Norman Loseby

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Independent investigation into
the death of Mr Norman Loseby,
a prisoner at HMP Isle of Wight,
on 7 November 2020
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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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 Norman Loseby died on 7 November 2020 having been found hanged in his cell at
HMP Isle of Wight. Mr Loseby was 54 years old. I offer my condolences to Mr Loseby’s
family and friends.
I have concluded that Mr Loseby hid the full extent of his distress from staff, and they
could not have been expected to predict or prevent Mr Loseby’s actions that day.
However, I am concerned that Mr Loseby’s mental health care was inadequate, both at
HMP Wormwood Scrubs and Isle of Wight, and he was not sufficiently assessed,
supported or reviewed.
Another prisoner found Mr Loseby hanged after staff unlocked prisoners for lunch. He had
clearly been dead for several hours when he was found. This is unacceptable. Prison
staff remained unclear about the timing and expectations of roll checks and welfare
checks.
I am very concerned that we have made recommendations in this report that we have
made repeatedly following previous investigations into deaths at Isle of Wight. This
suggests that lessons are not being learned. I have, therefore, asked the Prison Group
Director to meet me to discuss what more can be done to reduce self-inflicted deaths at
the prison.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister, CB
Prisons and Probation Ombudsman November 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. Mr Norman Loseby had a history of suicidal thoughts and had previously been
admitted to a psychiatric unit and was prescribed antidepressants in the community.
In October 2019, he was convicted of rape and taken to HMP Wormwood Scrubs.
It was his first time in prison.
2. Mr Loseby disclosed his mental health issues to a nurse when he arrived at
Wormwood Scrubs and she referred him to the mental health team. He later told a
nurse that he felt anxious and had thoughts of suicide but no intention of acting on
these thoughts. He had no further appointments with the mental health team at
Wormwood Scrubs.
3. In November, Mr Loseby was sentenced to six and a half years imprisonment. On
15 January 2020, he transferred to HMP Isle of Wight. He told a nurse about his
mental health issues, but said he had no thoughts of suicide or self-harm. The
nurse did not refer him to the mental health team. The next day, a prison GP
assessed Mr Loseby and continued his prescription of antidepressants.
4. Over the following months, Mr Loseby seemed to settle and told staff he was keen
to progress with his sentence. The COVID-19 pandemic meant that Mr Loseby’s
time out of his cell was very restricted. Staff regularly checked on his welfare and
he did not raise any concerns with them.
5. During September and October, Mr Loseby had some ongoing issues with the
family court as well as a court appearance for a further criminal offence. Prisoners
told the investigator that he was stressed about these events. Another prisoner
gave Mr Loseby his own antidepressant medication to help him cope. Staff did not
know this until after Mr Loseby died.
6. On 6 November, staff and prisoners said that Mr Loseby seemed his usual self and
had no concerns about him. An operational support grade (OSG) checked Mr
Loseby that evening and at 5.10am the next day and noted nothing unusual.
7. At 11.40am, staff unlocked Mr Loseby for lunch. Another prisoner went into his cell
and found him hanged from his bed. He alerted staff who quickly responded and
cut Mr Loseby down. Since rigor mortis had set in, they did not attempt to
resuscitate him. A prison GP pronounced him dead at 12.35pm.
8. Mr Loseby had been due to appear in court on 9 November charged with an
outstanding sexual offence.
Findings
9. Mr Loseby had several factors which increased his risk to himself according to
Prison Service guidance. However, he presented to staff as a settled prisoner who
was keen to progress through his sentence. Both staff and prisoners had no
concerns that he was a risk to himself and we are satisfied that this was a
reasonable assessment.
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10. We are concerned that the COVID-19 restrictions meant that Mr Loseby spent long
periods in his cell and that staff had limited contact with him. In addition,
information about factors that increased his risk – his family court issues and the
fact that he was facing further serious criminal charges – was not shared.
11. The clinical reviewer concluded that both Mr Loseby’s physical and mental health
care were not of the required standard and therefore not equivalent to what he
could have expected to receive in the community. Mr Loseby was not appropriately
followed up by mental health services at Wormwood Scrubs and was not referred to
the mental health team at Isle of Wight. Despite being prescribed antidepressant
medication, Mr Loseby was not reviewed as he should have been.
12. After Mr Loseby’s death, staff became aware that another prisoner gave Mr Loseby
his own antidepressant medication in the last weeks of his life. We are very
concerned that, despite this, the other prisoner was still being prescribed this
medication and allowed to keep it in his possession when we interviewed him some
weeks later. We have expressed concerns about the inadequate management of
‘in possession’ medication at Isle of Wight in previous investigations.
13. Local instructions about when prisoners needed to be checked in the morning were
not clear at the time of Mr Loseby’s death. In addition, staff did not check Mr
Loseby when he was unlocked for lunch and gave different accounts of the
expectations of roll checks. We have identified similar shortcomings in previous
investigations.
