or becomes
seriously ill.
Keywork delivery and wellbeing checks
80. The Prison Service’s COVID-19: National Framework for Prison Regimes and
Services (updated August 2021) sets out five regime stages that prisons will move
up or down, depending on local conditions. Stage one being regimes operating with
minimum control measures in place and stage five being complete lockdown. All
areas of the regime are subject to exceptional delivery models (EDMs) and these
vary depending on the stage at which the prison is operating.
81. During the time that Mr Marsh was at Exeter, the prison was subject to stage four
regime delivery. Exeter’s Wellbeing and Keywork Delivery Model (January 2021)
states that stage four regimes are expected to deliver keywork or wellbeing checks
in line with the keywork EDM. Specifically, when unable to deliver full keywork
sessions during the recovery period, prisoners identified as vulnerable must been
seen daily and an entry made in the prisoner’s case note record. Prisoners being
supported by CSIP or ACCT measures are regarded as vulnerable at Exeter and
would therefore require a daily wellbeing check.
82. Mr Marsh was eligible for a daily wellbeing check for 42 days, but only five
wellbeing checks and one keywork session were recorded as taking place. We are
also particularly concerned that staff did not record whether they conducted a
welfare check following intelligence to indicate that Mr Marsh had been assaulted
while in the shower. While we appreciate the additional pressures placed on
prisons in the wake of the pandemic, we consider that staff should have made a
more concerted effort to ensure that Mr Marsh received a daily wellbeing check.
This is also a missed opportunity to identify any increase to the risk of suicide and
self-harm. We make the following recommendation:
The Governor should ensure that staff conduct wellbeing checks and
keywork sessions for all prisoners identified as vulnerable, in line with
national and local policy.
Learning lessons
83. We have identified a number of concerns in this report. We consider it is important
that staff learn from our findings. We recommend the following:
The Governor and Head of Healthcare should ensure that a copy of this report
is shared with the staff named in this report and that a senior manager
discusses the Ombudsman’s findings with them.
Inquest
84. At the inquest, which took place on 5 May 2026, the Coroner concluded that Mr
Marsh deliberately ligatured himself but the evidence presented did not adequately
explain whether or not he intended to take his own life.
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