Nezam Ghalate

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Nezam Ghalate,
a prisoner at HMP Manchester,
on 15 June 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Nezam Ghalate was found hanged in his cell on 15 June 2024 at HMP Manchester. He
was 55 years old. I offer my condolences to Mr Ghalate’s family and friends.
There have been eight self-inflicted deaths at Manchester in the last three years.
Mr Ghalate had been at HMP Durham from January 2022, and during this time he had
self-harmed and attempted suicide on at least eight occasions. His risk factors were known
to staff when he arrived at Manchester in January 2023. While at Manchester, Mr Ghalate
consistently denied thoughts of suicide and self-harm. He had good rapport with staff and
his peers and received regular support from healthcare and other agencies. He was not
subject to suicide and self-harm monitoring at Manchester.
My investigation found no evidence to indicate that Mr Ghalate’s risk of suicide had
substantially risen in the days before his death, and I do not think staff could have
foreseen his actions.
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 March 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 13 January 2022, Mr Nezam Ghalate was remanded to HMP Durham, charged
with the attempted murder of his wife. On 10 September 2022, he was found guilty
and sentenced to 20 years in prison. Due to the offence taking place in front of his
children, the court had imposed an indefinite restraining order against Mr Ghalate,
preventing him from having any contact with his wife and children. Mr Ghalate was
originally from Iran but had been living in the UK since 2000 and spoke English well.
2. Mr Ghalate remained at Durham until January 2023. During this time, he was
subject to suicide and self-harm monitoring (known as ACCT) on eight occasions
after a suicide attempt and incidents of self-harm. The last ACCT document was
closed on 4 January 2023, following a period of stability.
3. On 24 January 2023, Mr Ghalate was transferred to HMP Manchester. On his
arrival, reception staff noted that Mr Ghalate had been monitored under ACCT
procedures previously but that he denied any current thoughts of suicide and self-
harm. Staff noted that he was cheerful, upbeat and had engaged well.
4. Mr Ghalate was located on K wing (for older prisoners) for the majority of the time at
Manchester. He had good rapport with staff and his peers. Mr Ghalate often spoke
about his children and, at times, not being able to have contact with them led to Mr
Ghalate feeling low, and he would keep to himself and often remained in his cell.
5. While at Manchester, Mr Ghalate was not subject to ACCT monitoring, and staff
recorded no concerns about his risk.
6. The day before his death, Mr Ghalate had spent most of the day in bed as he had
told his friend that he had not slept well and was tired. Those who had contact with
Mr Ghalate described him as being his usual self, and there were no obvious signs
that he was at increased risk.
7. At 5.04am on 15 June 2024, during a routine check, staff found Mr Ghalate hanging
in his cell. They radioed a medical emergency code, entered the cell and after
removing the ligature, performed cardiopulmonary resuscitation. At 5.20am,
paramedics arrived and took over resuscitation attempts, but at 5.52am, confirmed
that Mr Ghalate had died.
8. The post-mortem report concluded that Mr Ghalate died from hanging.
Findings
9. Mr Ghalate had some risk factors for suicide and self-harm most notably the nature
of his offence and consequent lack of contact with his children, and his history of
self-harm and attempted suicide. However, he had settled well at Manchester,
apparently had a good rapport with both staff and his peers and had consistently
denied thoughts of suicide and self-harm. While it was known that Mr Ghalate had
some days where he was low, we do not think that there was sufficient evidence
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
that his risk of suicide had substantially increased in the days before his death or
that staff should have considered suicide and self-harm monitoring.
10. The clinical reviewer concluded that the physical care extended to Mr Ghalate at
Manchester, was of a good standard and was equivalent to what he could have
expected to receive in the community. She did, however, conclude that the mental
health care was not of a good standard and not equivalent due to a lack information
sharing and multidisciplinary team working.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
11. HMPPS notified us of Mr Ghalate’s death on 15 June 2024.
12. The investigator issued notices to staff and prisoners at HMP Manchester informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
13. The investigator visited Manchester on 10 July. He obtained copies of relevant
extracts from Mr Ghalate’s prison and medical records. He viewed CCTV and body
worn video camera (BWVC) footage.
14. The investigator interviewed three members of staff and one prisoner at Manchester
on 2 September 2024.