14. Mr Loseby’s death was the fourth self-inflicted death at Isle of Wight since
November 2018 where we have concluded that the staff did not consider that the
prisoner was at risk of suicide. Although it is the case that prisoners sometimes
successfully hide their distress from staff, all the prisoners who died at Isle of Wight
did have risk factors for suicide
Recommendations
To HMP Wormwood Scrubs
• The Head of Healthcare should ensure that mental health staff:
• Appropriately assess a prisoner’s clinical history and risk of suicide before
deciding whether or not to accept the prisoner onto their caseload;
• open an ACCT if a prisoner expresses suicidal thoughts or is assessed to be a
risk to themselves: and
• fully document reasons for any decision not to open an ACCT or accept a
prisoner onto the mental health caseload.
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To HMP Isle of Wight
• The Head of Healthcare should:
• conduct a fresh review of in-possession medication risk assessments; and
• ensure that staff know what events and triggers should prompt additional
reviews.
• The Head of Healthcare should ensure that all healthcare staff make appropriate
and timely mental health referrals having, reviewed all relevant records available to
them.
• The Head of Healthcare should ensure that all prisoners with mental health issues
are reviewed appropriately, including repeat prescription medication.
• The Governor should review the prison’s local instructions on roll checks and
welfare checks to ensure that:
• staff are clear about the type of check required, when they should do it, and how
the check should be carried out;
• a welfare check is carried out on all prisoners at or before unlock;
• a morning welfare check takes place on all prisoners, regardless of whether they
are being unlocked; and
• they consider how best to ensure that staff understand what is required (as
repeated written reminders do not seem to have been effective).
• The Prison Group Director for the Long-term and High Security Estate (South)
should arrange a meeting with the Ombudsman to discuss what is being done to
reduce the number of self-inflicted deaths at Isle of Wight.
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The Investigation Process
15. The investigator issued notices to staff and prisoners at HMP Isle of Wight informing
them of the investigation and asking anyone with relevant information to contact
her.
16. Due to the COVID-19 pandemic, the investigator was unable to visit the prison. She
obtained copies of relevant extracts from Mr Loseby’s prison and medical records
via post and email.
17. The investigator interviewed nine members of staff and four prisoners in December
2020. NHS England commissioned a clinical reviewer to review Mr Loseby’s
clinical care at the prison. The investigator and clinical reviewer jointly interviewed
healthcare staff. All the interviews were conducted by telephone because of the
COVID-19 restrictions.
18. We informed HM Coroner for the Isle of Wight of the investigation. She gave us the
results of the post-mortem examination. We have sent the coroner a copy of this
report.
19. One of the Ombudsman’s family liaison officers contacted Mr Loseby’s sister to
explain the investigation and to ask if she had any matters she wanted the
investigation to consider. Mr Loseby’s sister asked:
• What happened before Mr Loseby died?
• What information was there on Mr Loseby’s state of mind?
• What medication was he prescribed?
• How was Mr Loseby assaulted when he was locked in his cell for most
of the day?
• Why was Mr Loseby sent to a category B prison when he was
vulnerable due to his mental health issues?
20. We have found no evidence that Mr Loseby was assaulted. In July 2020, he
fractured his collar bone falling over in the exercise yard. This was witnessed by
staff. There are no other injuries reported in his medical records and both staff and
prisoners said they never witnessed Mr Loseby being assaulted. In addition, the
post-mortem examination found no evidence of recent or healing injuries.
21. Mr Loseby was transferred to HMP Isle of Wight due to the nature of his offences,
his length of sentence and his security classification. He was a category B prisoner.
22. Mr Loseby’s sister’s other questions are answered in this report.
23. Mr Loseby’s sister received a copy of the initial report. She did not make any
comments.
24. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Isle of Wight
25. HMP Isle of Wight is an amalgamation of two former prisons, Parkhurst and Albany,
and holds approximately 1,100 men, almost all of whom have been convicted of
sexual offences. Care UK provides healthcare services at the prison. There is a
healthcare inpatient unit at the Albany site, providing 24-hour care for prisoners.
HM Inspectorate of Prisons
26. The most recent full inspection of HMP Isle of Wight was in April and May 2019.
Inspectors found that relationships between staff and prisoners were good and most
prisoners said they had a member of staff they could turn to if they had a problem.
They also found that clinical care was very good with effective physical healthcare,
improved mental health services and good medicine management. They found that
prisoners with long-term conditions were managed and reviewed as necessary and
they had appropriate care plans.
27. However, inspectors found that prisoners had very poor perceptions of safety, with
more than half saying that they had felt unsafe during their time at Isle of Wight.
Violence had risen significantly, and staff’s response was unsatisfactory and
inconsistent. Inspectors found that levels of self-harm were high and some of the
PPO’s recommendations following deaths at the prison had not been implemented.
28. Inspectors noted that the prison had an ‘in possession’ medicines policy that
reflected both the patient and the drug, and that ‘in possession’ risk assessments
were completed and reviewed and that spot checks took place according to the
policy.
