Nigel Keenan

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Independent investigation into
the death of Mr Nigel Keenan,
a prisoner at HMP Haverigg, on
13 March 2025
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 Nigel Keenan (who was also known as John) was found hanged in his cell at HMP
Haverigg 13 March 2025. He was 62 years old. I offer my condolences to Mr Keenan’s
family and friends.
Mr Keenan was the second prisoner to take their own life at Haverigg since March 2022.
Mr Keenan took his own life on the day he was due for release. In the weeks before he
died, Mr Keenan was prescribed a new medication for nerve pain. He subsequently
reported thoughts of suicide to healthcare staff, who considered them to be a side effect of
the medication.
Prison staff were reassured by Mr Keenan’s behaviour and no one thought he needed
additional support from suicide and self-harm monitoring procedures (known as ACCT).
However, Mr Keenan had risk factors for suicide including a history of anxiety, recent
relationship breakdown, and fears about risks to his safety on release. I consider there
was sufficient reason to think that ACCT procedures were appropriate.
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 July 2026
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 11
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Summary
Events
1. On 16 June 2022, Mr Nigel Keenan was sentenced to five and a half years in prison
for sex offences. He was sent to HMP Doncaster. He had no significant recorded
history of thoughts of suicide or acts of self-harm.
2. On 13 February 2024, Mr Keenan moved to HMP Haverigg. A nurse conducted an
initial health screen and recorded that he reported anxiety. The mental health team
offered Mr Keenan an appointment and anxiety group work, but he declined.
3. Over the next 11 months, Mr Keenan progressed through his sentence relatively
well. However, he had difficult relationships with his prison offender managers
(POMs).
4. On 13 January 2025, a GP reviewed Mr Keenan and prescribed him medication to
treat nerve pain. However, this was stopped after he reported suicidal thoughts.
Healthcare staff did not make a mental health referral or start suicide and self-harm
prevention measures, known as ACCT, as they thought he was experiencing side
effect of his medication. Prison staff who spoke to him were reassured that he did
not intend to act on the thoughts.
5. Between 11 February and 11 March, prison staff submitted intelligence reports
following prison phone monitoring indicating that Mr Keenan’s risk of suicide and
self-harm may have increased. However, staff concluded that his comments were
indicative of his history of perceived manipulative behaviour and took no action.
6. Mr Keenan was due to be released on 13 March. Mr Keenan’s prison offender
managers worked closely with his community offender manager (COM) on his
release planning. His COM considered several release addresses, including his
partner’s, but hers was assessed as inappropriate and she ended their relationship.
It was agreed that Mr Keenan would live with a brother on release, despite
concerns about so-called paedophile hunter groups operating in the area.
7. At approximately 3.15am on 13 March, an Operational Support Grade (OSG)
conducted a routine roll check and found Mr Keenan had covered the observation
panel on his cell door. The OSG opened the door and found Mr Keenan hanging
from a ligature. He radioed a medical emergency.
8. At 3.18am, a custodial manager (CM) arrived at the cell with an officer. The officer
cut the ligature and started cardiopulmonary resuscitation (CPR). At 3.35am,
paramedics arrived at the prison. They reached Mr Keenan’s cell two minutes later
and took over the resuscitation. At 4.20am, a paramedic pronounced life extinct.
Findings
Assessment of risk
9. Mr Keenan had risk factors for suicide and self-harm, including some that increased
in the weeks leading to his death. We consider that there was sufficient evidence to
indicate that suicide and self-harm monitoring procedures (ACCT) would have been
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appropriate and provided staff with an opportunity to properly explore his risk.
Instead, staff placed greater emphasis on their perceptions of him as manipulative.
Recommendations
• The Governor and Head of Healthcare should ensure that all staff understand their
responsibilities to identify and assess risk information and begin ACCT procedures
when required.
• The Head of Healthcare should ensure that when a prisoner reports suicidal
thoughts, staff consider making a referral to the mental health team and document
their decision making.