15. NHS England commissioned a clinical reviewer to review Mr Ghalate’s clinical care
at the prison. The investigator and clinical reviewer conducted joint interviews with
seven members of the healthcare and drug treatment team.
16. We informed HM Coroner for Manchester City area of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
17. The Ombudsman’s office contacted Mr Ghalate’s wife to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Ghalate’s wife
raised no specific issues.
18. An inquest into Mr Ghalate’s death was concluded on 8 June 2026 and a jury
returned a verdict of suicide.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Manchester
19. HMP Manchester is a high security training prison which accepts long-term
prisoners. There is a category A unit for prisoners posing greater security risks.
Greater Manchester Mental Health NHS Foundation Trust provides 24-hour nursing
care at the prison.
HM Inspectorate of Prisons
20. The most recent full inspection of HMP Manchester was between 17 September
and 3 October 2024. Following this inspection HM Inspectorate of Prisons issued an
urgent notification (UN, a mechanism for the Chief Inspector to raise urgent
concerns with the Secretary of State) as a result of their findings. The UN cited the
number of weapons and other illicit items found in recent months was amongst the
highest of all prisons holding adult men and those testing positive for drug use was
very high. There was poor physical security and failing CCTV systems. The UN also
highlighted that more than half of prisoners surveyed felt unsafe, and the rate of
serious assaults had increased, making Manchester one of the most violent adult
prisons.
21. Since the last inspection, there had been six self-inflicted deaths and a further three
deaths with suspected links to drug abuse and a steep rise in the rate of self-harm,
which was the highest amongst adult male prisons.
Independent Monitoring Board
22. 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. The IMB at Manchester has not published an annual report since August
2022. Their last report covered the immediate post-pandemic period.
Previous deaths at HMP Manchester
23. Mr Ghalate was the seventeenth prisoner to die at Manchester since September
2020. Of the previous deaths, seven were self-inflicted, six were natural causes and
three were from other causes or drug related. Up to the end of November 2024,
there had been one self-inflicted death at Manchester since Mr Ghalate’s death.
There are no similarities between the circumstances of Mr Ghalate’s death and
those of previous deaths.
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 decide the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011. After a first assessment of the prisoner’s main concerns, levels of
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
supervision and interactions are set according to the perceived risk of harm. Checks
should be irregular to prevent the prisoner predicting when they will occur. There
should be regular multidisciplinary review meetings involving the prisoner.
25. As part of the process, a caremap (plan of care, support, and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which goes with the prisoner as they move around the prison.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
26. On 13 January 2022, Mr Nezam Ghalate was remanded to HMP Durham charged
with the attempted murder of his wife. Mr Ghalate had previously spent twelve days
in prison for domestic violence. The Liaison and Diversion team at court completed
a Suicide and Self-Harm (SASH) warning form (which alerts the prison to any
concerns) which recorded that Mr Ghalate was low in mood and had previous
mental health concerns. The form went with Mr Ghalate to Durham.
27. Reception staff started suicide and self-harm monitoring procedures (known as
ACCT). While at Durham, Mr Ghalate was subject to ACCT monitoring eight times
either due to low mood or acts of self-harm (including cutting himself and jumping
on the netting between the wings). Mr Ghalate had received support from mental
health services in the community and was prescribed antidepressant medication.
He was placed on the mental health caseload, and he continued to receive support.
28. On 10 September, Mr Ghalate was convicted of attempted murder and sentenced
to 20 years imprisonment.
HMP Manchester
29. On 24 January 2023, Mr Ghalate was transferred to Manchester.
30. During his reception screen, it was noted that Mr Ghalate had been subject to
ACCT monitoring at Durham up until 4 January, and that the post closure review
had been completed. Mr Ghalate denied any current thoughts of suicide and self-
harm. Staff recorded that he was cheerful, upbeat and had engaged well. Staff did
not feel that an ACCT was required. Mr Ghalate was offered a reception telephone
call, but he declined and said that he had no one to call. Mr Ghalate did not call
anyone or receive any visits during his time at Manchester.
31. The reception health screen highlighted no significant physical health problems but
noted his previous contact with mental health services. Healthcare staff referred Mr
Ghalate to the mental health team.
32. On 1 February, a community mental health nurse completed a mental assessment.
Mr Ghalate said that he was originally from Iran and had been in the UK since 2000.