29. HMIP carried out an Independent Review of Progress in January 2020 to review
progress against 11 key recommendations from the 2019 inspection. They
concluded that the outcomes were mixed. Local managers had worked well and
made progress in some important areas, including ensuring that staff understood
their roles and responsibilities in the event of a medical emergency and that an
ambulance was called when an emergency code was used. However, they also
found that HMPPS needed to ensure accommodation met basic standards and all
prisoners received appropriate support and healthcare.
Independent Monitoring Board
30. 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 31 December 2019, the IMB
reported several positive developments in support for prisoners with mental health
difficulties, including increased cover of support. The IMB also reported a 10%
increase in the number of self-harm incidents compared to the previous reporting
year.
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Previous deaths at HMP Isle of Wight
31. Mr Loseby was the thirteenth prisoner to die at Isle of Wight since November 2018.
Of the previous deaths, eight were due to natural causes and four were self-
inflicted. There has been one further self-inflicted death and seven due to natural
causes since Mr Loseby’s death.
32. We have recommended in previous investigations that welfare checks and roll
checks are completed properly; that prisoners with long-term chronic conditions
have appropriate care plans in place; and that assessments for ‘in possession’
medication need to take full account of risk factors.
Assessment, Care in Custody and Teamwork (ACCT)
33. ACCT is the care planning system the Prison Service uses to support prisoners at
risk of suicide or self-harm. The purpose of the ACCT is to try to determine the
level of risk posed, the steps that staff might take to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Checks should be made at
irregular intervals to prevent the prisoner anticipating when they will occur.
34. Part of the ACCT process involves assessing immediate needs and drawing up a
caremap to identify the prisoner’s most urgent issues and how they will be met.
Staff should hold regular multidisciplinary reviews and should not close the ACCT
plan until all the actions of the caremap are completed. Guidance on ACCT
procedures is set out in Prison Service Instruction (PSI) 64/2011, Management of
prisoners at risk of harm to self, to others and from others (Safer Custody).
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Key Events
35. Mr Loseby’s clinical records note that after one of his sisters killed herself in
February 2019, he told his community GP that he was anxious, depressed, could
not sleep and had thoughts of self-harm. He was prescribed sleeping tablets and
antidepressants. In March, he was admitted to a psychiatric unit for two weeks after
expressing suicidal thoughts.
HMP Wormwood Scrubs, 9 October 2019 – 15 January 2020
36. On 9 October, Mr Loseby was found guilty of rape and actual bodily harm and was
remanded into custody and taken to HMP Wormwood Scrubs. On arrival, he told a
nurse that he had generalised anxiety disorder and had psychotic symptoms,
including hearing voices. Mr Loseby said he was anxious but had no thoughts of
suicide or self-harm. He told the nurse that he had been admitted to a mental
health unit in October 2018 (the correct date was March 2019) and was under the
care of a community mental health team. Mr Loseby used a stick to help him walk,
following a stroke. The nurse referred him to the prison’s mental health team.
37. On 11 October, a prison GP continued Mr Loseby’s prescription of amlodipine and
lisinopril (to treat high blood pressure), atorvastatin (to lower cholesterol),
clopidogrel (a blood thinner) and fluoxetine (an antidepressant).
38. On 29 October, staff from the mental health team assessed Mr Loseby. They noted
that he said he felt anxious and worried about his future. He said he had thoughts
of suicide but no plan or intention to take his own life. Mr Loseby did not have any
further appointments with the mental health team at Wormwood Scrubs.
39. On 28 November, Mr Loseby was sentenced to six and a half years imprisonment.
On return to Wormwood Scrubs, he told a nurse that he was expecting the
sentence and felt “okay”. Mr Loseby said he had no thoughts of suicide.
HMP Isle of Wight, 15 January 2020 – 7 November 2020
40. On 15 January 2020, Mr Loseby transferred to HMP Isle of Wight. During a
reception health screen, he told a nurse that he had had a mental breakdown in
2018 and spent two weeks in hospital. Mr Loseby said he had no thoughts of
suicide or self-harm. She told the investigator that she had no concerns Mr Loseby
was a risk to himself.
41. On 16 January, a prison GP assessed Mr Loseby. He noted that Mr Loseby had
hypertension, depression and anxiety and asked for something to help him sleep for
the first few nights. He prescribed him sleeping tablets for three days. Mr Loseby
said he had a partner and daughter who he hoped would visit him. The GP told the
investigator that Mr Loseby seemed “quite anxious”.
42. On 21 February, Mr Loseby met with his offender manager (probation officer). Th
offender manager told the investigator that Mr Loseby seemed “fine” and was
adjusting to being in prison. He said that Mr Loseby seemed motivated to progress
through his sentence.
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43. On 27 February, an officer held a key work session with Mr Loseby. On 11 March
and 19 March, an officer met Mr Loseby as she had been allocated as his key
worker. She told the investigator that, although it was his first time in prison, Mr
Loseby did not seem worried and was focussed on getting through his sentence.