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The Investigation Process
10. HMPPS notified us of Mr Keenan’s death on 13 March 2025.
11. The investigator issued notices to staff and prisoners at HMP Haverigg informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
12. The investigator visited Haverigg on 20 March and interviewed four prisoners.
13. The investigator interviewed eight members of prison staff at Haverigg on 27 and 28
May. He also interviewed four members of healthcare staff by video conference
between 14 May and 24 June
14. NHS England commissioned an independent clinical reviewer to review Mr
Keenan’s clinical care at the prison. The investigator and the clinical reviewer jointly
interviewed healthcare staff.
15. We informed HM Coroner for Cumbria of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
16. The Ombudsman’s office contacted Mr Keenan’s wife to explain the investigation
and to ask if she had any matters she wanted us to consider. She wanted to know
about Mr Keenan’s relationship with his prison and community offender managers.
17. Mr Keenan’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.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out two factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Haverigg
19. HMP Haverigg is an open prison for adult men, located in Cumbria. It provides a
variety of living arrangements, including cellular house blocks, residential treatment
units, and billet-style accommodation that are largely shared dormitory-like setups.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Haverigg was in March 2025. Inspectors found
that Haverigg was one of the most impressive prisons in the country and provided a
safe environment that reduced the risk of self-harm and suicide. They also found
that incidents of self-harm were very low and that leaders proactively identified
prisoners who may need additional 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 the year to December 2024, the IMB
reported that Haverigg was a safe prison, with incidents of self-harm remaining low.
However, they also reported that problems arose when discharge housing could not
be secured in good time.
Previous deaths at HMP Haverigg
22. Mr Keenan was the seventh prisoner to die at Haverigg since March 2022. Of the
previous deaths, five were from natural causes and one was self-inflicted. There
were no similarities between any of these and Mr Keenan’s death.
Assessment, Care in Custody and Teamwork (ACCT)
23. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The policy for supporting prisoners assessed as at risk of
suicide and self-harm, including ACCT procedures, is set out in the Prison Safety
Policy Framework, which was implemented in January 2025.
24. 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 multi-disciplinary
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.
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Key Events
26. On 16 June 2022, Mr Nigel Keenan (who was also known as John) was sentenced
to five and a half years in prison for sexual offences. He was sent to HMP
Doncaster. On 22 September, Mr Keenan was moved to HMP Moorland. He had no
significant recorded history of thoughts of suicide or acts of self-harm.
2024
27. On 13 February 2024, Mr Keenan was moved to HMP Haverigg. Nurse A
conducted an initial health screen and recorded that he was prescribed medication
for diabetes. Nurse B, a mental health nurse, saw him for a mental health review
and recorded that while he did not have a history of self-harm in prison, he did
report anxiety. The mental health team offered him an appointment and anxiety
group work, but he declined.
28. On 5 May, Officer A saw Mr Keenan for a link session (which provide one-to-one
support for prisoners). He noted that Mr Keenan had difficulty deciding who he
wanted to live with on release and said that he was not sure whether he could live
with his partner as she had a young daughter.
29. On 21 August, Ms A, a Prison Offender Manager (POM) saw Mr Keenan for
enhanced behaviour monitoring (EBM, a collaborative approach to helping
prisoners understand and manage their own risks). She recorded that they
discussed his attitude towards children and that he said he continued to have a
good relationship with his partner. She added that he also said he had decided to
write to his wife in India, from whom he was separated.
30. On 18 December, Ms A reviewed Mr Keenan and reminded him that he would not
be able to visit his partner’s address due to her daughter, who was under the age of
18, living there. She noted that Mr Keenan said he understood.
31. Mr Keenan appeared to settle well into life in Haverigg and staff recorded no
significant concerns about him.
2025
32. On 7 January 2025, Rethink Mental Illness, a charity that provides psychological
therapy for anxiety and depression at Haverigg, sent Mr Keenan a letter offering
him the opportunity to attend anxiety management groupwork before he was
released on 13 March. He did not attend.
33. On 13 January, Dr A, a GP, reviewed Mr Keenan and noted that he reported
ongoing pain caused by meralgia parasethetica (a condition that causes nerve pain
in the outer thigh). He prescribed duloxetine (an antidepressant that can also be
used to treat nerve pain) and set a review for four weeks.