He said that he had no contact with anyone in the community, and although he had
children, they had witnessed his offence and a lifetime restraining order prevented
any contact. Mr Ghalate said that he had previously been prescribed mirtazapine
(antidepressant), however, he did not feel that this helped. She made an
appointment for the GP to review his medication. Mr Ghalate told her that he had no
other concerns about his mental health.
33. The community mental health nurse asked Mr Ghalate about his previous self-harm
attempts while at Durham. Mr Ghalate said that he now felt ‘happy to be alive’ and
denied any current thoughts of suicide or self-harm. She noted that a trigger for Mr
Ghalate’s previous self-harm was a visit by an immigration officer, who had
discussed his deportation back to Iran. Mr Ghalate had previously said that if he
were deported, he would end his life. Mr Ghalate said that while in Durham he had
been working, which had helped, and he wanted to get a job (he later gained
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
employment in the workshop). He denied any current substance misuse issues. The
Drug and Alcohol Rehabilitation Services supported Mr Ghalate during his time at
Manchester to help progress his sentence plan. (Mr Ghalate had some history of
substance misuse and it was considered a contributory factor to his offence. He
was not suspected of using drugs or alcohol in prison.)
34. Mr Ghalate was later prescribed trazodone (an antidepressant) and medication for
blood pressure and asthma.
35. In April 2023, Mr Ghalate moved to K wing (incentivised substance free living wing
and for those on enhanced privileges). Mr Ghalate developed a close friendship
with Prisoner A. Prisoner A is a mentor for the Shannon Trust and assists prisoners
(including Mr Ghalate) who struggle with reading and writing. He said that Mr
Ghalate had spoken about his previous self-harm and that not being allowed to
have contact with his children was the biggest issue for him and caused low mood.
However, he said that he never had any reason to be concerned that Mr Ghalate
would harm himself and he never mentioned thoughts of suicide or self-harm.
36. On 18 August, Mr Ghalate complained of chest pain. He was seen by a nurse, who
referred Mr Ghalate to the mental health team as he appeared to be in a low mood.
37. On 19 August, an officer spoke to Mr Ghalate as his appointed keyworker. She
asked Mr Ghalate about the events of the previous day when he was reported as
being in a low mood and having chest pains. Mr Ghalate said he was feeling much
better, had collected his medication and his lunch meal. Mr Ghalate said that he no
longer had any chest pain, and had been seen by nursing staff, and that he usually
experienced chest pain and headaches when he did not take his medication. She
told Mr Ghalate that if he felt low, he could talk to her or other staff if she was
unavailable. This was the only keywork contact Mr Ghalate received while at
Manchester.
38. On 16 September, a nurse spoke with Mr Ghalate when he attended the medication
hatch, and he asked her about his mental health appointment. She told him that it
was yet to be allocated, but she would chase this for him. She asked Mr Ghalate
what he wished to speak to the mental health staff about and he said that he felt
upset and had not been eating. She spoke with wing staff who said that they did not
know that Mr Ghalate was not eating.
39. The nurse asked Mr Ghalate whether he had thoughts of suicide or self-harm,
which he denied. Wing staff told her that they would keep an eye on Mr Ghalate and
open an ACCT if necessary. She told the staff that she would also monitor Mr
Ghalate and would open an ACCT if she felt he was not improving.
40. During the afternoon of 17 September, an officer spoke with Mr Ghalate, after
Prisoner A raised concerns that Mr Ghalate had not collected meals from the
servery for a few days. Mr Ghalate told the officer that he was experiencing a low
mood due to a number of factors, including wanting to return to Iran. She said that
this could be followed up with the Offender Management Unit (OMU) and the
foreign national officer. Mr Ghalate told her that although he was feeling low, he had
no thoughts of suicide or self-harm. She noted that Mr Ghalate had food in his cell
and recorded that she did not feel Mr Ghalate needed the support of the ACCT
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
process at that time. However, she reminded Mr Ghalate that if he was struggling,
he could speak to staff, listeners and the chaplaincy team.