44. From mid-March, all face-to-face key working sessions had been stopped but
officers were expected to do quicker welfare checks with prisoners. Officers were
expected to record these monthly, but the key worker said that she saw Mr Loseby
more frequently than this.
45. Between 25 March and 9 October, the key worker recorded 12 welfare checks with
Mr Loseby, who raised no issues. She noted that he had a small group of prisoners
he mixed with and seemed to be coping well with the limited regime. She said that,
during the pandemic, prisoners had initially only been allowed out of their cells for
exercise and a shower, but that this progressed to having 40 minutes out of their
cell for association in cohorts of around 20 prisoners from their landing.
46. On 15 May, safer custody staff contacted Mr Loseby on the in-cell telephone
system as part of a system of routine checks. He said that he was coping well, had
enough distraction packs and was aware that he could contact the Samaritans on
the in-cell telephones.
47. On 21 May, Mr Loseby had a videolink with the family court about his young son.
On 22 July, Mr Loseby fell over in the exercise yard, witnessed by staff. He was
taken to hospital where it was confirmed he had fractured his collarbone.
48. On 11 August, the offender manager met Mr Loseby to discuss his sentence plan.
He told the investigator that he normally met prisoners on his caseload at least
every three months but, due to COVID-19, he had not been allowed to travel to the
prison. Mr Loseby said he was motivated to engage and understood the
importance of evidencing changes in his offending behaviour. The offender
manager said he seemed relatively positive. Mr Loseby said that he had had some
thoughts of suicide in the past but that they were fleeting, and he would never act
on them because of his son. The offender manager had no concerns that Mr
Loseby was a risk to himself.
49. An officer who worked on Mr Loseby’s wing said Mr Loseby was a polite and chatty
prisoner, who spoke to staff if he needed to. Mr Loseby spoke to him around
August about his ex-partner trying to stop him having contact with his children.
50. On 2 September, the offender manager organised a telephone call between Mr
Loseby and the Child and Family Court Advice and Support Service (CAFCASS)
about Mr Loseby’s ex-partner trying to get his name removed from his son’s birth
certificate. He noted that Mr Loseby was going to seek legal advice before making
any decisions and offered his assistance if Mr Loseby needed it.
51. On 7 September, the offender manager met Mr Loseby in passing, and Mr Loseby
asked him to organise a telephone call with CAFCASS. He said he would see if it
was possible. On 10 September, he facilitated a brief telephone call between Mr
Loseby and CAFCASS. On 25 September, Mr Loseby had a videolink with the
family court.
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52. A prisoner who shared a cell with Mr Loseby from February until the beginning of
October told the investigator that Mr Loseby was “alright” but became increasingly
stressed about his conviction and being in prison. Mr Loseby told him that he had
another court case outstanding, which the prisoner thought he was worried about.
He told the investigator that they started to argue, and he moved to a different cell.
Mr Loseby stayed in the same cell without a cellmate until his death. The prisoner
said that they never physically fought each other.
53. On 1 October, Mr Loseby had a video link meeting with his solicitor. On 8 October,
Mr Loseby appeared at Luton Magistrate Court via videolink regarding a further
sexual offence. His case was committed to Luton Crown Court and adjourned for
reports. This information was contained in videolink records but was not noted in
Mr Loseby’s prison record.
54. On 12 October, the offender manager met Mr Loseby who said he was worried
about his contact with CAFCASS. He said he would try and contact CAFCASS on
Mr Loseby’s behalf.
55. On 21 October, the offender manager gave Mr Loseby documentation to complete
for the family court. Mr Loseby said he would like to talk to CAFCASS and Mr
Heath said he would try to arrange this the following week. He said he had no
concerns about Mr Loseby.
56. A prisoner told the investigator that Mr Loseby was “quite stressed” about his
outstanding court case and about his ex-partner trying to remove his name from his
son’s birth certificate, although he never had any concerns that Mr Loseby was a
risk to himself. He said that he was prescribed mirtazapine (an antidepressant
which is also used to treat anxiety) which he did not feel he needed to take.
Towards the end of October, he started giving this medication to Mr Loseby, seven
tablets at a time (a week’s supply). He said that Mr Loseby did not pay for the
medication and he gave it to him to try to help him as a friend.
57. Another prisoner told the investigator that he was good friends with Mr Loseby who
told him that he did not want to mix with other prisoners. He said that he witnessed
other prisoners calling Mr Loseby derogatory names related to his offence. He said
this stopped after Mr Loseby confronted them around May or June. He said that Mr
Loseby was upset that his ex-partner was trying to take his son’s name off his birth
certificate. He was also concerned about his outstanding court case. He did not
see Mr Loseby as much after mid-October as he was employed off the wing, but
other prisoners told him that Mr Loseby was not coming out of his cell as much.
The prisoner thought he was struggling to cope.