34. On 27 January, B, Mr Keenan’s Community Offender Manager (COM), attended a
pre-release meeting by video conference with Ms A, Ms C, also Mr Keenan’s POM,
and Mr Keenan. Ms B noted that Mr Keenan said he wanted to live with his father
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following release and that while he reported feeling anxious, he said he did not
need support.
35. On 31 January, Ms B visited Mr Keenan’s father’s address to assess the suitability
of him being released there. Ms B noted that she discussed with Mr Keenan’s
partner, who was present, how they would manage contact between Mr Keenan
and his partner’s daughter.
36. On 2 February, prison staff submitted an intelligence report (IR) stating that Mr
Keenan’s partner had given him a letter during a visit stating that she wanted to end
their relationship.
37. On 3 February, Ms B emailed Ms A to tell her that Mr Keenan’s father’s address
was not suitable as it backed onto a school. Later the same day, Ms A met with Mr
Keenan and recorded that he said he disagreed with the assessment that he
presented a risk to children. He added that he would go to his former wife’s address
and that he had wanted to end his relationship with his partner for months.
38. On 4 February, Mr A, an Advanced Clinical Practitioner (ACP) and acting Head of
Healthcare, saw Mr Keenan for a diabetes review and recorded that Mr Keenan
said he felt irritable and anxious since starting duloxetine and had been thinking
about ways to kill himself. ACP A added that Mr Keenan said he would not act on
his thoughts and said he had “everything to live for”.
39. Later that day, Dr B, a GP, reviewed Mr Keenan and changed his medication to
amitriptyline (for pain management and to reduce his thoughts of suicide and self-
harm). There is no record that ACP A or Dr B considered starting suicide and self-
harm monitoring procedures, known as ACCT, or making a mental health referral.
40. On 6 February, Ms A and Custodial Manager (CM) A spoke to Mr Keenan about his
suicidal thoughts. Ms A recorded that he said that he had been on medication for
nerve pain and that suicidal thoughts were a known side effect. He added that he
had no intention of acting on his thoughts and had started a new medication. They
concluded that it was not necessary to start ACCT procedures.
41. On 10 February, Ms B recorded that Mr Keenan’s former wife did not want him to
live with her, but one of his brothers said he could live with him. She asked the
police for a housing review and noted that she had spoken to Mr Keenan’s partner,
who confirmed that she ended their relationship after social services told her they
would need to notify her daughter’s father.
42. On 11 February, prison staff submitted an intelligence report (IR). Mr Keenan’s
phone calls had been subject to monitoring (prison staff can listen to phone calls
prisoners make either at random, or based on suspicion or intelligence) and staff
reported that Mr Keenan had encouraged his former partner to tell social services
they had split up and she said that as she was still supporting him, they would
interpret that as a relationship. Staff also noted that Mr Keenan said, “life has gone
downhill real fast”. However, they concluded that; “this is indicative of his [Mr
Keenan’s] well-known history of manipulative behaviour. Therefore, it is highly likely
that this is just malicious behaviour”.
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43. On 19 February, Ms B recorded that the police had concluded that as Mr Keenan’s
brother’s address was located within a mile of several children’s facilities, and that
residents of the village had previously put sex offenders in danger by posting online,
they did not assess the address as suitable. (The danger is taken to be from self-
organised groups, often referred to as paedophile hunters, who attempt to identify,
expose and sometimes confront individuals they believe to have sexually exploited
children.)
44. Later that day, Ms B copied Ms A and Ms C into an email stating that although the
police did not assess Mr Keenan’s brother’s address as suitable, she had spoken to
her manager, and they decided that based on the risk assessment of his known
offending behaviour, he could live there. (As the lead agency, the Probation Service
can override the police’s decision if they assess the risks could be appropriately
managed.) There was no reference to paedophile hunter groups in the email.
45. On 4 March, Nurse C noted that she had reviewed Mr Keenan after he collapsed.
He was taken to hospital, where medical staff identified raised blood sugar levels,
but he was unwilling to wait and discharged himself. Prison staff submitted an IR
stating that Mr Keenan said he would “do something next week that will shock the
fucking prison”'. The assessment said, “due to the amount of intelligence regarding
[Mr] Keenan's behaviour, it is likely these are empty threats made by him as a way
of causing trouble for the sake of it.”
46. At 10.59am on 5 March, Officer B recorded that he had spoken to Mr Keenan about
the intelligence indicating that he would be doing “things” during his last few days in
prison. Mr Keenan denied saying anything and said he planned on keeping his
head down. There is no record that Officer B asked him about thoughts of suicide
and self-harm or considered starting ACCT procedures.
47. At 11.30am, Ms C recorded that she and Ms A met with Mr Keenan for the first time
since Ms B’s email on 19 February and informed him that his brother’s address had
been approved by probation.
48. On 9 March, Mr Keenan phoned one of his brothers (not the one he planned on
living with). Unfortunately, we have not been able to listen to the call due a technical
issue. However, prison phone records show that this was the only time he phoned
one of his brothers between 19 February (the first recorded reference to so-called
paedophile hunters) and 12 March. This would suggest it was during this call that
he told him about the so-called paedophile hunter groups.
49. On 10 March, prison phone records show Mr Keenan phoned his former wife (who
was now in England). He told her that he was sorry for everything he had done and
she said she would never forgive him. He told her that it was the last time he would
hear her and she said, “it sounds like you’re dying”. He told her to look after herself
and that he would love her forever. Mr Keenan’s former wife told us that Mr Keenan
was “filled with regret” and “sounded like he was going to kill himself”. There is no
evidence that prison staff listened to the call as part of the monitoring process or
that Mr Keenan’s former wife notified the prison of her concerns.
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Events on 11 March
50. On Friday 11 March, ACP A saw Mr Keenan for a diabetes review and noted that
Mr Keenan said he had been feeling very stressed over the past few weeks. He
said that he felt his POMs had “got it in for him” and that his partner no longer
wanted contact with him. There is no evidence ACP A considered a mental health
referral or followed up on Mr Keenan’s previous thoughts of suicide and self-harm.
51. Later that day, prison staff submitted an IR stating that during phone monitoring,
staff had heard Mr Keenan tell a friend that he felt stressed, and anxiety had caused
his “levels to rise”. He said that his ex-partner had left him with nothing and not sent
him any more money. Staff also noted that a male named “Mr B” had spoken to Mr
Keenan’s partner about money and that he [Mr Keenan] could not do “any
business” (we do not know what this might have referred to).
52. At 4.00pm, Ms C recorded that she and Ms A met with Mr Keenan and told him that
his brother’s address had been approved. Ms C recorded that Mr Keenan remained
adamant that he could travel to India on licence despite them telling him it would be
unlikely.
Events of 12 March
53. At 4.00pm on 12 March, Ms B phoned Mr Keenan’s brother to inform him of Mr
Keenan’s licence conditions. Mr Keenan’s brother said that Mr Keenan had told
their other brother that paedophile hunter groups were operating near his address.
She noted that Mr Keenan’s brother was worried about these groups finding out that
Mr Keenan was living with him.
54. At 4.05pm, Ms B contacted Ms A who confirmed that she and Ms C had told Mr
Keenan that so-called paedophile hunter groups operated in the area of his
brother’s address.
55. At 6.00pm, Ms B telephoned Mr Keenan’s brother and told him that Mr Keenan’s
sexual offence did not appear in an internet search. She noted that having
reassured his brother, he agreed that Mr Keenan could stay with him.
56. Between 7.35pm and 9.20pm, Mr Keenan made 10 phone calls to his family and
friends. Again, the investigator was unable to listen to the calls. He expressed
emotional distress, health concerns and anxieties about his release, particularly his
living arrangements. During the calls he expressed gratitude, love and affection.
57. At 8.00pm, Officer C conducted an evening roll check and did not see anything
unusual. Four prisoners, who lived on the same billet as Mr Keenan, told the
investigator that he presented as his normal self and was laughing and joking
throughout the night. They said that while he was giving his property away (which
can be a sign of suicidal intent), handing out cards and saying things like “I won’t
need that were I’m going”, they did not think anything of it as he was due for release
the following day.
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Events of 13 March
58. At around 3.15am, Operational Support Grade (OSG) A and OSG B entered Mr
Keenan’s billet to conduct a roll check. When OSG A arrived at Mr Keenan’s cell, he
found that he had covered the cell observation panel from the inside. OSG A
opened the door and saw Mr Keenan stood at the back of the cell with a cord
around his neck, attached to the window handle. At 3.17am, OSG A radioed a
medical emergency code blue (which indicates that a prisoner is unconscious or
has breathing difficulties). At interview, he told the investigator that he tried to lift Mr
Keenan’s body to reduce the pressure on his neck. He did not cut the ligature.
59. At 3.18am, the control room called an ambulance. At the same time, CM A arrived
at Mr Keenan’s cell, but without a prison mobile phone, which would have allowed
her to speak to the ambulance service. Body worn video camera (BWVC) footage
shows OSG B stood outside Mr Keenan’s cell and OSG A in the middle of the cell,
not holding the weight of Mr Keenan’s body.
60. Around 20 seconds later, Officer D arrived at the cell. BWVC footage shows CM A
and OSG A stood in the middle of the cell while Mr Keenan remained hanging. CM
A and Officer D entered the cell and Officer D cut the ligature, before laying Mr
Keenan on the floor. He attached a defibrillator (a machine that monitors and, in
some situations restarts, the heart) with assistance from OSG A and started
cardiopulmonary resuscitation (CPR).
61. At 3.35am, paramedics arrived at the prison. They got to Mr Keenan’s cell around
two minutes later. Paramedics took over the resuscitation effort but pronounced life
extinct at 4.20am.
Contact with Mr Keenan’s family
62. At 5.51am, CM A contacted HMP Wakefield to ask whether one of their family
liaison officers (FLOs) could notify Mr Keenan’s former partner, his named next of
kin, of his death, as she lived near Leeds, around 150 miles away from Haverigg.
Wakefield agreed to help.
63. At 8.00am, Haverigg appointed Officers E and Officer F as the prison FLOs. At
10.15am, FLOs from Wakefield visited Mr Keenan’s ex-partner and broke the news.
They left contact details for Officer E and Officer F.
64. At 11.00am, Mr Keenan’s former partner phoned Officer F and told her that Mr
Keenan’s family thought he had 10 months left to serve. At 4.00pm, Mr Keenan’s
wife phoned Officer F about his death. Officer F offered support.
65. Officer E and Officer F continued to support to Mr Keenan’s family until his
cremation, which took place on 11 April. The prison contributed towards the cost in
line with national policy.
Support for prisoners and staff
66. 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
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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.
67. After Mr Keenan’s death, Mr C and Mr D, prison managers, debriefed the staff
involved in the emergency response, and staff and prisoners were offered ongoing
support. The prison deployed Listeners (prisoners trained to offer peer-led support),
and the Samaritans visited the prison to offer support to staff and prisoners. We are
satisfied that the prison appropriately initiated postvention procedures.
Post-mortem report
68. A post-mortem examination found that Mr Keenan died as a result of hanging.
Toxicology analysis of Mr Keenan’s blood found therapeutic levels of amitriptyline.
Events after Mr Keenan’s death
69. Mr Keenan left several letters addressed to various members of staff at Haverigg. In
a letter addressed to Mr E, the Head of Security, he said, “my mind has been
broken for the last two months” and “I’ve had so much stress from my OMU” (which
we take to mean from his POMs). He said that social services had threatened his
partner, and this led to her ending their relationship. He added that his health had
also gone “downhill” in the last eight days and therefore “my head is truly screwed”.
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Findings
Assessment of risk
70. The Prison Safety Policy Framework (which was issued on 1 November 2024 and
came into effect in January 2025) requires all staff who have contact with prisoners
to be aware of the risk factors and triggers that might increase a prisoner’s risk of
suicide and self-harm. Any prisoner identified as at risk of suicide and self-harm
must be managed under ACCT procedures.
71. Mr Keenan was not subject to ACCT monitoring at Haverigg. Prison records show
that he had a good relationship with most staff, engaged well with other prisoners
and generally abided by the rules.
72. On 4 February, Mr Keenan told ACP A that he was having thoughts of suicide. Later
the same day, Mr Keenan also saw a GP. Both members of healthcare staff
considered that Mr Keenan’s thoughts of suicide were most likely to be a side effect
of duloxetine, the antidepressant he had recently been prescribed for nerve pain.
This, combined with Mr Keenan’s assurances that he had no plans to act on the
thoughts, was sufficient to satisfy them that he was not at raised risk of suicide or
self-harm. They did not consider starting ACCT procedures or make a referral to the
mental health team. The clinical reviewer considered that voicing suicidal thoughts
was a change in Mr Keenan’s presentation, no matter the reason for those
thoughts, and that staff missed an opportunity to assess his risk and to explore any
emerging suicide plans.
73. Prison staff only considered starting ACCT procedures once, on 6 February. Again,
the staff were reassured by Mr Keenan’s explanation and did not think ACCT
procedures were necessary.
74. Staff submitted intelligence over the following weeks that indicated Mr Keenan’s risk
of suicide might be raised. However, staff who worked with Mr Keenan described
him as manipulative and considered this was manipulative behaviour rather than
concerning behaviour. We are concerned that staff allowed this perception of Mr
Keenan to hold greater weight than what was known about his risks. He had
expressed thoughts of suicide, which was not usual behaviour for him, his
relationship had recently broken down and he was very close to release. Finding
him suitable release accommodation had not been straightforward, and Mr Keenan
had been told that his safety might be at risk at his brother’s address. The Prison
Safety Policy Framework is clear that ACCT procedures should be started where
there are concerns about a prisoner’s risk. The multi-disciplinary approach would
have allowed staff to explore Mr Keenan’s risk in a meaningful and supportive way.
That neither healthcare nor prison staff thought ACCT procedures were necessary,
based on assumptions and perceptions, is of concern and we make the following
recommendations:
The Governor and Head of Healthcare should ensure that all staff understand
their responsibilities to identify and assess risk information and begin ACCT
procedures when required.
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The Head of Healthcare should ensure that when a prisoner reports suicidal
thoughts, staff consider making a referral to the mental health team and
document their decision making.
75. Mr Keenan had a difficult relationship with his POMs and he documented the
negative emotional impact this had on him in his letter to M. We consider that they
had little direct evidence to indicate Mr Keenan’s risk of suicide was increasing
although they were aware that he was anxious and frustrated about some aspects
of his upcoming release. Mr Keenan’s death serves as a sobering reminder that the
time leading up to release is often a period of heightened vulnerability, during which
the risk of suicide and self-harm significantly increase.
Governor to note
Emergency response
76. CM A did not collect a mobile phone prior to responding to the code blue, as she
should have done according to the prison’s death in custody contingency plan.
While this did not impact the outcome in Mr Keenan’s case, as the seriousness of
his condition was promptly conveyed to the ambulance service, the prison reviewed
the contingency plan and amended it. The night CM must now always carry a prison
mobile phone. We are satisfied that this response was appropriate.
77. OSG A did not cut the ligature when he entered Mr Keenan’s cell. He told us that he
had an anti-ligature knife but could not access it as he was trying to lift Mr Keenan.
However, BWVC footage shows that CM A and OSG A were stood in the middle of
the cell when Officer D arrived, and Mr Keenan was still suspended by the ligature.
While we recognise the distressing nature of such situations, it is vital that staff
respond, cut the ligature and begin CPR without delay. The Governor will want to
reflect on this finding. D
Inquest
78. At the inquest, which took place between 10 and 13 May 2026, the Coroner
concluded that Mr Keenan died by hanging.
12 Prisons and Probation Ombudsman
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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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