41. On 18 September, a psychological wellbeing practitioner saw Mr Ghalate as a result
of the mental health referral. Mr Ghalate was very worried about his daughters as
he was unable to have any contact. He was also unhappy that he was not allowed
to keep his medication in his cell. She noted Mr Ghalate’s history of overdose, but
Mr Ghalate said that he had no intention of harming himself. She noted that she
would discuss with a GP whether in possession medication was a possibility. On 26
September, an in-possession risk assessment was completed, and Mr Ghalate was
allowed to keep his medication in his cell.
42. On 12 October, an officer recorded that he had looked into Mr Ghalate’s request to
be returned to Iran. He noted that he had contacted the immigration team at HMP
Risley and been told that there was currently no repatriation agreement between
the UK and Iran. Mr Ghalate was informed of this, and he raised no further
concerns.
43. In December, Mr Ghalate asked to speak with someone from the mental health
team. On 12 December, a community mental health nurse spoke with Mr Ghalate.
Mr Ghalate said that he heard a voice and reported seeing a ‘black dot’ in his cell.
He said that the voice told him to harm himself because he was useless, due to not
having contact with his daughters. Mr Ghalate denied having thoughts of suicide
and self-harm and said that he had a good relationship with staff and other
prisoners who he spoke with daily. Mr Ghalate said that he wanted to know that his
children were safe as he had not had contact with them for over two years. She said
that she would find out whether this was possible. She referred Mr Ghalate to a GP
for a medication review. (Prison staff were not able to contact Mr Ghalate’s children
on his behalf due to the restraining order in place.)
44. On 18 December, a GP at the prison completed a medication review by telephone
consultation and Mr Ghalate agreed for his antidepressant medication dose to be
increased from 100mg to 150mg. The GP had previously seen Mr Ghalate for other
issues and said that he always took the opportunity to ask Mr Ghalate about his
mood, which Mr Ghalate said was improving. Mr Ghalate denied thoughts of suicide
and self-harm.
45. On 18 January 2024, the wellbeing practitioner met with Mr Ghalate and completed
an Improving Access to Psychological Therapies (IAPT) assessment for
psychological treatment of depression and anxiety disorders. Mr Ghalate said that
his main concern was about his daughters. He said that the worry was worse when
he was in his cell and unoccupied. He said that he was hearing a negative voice in
his head at night, but that he had no thoughts of suicide or self-harm. She
concluded that Mr Ghalate was future focused, and did not need further
psychological well-being input, but that she would check on him again once he had
started education.
46. On 2 February, Mr Ghalate submitted an application to the Drug and Alcohol
Services (Delphi) team requesting to complete work with them as part of his
sentence plan, (rather in relation to any current use or problems) and was added to
their waiting list.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
47. On 8 February, a mental health nurse, who works for Delphi, completed a telephone
assessment with Mr Ghalate. Mr Ghalate said that he had previously only ever used
cannabis and alcohol. Mr Ghalate spoke about previous self-harm and told her that
in Iranian culture it was more honourable for a man to kill himself if his wife had
cheated on him. Mr Ghalate said that it reduced the worth of a man if he was
cheated on. Mr Ghalate said that he had previously made several attempts to end
his life, but said that he had no thoughts, plans or intention of harming himself at the
time of assessment. At interview, she said that in her view, Mr Ghalate was stating
a fact about his culture, rather than indicating that he had any intent to harm
himself. She said that they had also spoken about religion, and that it was against
his religion to end his life.
48. Mr Ghalate told the nurse that he was prescribed medication for anxiety and
depression but had no concerns about his physical health. Mr Ghalate confirmed
that he wanted to work with Delphi as part of his sentence plan targets but also to
‘better himself’. She recorded that Mr Ghalate would be allocated a Delphi
keyworker, but she did not record their conversation about suicide and self-harm in
Mr Ghalate’s medical record (Delphi maintains a separate record system.)
49. Mr Ghalate was allocated a Delphi keyworker and met with him on 27 February. Mr
Ghalate told him that he had no current issues with illicit drug use but wanted to
complete work for his sentence plan. Mr Ghalate agreed with him that he would
complete in-cell work and would receive certificates for it. He recorded that Mr
Ghalate was also connecting with the Delphi Orderly Recovery Peer (trained
prisoner) on the wing for support when required.
50. Over the months that followed, no concerns were raised by or about Mr Ghalate. He
continued to attend work, helped around the wing, and had a good rapport with both
staff and peers.