58. The prisoner told the investigator that on 4 November, Mr Loseby was stressed,
and said he had been up all night and did not know whether to “hang myself off the
telly or hang myself off the bed”. He also told the prisoner that he had taken three
mirtazapine tablets which he had not been prescribed as he thought they would
help calm him down. Mr Loseby told him that he had got the medication from
another prisoner, who had just arrived at the cell and confirmed it. The prisoner did
not think that Mr Loseby was genuinely having suicidal thoughts and so did not tell
staff.
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59. On 6 November, the key worker had a brief conversation with Mr Loseby in the
morning to conduct her welfare check. He said that he was fine with the current
restricted regime and was out of his cell collecting some more puzzles. She said
they joked that they needed some new ones as he had done most of them. She
told the investigator that she never had any concerns about Mr Loseby.
60. An officer was working on Mr Loseby’s landing that day. He said he had no
concerns about him. Mr Loseby was unlocked to collect his evening meal and
locked back in his cell around 4.40pm. Two prisoners both saw Mr Loseby around
this time. They said that he seemed “fine”. Another prisoner also saw him, said he
seemed his usual self and gave him seven mirtazapine tablets. Staff did roll checks
at 5.00pm and 7.30pm.
61. Around 8.10pm, an Operational Support Grade (OSG) did the night roll check on Mr
Loseby’s wing. She told the investigator that she checked that every prisoner was
in their cell and responding. She could not specifically remember checking Mr
Loseby’s cell but knows that she did. (There is no CCTV on the wing.)
Events of 7 November
62. On 7 November around 5.10am, the OSG did another roll check. She told the
investigator that she checked every prisoner was in their cell and that there were no
obvious issues. She said that she always uses a torch and the cell nightlights. She
said that it was not always possible to tell whether a prisoner was breathing since
most of them were in bed and under their covers at that time. Again, she could not
specifically remember checking Mr Loseby’s cell but said that she would have
remembered if Mr Loseby was out of bed.
63. Officer A started work on the wing at 8.15am. Mr Loseby’s time out of his cell was
scheduled for the afternoon that day, so he was locked in his cell all morning. He
wrote in his statement that it was not unusual not to see Mr Loseby until he
collected his lunch.
64. Around 11.15am, Officers A and B started unlocking prisoners for lunch. By the
time they got to Mr Loseby’s landing it was around 11.40am. Officer B unlocked Mr
Loseby’s side. He told the investigator that he unlocked each cell door, opened it
slightly and shouted for the prisoner to get their lunch.
65. After he was unlocked, a prisoner went to Mr Loseby’s cell, knocked on the door
and opened his observation panel. He could not see Mr Loseby initially, but then
noticed him lying on the floor, looking like he was trying to reach something under
his bed. He banged on his door and shouted to Mr Loseby, but he did not respond,
so he went into the cell. He then noticed a ligature around Mr Loseby’s neck. He
went to the cell entrance and shouted to staff to come to the cell quickly.
66. Three officers went straight to Mr Loseby’s cell. Officer A noted that Mr Loseby was
lying on his right side with his feet at the back of the cell and his head and
shoulders level with the bottom bunk. He initially thought that Mr Loseby had fallen.
Officer C then realised that Mr Loseby was hanging from the top bunk by a dressing
gown cord. He radioed a code blue (an emergency code which indicates a prisoner
is not breathing or is having difficulty breathing). The officers cut the ligature from
Mr Loseby’s neck using an anti-ligature knife and lowered him to the floor. They
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noted that Mr Loseby was pale and stiff. They did not try to resuscitate him as they
believed he had been dead for some time and it would be futile and undignified.
Officer C radioed that they believed the prisoner was deceased.
67. A nurse responded to the code blue. She assessed Mr Loseby and noted that he
was cold with signs of rigor mortis. At 11.52am, the ambulance arrived at the prison
and the paramedics agreed with the nurse’s assessment. At 12.35pm, the prison
GP confirmed that Mr Loseby had died.
68. In the days after Mr Loseby died, staff submitted intelligence reports that some
prisoners alleged that Mr Loseby had been bullied by other prisoners and called
derogatory names by prisoners working on the servery. They also alleged that
prisoners had stolen a vape and television remote control from Mr Loseby. Another
intelligence report was submitted with information from Mr Loseby’s family that he
had told them that he had been assaulted in the shower due to the offence he had
committed but had not reported the assault. Staff also discovered that a prisoner
had been giving Mr Loseby his medication.
69. On 9 November, Mr Loseby had a videolink appearance scheduled at Luton Crown
Court for an outstanding sexual offence.
Contact with Mr Loseby’s family
70. Due to restrictions on face-to-face contact during the COVID-19 pandemic, the
Head of Safety telephoned Mr Loseby’s sister to inform her of her brother’s death
and passed on his condolences. An officer was appointed as the family liaison
officer. She remained in contact with Mr Loseby’s sister and offered a contribution
to funeral expenses in line with Prison Service policy.
Support for prisoners and staff
71. After Mr Loseby’s death, the Head of Safety 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.
72. The prison posted notices informing other prisoners of Mr Loseby’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 Loseby’s death.
Post-mortem report
73. The pathologist concluded that the cause of Mr Loseby’s death was ligature
suspension (hanging). The toxicology results indicated that mirtazapine was
present in Mr Loseby’s system at a raised level but below a level that would have
contributed to his death. Fluoxetine, which Mr Loseby was prescribed, was also
found in his system, but at a low level which seemed to indicate he was not taking it
consistently.
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Findings
Assessment of risk of suicide and self-harm
74. Mr Loseby had several factors which increased his risk to himself according to PSI
64/2011, Safer Custody, including his diagnosis of depression, family history of
suicide, physical illnesses, separation from his partner and his son, and concerns
about facing further charges which could have resulted in a longer prison sentence.
75. All the staff we spoke to said that Mr Loseby was a settled prisoner who seemed to
be coping well and wanted to progress with his sentence. Officers checked
regularly on Mr Loseby’s welfare, including the day before he died, and he never
raised any issues with them.
76. Prisoners gave the impression of a slightly more anxious prisoner who was
concerned about his upcoming court case and issues with the family court and his
ex-partner. Intelligence submitted after he died also alleged that he had been
bullied but this was not known to staff at the time.
77. Mr Loseby had a court appearance for a further offence two days after he died. The
offender manager told the investigator that he thought Mr Loseby would have
known about this appearance either from his solicitor or wing staff. Prisoners said
that this outstanding charge was a source of stress for Mr Loseby although he did
not speak to staff directly about it.
78. We are satisfied that Mr Loseby hid the full extent of his distress from staff and
other prisoners. In these circumstances, we do not consider that staff could have
been expected to predict or prevent Mr Loseby’s actions that day.
Clinical care
79. The clinical reviewer concluded that Mr Loseby’s healthcare was not of the required
standard and therefore not equivalent to that he could have expected to receive in
the community.
Mental health care
80. The clinical reviewer noted that Mr Loseby had significant and chronic mental health
issues (anxiety and depression with psychotic symptoms) and had been admitted to
a psychiatric unit in March 2019 after expressing suicidal thoughts. When he was
remanded to Wormwood Scrubs, he was referred to mental health services who
assessed him but did not accept him onto their caseload. At this point he
expressed thoughts of suicide to the nurse, although he said he had no intention of
acting on them. The clinical reviewer concluded that Mr Loseby should have
received further mental health input from the team. Given Mr Loseby’s assertion
that he was having suicidal thoughts, the nurse should also have opened an ACCT.
We make the following recommendation:
The Head of Healthcare at Wormwood Scrubs should ensure that mental
health staff:
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• appropriately assess a prisoner’s clinical history and risk of suicide
before deciding whether to accept the prisoner onto their caseload;
• open an ACCT if a prisoner expresses suicidal thoughts or is assessed
to be a risk to themselves: and
• fully document reasons for any decision not to open an ACCT or accept
a prisoner onto the mental health caseload.
81. When Mr Loseby transferred to Isle of Wight, he disclosed his mental health issues
to a nurse. She did not refer him to the mental health team. This was another
missed opportunity to assess and provide support to Mr Loseby. She told the
investigator that she was new to reception processes and felt under pressure to
process prisoners quickly. She was unaware of any guidance about who should be
referred to the mental health team at the time.
82. A prison GP also assessed Mr Loseby the day after he arrived at Isle of Wight. He
told the investigator that he did not believe Mr Loseby needed to be referred to
mental health services. He said that “you deal with the patient that’s in front of you”
and since Mr Loseby did not seem to be in crisis, he did not believe a mental health
referral was necessary.
83. It is not clear whether either the nurse or the prison GP reviewed Mr Loseby’s
previous clinical record when assessing him.
84. The Head of Healthcare told the investigator that Mr Loseby should have been
referred to the mental health team when he arrived at Isle of Wight. Local policy
indicates that staff should have reviewed Mr Loseby’s previous mental health
history including his risk to himself and referred him if there was any previous self-
harm or suicide attempts.
85. The Head of Healthcare has since recruited a dedicated reception nurse who
started at the prison in January 2021. She said she was also planning to recruit an
‘early days in custody’ mental health practitioner who would see all new prisoners,
although, at the time of interview, this had been delayed due to COVID-19. She
said that she had discussed the outcomes of the learning with the wider team,
including the reception nurse.
86. We note that improvements have been made since Mr Loseby’s death which we
welcome. However, we make the following recommendation:
The Head of Healthcare should ensure that all healthcare staff make
appropriate and timely mental health referrals, having reviewed all relevant
records available to them.
87. The prison GP said that, in usual circumstances, he would have reviewed Mr
Loseby three to six months after his arrival at Isle of Wight. However, this had not
been possible as the GP service was limited to emergency appointments only until
mid-October 2020 due to COVID-19.
88. National Institute for Health and Care Excellence (NICE) guidance states that
patients on long-term medication, including antidepressants, should be reviewed
regularly. While we note the difficulties presented by COVID-19, the clinical
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reviewer considered that this should not have “completely precluded follow up of a
vulnerable patient”. In addition, the post-mortem report indicated that the levels of
fluoxetine in Mr Loseby’s system suggested that he may not have been taking his
antidepressant medication consistently.
89. After Mr Loseby’s death, the prison became aware that another prisoner had been
giving Mr Loseby his own antidepressant medication. The prisoner told us that he
was able to do so because he did not need it himself.
90. We have investigated three deaths at Isle of Wight since November 2018 in which a
prisoner has killed himself using prescription medication which he had stockpiled.
In response, we have repeatedly recommended that healthcare staff at the prison
must do more to review and monitor ‘in possession’ medication. We were,
therefore, very concerned to find that this prisoner was continuing to receive his
medication weekly and to keep it in his own possession at the time of our interview
some weeks after Mr Loseby’s death. This meant that he was potentially able to
stockpile the medication, which put him and other prisoners at risk of overdose and
also provided opportunities for illicit trading.
91. We make the following recommendations:
The Head of Healthcare should ensure that all prisoners with mental health
issues are reviewed appropriately, including repeat prescription medication.
The Head of Healthcare should:
• conduct a fresh review of in-possession medication risk assessments;
and
• ensure that staff know what events and triggers should prompt
additional reviews.
Physical healthcare
92. The clinical reviewer concluded that Mr Loseby had several chronic diseases which
were not managed appropriately. However, he did not consider that this contributed
to Mr Loseby’s death.
93. The Head of Healthcare told us that in December 2020 she had recruited a long-
term conditions nurse to assist the robust care planning for people with long-term
conditions. We make no further comment.
Roll checks and welfare checks
94. PSI 75/2011, Residential Services, says:
“Reports from the Prisons and Probation Ombudsman on deaths in custody have
identified cases in which a prisoner has died overnight, apparently from natural
causes, but staff unlocking them have not noticed that the prisoner had died. This
is not acceptable.
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“The appropriate arrangements will depend on the local regime, but there need to
be clearly understood systems in place for staff to assure themselves of the well-
being of prisoners during or shortly after unlock ... Where prisoners are not
necessarily expected to leave their cell, staff will need to check on their well-being,
for example by obtaining a response during the unlock process.”
95. Mr Loseby was found dead in his cell by another prisoner at about 11.40am on 7
November. Rigor mortis, which usually occurs within two to six hours of death was
present, meaning Mr Loseby had been dead for some time when he was found.
96. Mr Loseby was last locked into his cell at 5.00pm on 6 November. An officer did a
roll check at 7.30pm and an OSG did one at 8.10pm that night and at 5.10am the
next morning. The OSG said that this check was to ensure all prisoners were in
their cells and there were no obvious issues. A Custodial Manager (CM) told the
investigator that this was appropriate for a roll check.
97. Mr Loseby was not checked by staff after this. Three officers all said that they were
not expected to check prisoners in the morning unless they were unlocking them.
On 7 November, there was no reason to unlock Mr Loseby until lunchtime, so he
remained locked in his cell.
98. The CM recognised that since altering the regime due to COVID-19, it had not been
clear whether staff were supposed to check all prisoners in the morning, regardless
of whether they were being unlocked. He said that on 8 November, the day after Mr
Loseby was found dead, he had emailed staff clarifying that day staff must do a
welfare check on all prisoners when they start their shift around 7.30am.
99. While we cannot be sure whether a morning welfare check at 7.30am would have
affected the eventual outcome for Mr Loseby, it is possible that it may have done.
100. Officer B was subject to a disciplinary hearing. This found that, as the officer who
was on the early shift, he was responsible for completing the welfare check that
morning. He received a formal warning.
101. We do not consider the lack of any morning check to be a failing on the part of any
particular staff member. Rather, we found it to be a failing in the guidance provided
to staff during COVID-19.
102. We are, however, concerned that when Officer B unlocked Mr Loseby for lunch
around 11.40am, he did not look into the cell or try to get a response from him.
Although he said that he would have returned to Mr Loseby’s cell if he had not
come out to collect his lunch, failing to check on Mr Loseby when he unlocked him
was a clear breach of PSI 75/2011.
103. This is now the fourth investigation into a death at Isle of Wight since November
2018 in which we have found serious shortcomings in the quality of roll checks and
welfare checks. Following these previous investigations, the Governor issued
Notices to Staff (NTS) in May and November 2019 clarifying that a welfare check
must be done on all residents at morning unlock to check the well-being of the
prisoner and to obtain a response from them. These NTS also stated that a
prisoner’s well-being must be checked at roll check.
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104. Following an investigation into a further self-inflicted death in November 2019, the
prison told us that a new template was implemented in July 2020 which set out the
times and expectations of both welfare and roll checks and was to be displayed in
wing offices. The prison also said that an updated operational instruction would be
issued to all staff to clarify the type of check required, the actions that must be taken
and when it should be completed. We have not seen any evidence of this
instruction, and ambiguity around both the time of checks and what was expected
remained at the time of Mr Loseby’s death.
105. Following Mr Loseby’s death, an email was sent to all staff on 3 December 2020
clarifying procedures for welfare and roll checks. This stated that:
“All staff must ensure that whenever a cell is checked, they satisfy themselves of
the safety and welfare of the resident and that there are no apparent immediate
issues or concerns.
“This check can take the form of a verbal or physical acknowledgement, positive
signs of breathing, the resident moving in the cell or in bed, or any other indication
that the resident in question is not in a state of distress.”
106. The email also reiterated that welfare checks must take place on all prisoners at
7.45am on weekdays and 8.45am at weekends, regardless of whether they are
being unlocked, and that during COVID-19 restrictions these could take place
through observation panel.
107. The investigator clarified the difference between a roll check and a welfare check
with the Head of Safety. He said that both involved checking the well-being of a
prisoner, but a welfare check would usually involve unlocking the door, although
during COVID-19 restrictions, all checks could be done through the observation
panel. However, the OSG and the CM did not understand that a check on the
prisoner’s wellbeing is required at roll check and we are concerned that staff are still
unclear about this.
108. In addition, we note that at the early morning roll check (around 5.00am) most
prisoners are asleep and covered by bedding, and it is therefore difficult for staff to
check their well-being without waking prisoners up in most cases. We consider that
at roll checks it is sufficient to ensure that a prisoner is in their cell and there are no
obvious issues, as the OSG stated, and that it is not reasonable to expect staff to
check their wellbeing as well. Making roll checks too onerous or disruptive may
mean they are not properly carried out in line with local instructions.
109. We are very concerned that, despite repeated written reminders, staff at Isle of
Wight are either still unclear about, or wilfully ignoring, the requirement to check the
wellbeing of prisoners at key times. This lack of clarity puts prisoners’ welfare at
risk. We therefore repeat a previous recommendation:
The Governor should review the prison’s local instructions on roll checks and
welfare checks to ensure that:
• - staff are clear about the type of check required, when they should do
it, and how the check should be carried out;
• - a welfare check is carried out on all prisoners at or before unlock;
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• - a morning welfare check takes place on all prisoners, regardless of
whether they are being unlocked; and
• - they consider how best to ensure that staff understand what is
required (as repeated written reminders do not seem to have been
effective).
Bullying
110. After Mr Loseby died, some prisoners alleged that he had been bullied. Staff all
said that they had never witnessed Mr Loseby being bullied or physically assaulted.
They said he seemed to get on well with other prisoners. Staff also said that there
was always someone located by the servery, so that if the bullying had taken place
there as alleged, a member of staff would have witnessed it.
111. Following the allegations, the CM interviewed two prisoners. They both said that
they used to call Mr Loseby “bacon” (a derogatory name for a sex offender) but that
Mr Loseby would also use this name to them. They said that they had no intention
of upsetting Mr Loseby. The ex-cellmate said that he had never physically fought
with Mr Loseby and after they stopped sharing a cell, they did not speak to each
other for around three weeks and then shook hands and agreed to be civil to each
other. The CM reminded both men that prisoners should not call each other names
as it could cause unnecessary stress and anxiety. In the circumstances, and given
the lack of evidence, we consider that this was appropriate and make no further
recommendation.
112. However, we note that the post-mortem toxicology tests suggested that Mr Loseby
had not been taking his fluoxetine (antidepressant) medication consistently. This
raises the question of what he had done with it if was not taking it. One possibility is
that he was being bullied to give it to other prisoners. Although we cannot say if that
was happening, it reinforces the need for regular monitoring of prisoners on long-
term medication, and for regular reviews of ‘in possession’ medication.
Implementing PPO recommendations
113. We are very concerned that although we have made repeated recommendations to
Isle of Wight about monitoring and risk assessing ‘in possession’ medication and
about roll checks and welfare checks, we have identified the same concerns in this
investigation.
114. We are also very concerned that Mr Loseby’s death was the fourth self-inflicted
death at Isle of Wight since November 2018 where we have concluded that the
prisoner gave staff no indication that he was at risk of suicide. Although it is the
case that some prisoners successfully hide their distress from staff, all the prisoners
who killed themselves at Isle of Wight did have risk factors for suicide. We
therefore make the following recommendation:
The Prison Group Director for the Long-term and High Security Estate (South)
should arrange a meeting with the Ombudsman to discuss what is being done
to reduce the number of self-inflicted deaths at Isle of Wight.
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Inquest
115. The inquest into Mr Loseby’s death finished on 18 May 2026 and concluded that he
died from a self-inflicted act but it was not possible to determine his intention.
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