51. On 28 May, a registered general nurse (RGN) saw Mr Ghalate. She noted that Mr
Ghalate showed no signs nor raised any thoughts of suicide or self-harm. He
engaged well, maintained good eye contact, showed positive body language and
was in a good mood. Mr Ghalate spoke about being unable to sleep and it was
noted that an appointment had already been booked with a GP.
52. On 4 June, a prison GP saw Mr Ghalate and prescribed zopiclone (a sleep aid) for
three days. He noted that Mr Ghalate was polite, engaging, and his mood was
stable with no evidence of suicidal thoughts. He planned to review Mr Ghalate again
in five weeks.
53. At 7.15am on 13 June, wing staff asked a healthcare assistant (HCA) if she would
see Mr Ghalate as they were concerned about his physical health. She said that
when she went to see Mr Ghalate, he was in his cell talking with another prisoner.
Mr Ghalate was polite, engaging, and pleasant, although he had told staff that he
had been unable to sleep and appeared low in mood. She asked a prison GP if he
would provide a sick note for Mr Ghalate to be excused from work, but the GP
declined because he considered that socialising could help Mr Ghalate’s low mood.
No further concerns were reported by Mr Ghalate about feeling unwell.
54. Prisoner A told the investigator that on the morning of 14 June, he had spoken with
Mr Ghalate after their cells were unlocked. Mr Ghalate told him that he had a bad
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
night’s sleep. He told him to go back to bed, which he did, and he slept for most of
the day. He collected Mr Ghalate’s lunch, canteen and evening meal for him as he
stayed in bed. Despite looking tired, he said that Mr Ghalate appeared no different
from his usual self.
Events of 15 June
55. The following account is based on written and documented evidence provided by
Manchester, CCTV and Body Worn Camera (BWVC) footage and transcripts of
interviews with staff.
56. At 5.00am on 15 June, Officer A, who had been working a night shift, undertook a
morning routine roll count of the wing. Upon reaching Mr Ghalate’s cell, she looked
in through the observation panel but could not see him on his bed. She said that
she had turned the cell light on and used her torch but could not see Mr Ghalate
and she got no response when calling to him. She radioed and asked for a patrol
officer to attend so they could unlock the cell to check (there must be two staff
present to unlock a cell during the night state unless there is a clear threat to life).
Another officer responded and made his way to Mr Ghalate’s cell.
57. An Operational Support Grade (OSG) was working on an adjoining wing and on
hearing the radio call from Officer A went across to K wing to see if he could assist.
The officer told the OSG that she was unable to get a response from Mr Ghalate
and when he looked into the cell, he noticed Mr Ghalate in the corner by his bed
with a ligature tied to the bunk. At 5.04am, the OSG radioed a medical code blue
(indicating the prisoner is unconscious or having breathing difficulties). When
interviewed, the officer said that it was not easy to see Mr Ghalate from the
observation panel, due to his position and she had not noticed him when she
initially looked into the cell.
58. Officer B arrived at 5.05am and along with the OSG and Officer A entered Mr
Ghalate’s cell. The control room called an emergency ambulance immediately.
Officer B cut the ligature from around Mr Ghalate’s neck while the OSG cut a
binding that Mr Ghalate had tied around his legs. Mr Ghalate was positioned at the
end of his bed in between the bed and the wall, and the staff moved him to the floor.
They established that he was not breathing, and had no pulse, and staff began
cardiopulmonary resuscitation (CPR). Nursing staff and further officers arrived at
5.07am and took over treatment, attaching a defibrillator. Efforts to resuscitate Mr
Ghalate continued until the paramedics arrived at 5.20am. Paramedics continued
treatment but at 5.52am, they confirmed that Mr Ghalate had died.
Contact with Mr Ghalate’s family
59. Following Mr Ghalate’s death, the prison appointed a family liaison officer (FLO).
Staff noted that Mr Ghalate’s ex-wife was listed as his next of kin and lived in the
Gateshead area. Managers decided to ask staff at HMP Durham to visit the family
(as they were geographically closer). Durham agreed, but informed Manchester that
the police had asked for them to wait so that their victim support officers could
accompany them due to Mr Ghalate’s index offence.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
60. At 3.25pm that afternoon, the FLO received a call from Durham informing her that
staff had visited the address, but the family had moved. A senior manager spoke
with Northumberland police who were able to assist with identifying the new
address and arrangements were made for staff from HMP Low Newton to visit the
address and inform the family of Mr Ghalate’s death. On Sunday 16 June, staff from
Low Newton attended the address, and informed Mr Ghalate’s daughter of her
father’s death. She said that her mother was at work, and she did not wish to
disturb her, but would update her on her return at 8.00pm. Staff from Low Newton
told the family that the family liaison officer from Manchester would be in contact on
Monday 17 June.
61. On 17 June, the FLO telephoned Mr Ghalate’s wife and spoke with her at length,
and explained the process that would follow. She also liaised with the Coroner, so
the family could visit Mr Ghalate. The family visited Manchester on 21 June, where
they met with Mr Ghalate’s friends on K wing.
62. The prison contributed towards funeral costs in line with national policy.
Support for prisoners and staff
63. After Mr Ghalate’s death, a custodial manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
64. The prison posted notices informing other prisoners of Mr Ghalate’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 the death.
Post-mortem report
65. The Coroner gave Mr Ghalate’s cause of death as hanging. Toxicology tests
identified no substances of concern in Mr Ghalate’s system.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of Mr Ghalate’s risk
66. Prison Service Instruction (PSI) 64/2011 on safer custody, requires all staff who
have contact with prisoners to be aware of the triggers and risk factors that might
increase the risk of suicide and self-harm, and take appropriate action. Mr Ghalate
had several factors that increased his risk of suicide including being convicted of a
violent offence against his wife and subsequent estrangement from his children, a
history of suicide attempts and self-harm and a history of drug and alcohol use.
These risks were appropriately identified when he first arrived at Manchester, but he
was not considered to need ACCT support at the time.
67. Mr Ghalate had contact with the GP, nurses and a psychological well-being
practitioner, all of whom routinely asked about his risk of suicide and self-harm and
were satisfied that he did not pose a significant risk or need ACCT monitoring.
68. Mr Ghalate was settled on K wing, apparently got on well with staff and had a good
friendship with Prisoner A. He said that Mr Ghalate had never mentioned thoughts
of suicide or self-harm. The day before his death, Mr Ghalate told him that he was
tired and had returned to bed and slept most of the day. He had no concerns about
his well-being.
69. We consider that Mr Ghalate received consistent and personalised support from
staff at Manchester, particularly on K wing. Mr Ghalate was never considered at
raised risk of suicide or self-harm, or subject to ACCT monitoring at Manchester,
and the reasons provided for reaching those conclusions are well documented and
reasonable. We consider that, on the evidence available, there were no clear
indications that Mr Ghalate’s risk of suicide had significantly increased in the days
before his death. We do not think that staff could have foreseen his actions.
Clinical care
70. The clinical reviewer concluded that the physical health care Mr Ghalate received at
Manchester was of a good standard and equivalent to what he could have expected
to receive in the community.
71. However, she concluded that the mental health care Mr Ghalate received was not
of a good standard and not equivalent. She found that there was a lack of
information sharing between healthcare staff, psychology and substance misuse
services and a lack of a multidisciplinary team approach to Mr Ghalate’s care. The
clinical reviewer has made a recommendation about record keeping, which the
Head of Healthcare will wish to address.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Governor to note
Postvention Support
72. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
73. There was no evidence that these procedures were followed after Mr Ghalate’s
death, and Manchester’s current contingency plans following a death in custody
dated February 2019, do not reflect this update as an action. The Governor will
want to ensure that local contingency plans reflect all current actions that must be
followed after a death in custody, including postvention.
Keywork
74. The key worker scheme provides prisoners with an allocated officer that they can
meet regularly to discuss how they are and any day-to-day issues they would like to
address. Improving safety is a key aim of the scheme. All adult male prisoners
should have around 45 minutes of key work each week, including a meaningful
conversation with their allocated officer.
75. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
76. The investigator was told that Manchester is currently delivering an adapted version
of the scheme due to staffing pressures. Mr Ghalate only received one keywork
session during his time at Manchester and, while this does not appear to have
adversely impacted him due to his good rapport with wing staff, the Governor
should be aiming for full delivery as soon as possible so that all prisoners can
benefit from keywork.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE