Patrick Driver

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Patrick Driver,
a prisoner at HMP Elmley,
on 5 October 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
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 Patrick Driver was found hanged in his cell at HMP Elmley on 5 October 2025. Staff
and paramedics tried to resuscitate him but were unsuccessful. He was 69 years old. I
offer my condolences to Mr Driver’s family and friends.
Staff supported Mr Driver using suicide and self-harm procedures for around 11 weeks
between August 2024 and February 2025, because he struggled with being in prison and
feared a long sentence. He also spent a long period in the prison’s inpatient department
(IPD) after he stopped eating. He was discharged from IPD on 21 February and staff
stopped ACCT monitoring on 26 February.
The investigation found that staff managed the ACCT procedures well and that the
decision to stop ACCT procedures on 26 February was a reasonable one. There was no
indication subsequently that Mr Driver’s mental health had declined, though there were
minimal records after 26 February.
The clinical reviewer found that the care provided to Mr Driver during his time in IPD and
while subject to ACCT monitoring was equivalent to that which he could have expected to
receive in the community. However, he found there was a lack of continuity of care
following Mr Driver’s discharge from IPD and that this aspect of his care was not
equivalent to that which he could have expected to receive in the community.
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 May 2026
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 26 July 2024, Mr Patrick Driver was remanded in prison charged with sexual
offences. He was sent to HMP Elmley. It was his first time in prison.
2. Mr Driver did not have a history of mental health issues.
3. A few days after Mr Driver arrived at Elmley, he stopped engaging in the prison
regime and refused food and medication.
4. On 12 August, staff started suicide and self-harm procedures (known as ACCT) for
Mr Driver after he told a GP that he did not want to be alive. Staff continued ACCT
monitoring until 10 September and then from 22 September to 6 December. Mr
Driver was worried he would not be granted bail and that he would get a long
sentence.
5. Due to concerns about his physical health, Mr Driver was admitted to the prison’s
inpatient department (IPD) on 16 August and remained there until 27 January 2025.
On 19 February, Mr Driver was readmitted to IPD due to refusing his food and
medication. He was discharged two days later.
6. On 21 February, staff restarted ACCT procedures after Mr Driver said he had lost
everything. They stopped ACCT monitoring on 26 February after Mr Driver told staff
he was no longer feeling depressed.
7. There are no records of any meaningful interactions between staff and Mr Driver
between 26 February and 5 October.
8. Mr Driver was due to attend court on 6 October for a six-week trial.
9. At around 5.04am on 5 October, during a routine check of all prisoners, an
operational support grade (OSG) saw Mr Driver on the floor of his cell. After she
knocked on the door but got no response, she radioed a medical emergency code.
An officer arrived a few minutes later and entered Mr Driver’s cell. He found Mr
Driver unresponsive, with a ligature tied around his neck attached to the phone
socket above. The officer cut the ligature, more staff arrived, and they started CPR.
10. At around 5.25am, paramedics arrived and applied a defibrillator which advised no
shock. At 5.34am, they pronounced life extinct.
Findings
11. We found that the ACCT procedures were managed well and that the decision to
stop ACCT monitoring on 26 February was a reasonable one.
12. Based on the prison records, there was no indication that Mr Driver was struggling
with his mental health after 26 February. However, there was little evidence of any
meaningful interaction with Mr Driver between 26 February and his death.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
13. The clinical reviewer concluded that the care provided to Mr Driver during the ACCT
process and his time in IPD was of a good standard. However, he found that Mr
Driver received no mental health follow up after he was discharged from IPD and
that this aspect of his care was not equivalent to that which he could have expected
to receive in the community.
Recommendations
• The Head of Healthcare should ensure that all prisoners discharged from IPD
following an ACCT, or who have presented with recent suicidal ideation or
significant mental health vulnerability, have a documented mental health review
prior to discharge and have a follow up appointment arranged when returned to the
residential unit.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
14. HMPPS notified us of Mr Driver’s death on 5 October 2025.
15. The investigator issued notices to staff and prisoners at HMP Elmley informing them
of the investigation and asking anyone with relevant information to contact her. One
member of staff contacted the investigator with information which is addressed in
the report.
16. The investigator visited Elmley on 16 October. She obtained copies of relevant
extracts from Mr Driver’s prison and medical records. She also obtained CCTV
footage, body worn video camera footage of the emergency response, the HMPPS
Early Learning Review and Ambulance Service records.
17. NHS England commissioned an independent clinical reviewer to review Mr Driver’s
clinical care at the prison.
18. The investigator and clinical reviewer interviewed ten members of prison and
healthcare staff at Elmley between 28 November and 18 December, both in person
and by video call.
19. We informed HM Coroner for Kent and Medway of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
20. The Ombudsman’s office contacted Mr Driver’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Driver’s sister said
she was concerned that the prison had leaked information about Mr Driver’s death
before she was told. We have addressed this issue in the report.
21. We shared our initial report with HMPPS and the prison’s healthcare provider,
Oxleas NHS Foundation Trust. HMPPS pointed out a factual inaccuracy with the
clinical review. The investigator passed this onto the clinical reviewer who amended
their report. The action plan is an additional annex to this report.
22. We sent a copy of our initial report to Mr Driver’s sister. She did not notify us of any
factual inaccuracies.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Elmley
23. HMP Elmley holds remand and sentenced prisoners in six houseblocks, with a
mixture of single and double cells. Oxleas NHS Foundation Trust provides
healthcare services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Elmley was in March 2025. Inspectors reported
that key work was not offered to prisoners regularly or with the same officer and that
it was often a task that was dropped when staffing was tight. In a sample
completed, each prisoner received about three sessions over a three-month period,
case notes were formulaic and there was no consistency in the officers taking the
sessions which meant prisoners could not develop rapport and were less likely to
discuss personal concerns with them. Inspectors reported that there was some
evidence of recent improvement following increased oversight by leaders.
25. Inspectors found that the inpatient unit provided good care. The unit was clinically
led and enabled operationally by a regular group of officers, facilitating continuity of
care. Nursing admission and discharge procedures had been updated and
documentation was of a reasonable standard. Inspectors found there was a weekly
ward round, during which the GP, nurses and consultant psychiatrist reviewed
every patient in a collaborative approach. This ensured holistic and joined-up care
(recorded on SystmOne, the medical record system) and post-discharge follow-up
of patients, which was good practice.
Independent Monitoring Board
26. 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 October 2024, the IMB
reported that, on average, only 20% of expected key work sessions occurred on a
weekly basis, usually because of low staff availability. Many prisoners with whom
Board members spoke had little knowledge of who their key worker was or the
purpose of key work.
27. The Board reported that a significant number of prisoners with mental health needs
were placed in the inpatient department (IPD) and on occasion, Board members
had witnessed prisoners displaying distress in a manner that made the atmosphere
unsettling and frightening, both for the individual concerned and others located in
IPD. The Board noted that it would like to see steps taken to improve mental health
provision for those prisoners in IPD.
Previous deaths at HMP Elmley
28. Mr Driver was the eleventh prisoner to die at Elmley since October 2022. Of the
previous deaths, four were from natural causes, three were self-inflicted and three
were drug related. Up to the end of February 2026, there has been one further
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
death, which was from natural causes. There are no similarities between the
findings from our investigation into Mr Driver’s death and the findings from our
investigations into the previous deaths.
Assessment, Care in Custody and Teamwork (ACCT)
29. 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.
30. Part of the ACCT process involves assessing immediate needs and drawing up
support actions 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 support actions are completed. Guidance on ACCT procedures
is set out in the Prison Safety Policy Framework (from January 2025, and prior to
that Prison Service Instruction (PSI) 64/2011 on safer custody).
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
31. On 26 July 2024, Mr Patrick Driver was remanded in prison charged with sexual
offences. He was sent to HMP Elmley. It was his first time in prison.
32. During his initial health screen, Mr Driver told the nurse that he did not have any
mental health problems and that he had no thoughts of suicide or self-harm.
33. Over the next few days, Mr Driver refused to engage in the prison regime and
refused food and medication (prescribed to treat nerve pain and high blood
pressure).
34. On 11 August, a nurse went to see Mr Driver. He told the nurse that he did not feel
like taking his medication because he had not been granted bail. The nurse booked
a GP appointment and arranged a welfare check for the next day.
ACCT – 12 August to 10 September 2024
35. On 12 August, a GP saw Mr Driver. Mr Driver told the GP that he did not want to be
alive anymore. The GP offered Mr Driver antidepressants, but he declined and said
he wanted to be left alone. The GP started suicide and self-harm prevention
procedures (known as ACCT) for Mr Driver. An entry in Mr Driver’s medical record
says that during the ACCT review, he appeared low and said he was struggling to
accept his circumstances. He said that he had given up on himself.
36. On 14 August, following Mr Driver refusing food for three days, wing staff opened a
food refusal log and informed healthcare staff. Mr Driver told an officer that he did
not want to live because he was looking at a lengthy sentence.
37. The same day, a mental health nurse went to see Mr Driver. Mr Driver told the
nurse that he did not need medication and that he wanted to be left alone. The
nurse recorded that Mr Driver did not engage enough to enable him to complete a
full mental state examination. He recorded in the medical record that he would
attend Mr Driver’s ACCT review the next day to complete the mental health review.
38. On 15 August, during an ACCT review, staff recorded that Mr Driver said he wanted
to die and that he would not self-harm or use a ligature around his neck but would
starve himself to death. Staff noted that he presented as weak and frail due to his
food refusal and that he refused all support from the mental health team. A mental
health nurse attended the ACCT review to complete the mental health assessment.
He referred Mr Driver back to the GP and for psychological support.
39. On 16 August, due to concerns about his physical health, Mr Driver was admitted to
the prison’s inpatient department (IPD).
40. On 19 August, during an ACCT review, Mr Driver told staff he had not eaten since
he arrived in IPD and in total had not eaten for 11 days. He said that his intention
was to end his life by starving himself. Mr Driver talked about his criminal case and
said he was due to attend court on Friday and that if he got bail, it might change his
mindset.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
41. On 23 August, Mr Driver attended a court hearing. No outcome was recorded.
Healthcare staff saw Mr Driver when he left for his court hearing and when he
returned to IPD. They noted that he seemed low in mood and did not want to
engage in conversation.
42. On 24 August, healthcare staff recorded that Mr Driver declined food and water and
that he had not eaten for 17 days. Due to concerns about his minimal fluid intake,
staff called a medical emergency code. Ambulance paramedics took him to hospital
for medical examination and he returned the next day.
43. On 26 August, during an ACCT review held in Mr Driver’s cell, Mr Driver told staff
that he had been issued with further charges and been denied bail.
44. On 10 September, during an ACCT review, Mr Driver told staff that he still felt low
and that his main concern was his court case and being charged with further
offences. Staff recorded that he said he was coping at present and had started
eating. They closed the ACCT as Mr Driver was no longer in crisis and was
receiving support from IPD and healthcare staff.
ACCT – 22 September to 6 December 2024
45. On 22 September, the Head of Safety recorded in Mr Driver’s electronic prison
record that she saw him during governor rounds and that he was very low and had
stopped eating again. He told her that he wanted to die and that he had nothing to
live for anymore. The Head of Safety reopened the ACCT and notified healthcare
staff. In an ACCT review the next day, staff noted that Mr Driver would remain in
IPD until a reintegration plan had been put in place for his return to the houseblock.
46. On 22 October, during an ACCT review, staff recorded that Mr Driver was in a very
low mood. He said he had received further charges from the police which had
stressed him out further and made him sick.
47. On 29 October, staff noted that Mr Driver engaged well in his ACCT review and that
he was eating and drinking small amounts. He declined medication for anxiety. Mr
Driver said he had a meeting arranged with his solicitor that day and that he hoped
to get bail. Mr Driver said that he felt supported and had good relationships with IPD
staff so did not want support from other agencies.
48. On 6 November, during an ACCT review, Mr Driver spoke about his criminal case
and said he felt sad, afraid and depressed. He said he had no appetite but that he
was eating what he could each day. He said that he was concerned information
about him was being leaked to the holiday camp where he lived and that he knew
one officer from the community but would not name him.
49. On 13 November, staff went to Mr Driver’s cell to complete an ACCT review. He
told them that he had not been granted bail and this had made him feel lower than
before. He said that he was concerned that his trial set for January would be
cancelled and that a new trial date would be set. He told staff that he would not
cope with being in custody for months and that if he was found guilty, he would
have nothing to live for.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
50. On 14 November, a further ACCT review took place due to concerns about his
presentation the previous day. Staff increased his ACCT checks.
51. On 25 November, a best interests meeting was held during which Mr Driver
expressed concerns about his mental state and talked about ending his life “in the
long run”. Staff spoke to Mr Driver about an advanced directive (a legally binding
document that outlines an individual’s wishes for their health if they are unable to
communicate them), it was agreed he would need support and assistance with this
to ensure his understanding. At the end of the meeting staff offered Mr Driver a
cleaning job in IPD which he later accepted.
52. During the next ACCT review on 6 December, staff noted that Mr Driver’s work as
IPD cleaner was keeping him busy, he was now eating and drinking and had no
recent thoughts to end his life. Staff stopped ACCT monitoring.
January to February 2025
53. On 20 January 2025, an officer spoke to Mr Driver about returning to Houseblock 6.
The electronic prison record noted that Mr Driver was “completely against this”
however he agreed to attend the houseblock to look around. He told the officer that
he had been assured he would return to a single cell. The officer agreed to look into
this.
54. On 22 January, an officer and the manager from IPD went to see Mr Driver to talk
about him returning to the houseblock. They told Mr Driver that he did not meet the
criteria for a single cell and that he would be sharing. Mr Driver was not happy
about this and said if he was made to share a cell he would refuse to eat so he
could return to IPD. The manager told Mr Driver that this would be managed with a
food refusal log on the houseblock. Mr Driver then said he no longer wanted the
IPD cleaner job.
55. Over the next couple of days, staff issued Mr Driver with negative behaviour
warnings for failing to attend work.
56. On 27 January, Mr Driver was moved to a shared cell on Houseblock 6.
57. On 2 February, Mr Driver told an officer that he was not eating as he had been
promised a single cell. Staff noted on his electronic prison record that this was
incorrect and that he had not been promised a single cell.
58. On 18 February, Mr Driver attended Maidstone Crown Court. Healthcare staff saw
Mr Driver before he left the prison, and on his return, and noted no concerns.
59. On 19 February, Mr Driver was readmitted to IPD due to refusing to eat or take his
medication.
ACCT – 21 to 26 February
60. On 21 February, staff restarted ACCT procedures for Mr Driver. He told staff that he
had lost everything. He thought he would get a long sentence and said he did “not
want to be here anymore”. Mr Driver told the staff he was happy to move to
Houseblock 6 to his original cell with the same cellmate.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
61. The GP noted a plan that included Mr Driver being placed back on an ACCT, that
he had been offered mental health support but declined, to stop medication
(pregabalin) as requested by Mr Driver, and for his sister to be contacted as his
power of attorney.
62. A nurse phoned Mr Driver’s sister to inform her of his food refusal and the current
ACCT monitoring.
63. Mr Driver was discharged from IPD later that day, and he returned to Houseblock 6.
64. On 26 February, Mr Driver attended an ACCT review. He said he was no longer
feeling depressed and found the staff on Houseblock 6 to be helpful and caring.
When staff asked Mr Driver if he had any current thoughts of suicide or self-harm,
he said he had never self-harmed and that he had “not got the guts to attempt to
end his life”. Mr Driver told the staff that he did not want to be on the ACCT and that
he found it depressing and not very supportive. Staff stopped ACCT monitoring.
March to October
65. On 10 March and 1 May, Mr Driver attended Maidstone Crown Court. Healthcare
staff saw Mr Driver before he left the prison, and on his return, and noted no
concerns.
66. There were only three entries in Mr Driver’s electronic prison record between 10
March and the day of his death. On 27 March, healthcare staff recorded that Mr
Driver needed a single cell (he was subsequently moved to a single cell on the
ground floor due to his poor mobility). On 16 May, there was an entry about a bail
hearing. The last entry was on 14 August, about a cancelled move to Houseblock 1
(as he needed to remain in his ground floor, single cell which he had on medical
grounds).
67. Between 10 March and the day of his death, there were several entries in Mr
Driver’s medical record which mainly related to routine appointments and
medication. On 13 March, healthcare staff recorded that Mr Driver refused to attend
an outside hospital appointment with dermatology due to being unwell. On 19 May,
a mental health nurse responded to an email about a bail information report,
confirming that Mr Driver was not under a nursing caseload with the mental health
team and that he was on the waiting list for a psychology workshop. On 31 July,
there is an entry saying that Mr Driver did not attend a vaccination clinic. On 29
August, healthcare staff recorded that Mr Driver was having nosebleeds and that he
was suffering with low blood pressure which was monitored over the next couple of
days.
68. Between 19 September and 3 October, Mr Driver made several calls to his sister.
(All calls are recorded but prison staff do not routinely listen to them so they would
have been unaware of the content of these calls.) The investigator listened to the
calls. Mr Driver talked about his concerns about his trial (due to start on 6 October)
and the logistics of how he would get there. During a call to his sister on 3 October,
Mr Driver said “I just wish I wouldn’t wake up, I really do”.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Events of 5 October 2025
69. The investigator watched CCTV footage and body worn video camera (BWVC)
footage from 5 October. She also obtained information from South East Coast
Ambulance Service NHS Foundation Trust. The following account has been taken
from all sources.
70. At around 5.09am, during a routine check of all prisoners, an operational support
grade (OSG) went to Mr Driver’s cell. CCTV footage shows the OSG at Mr Driver’s
cell door for around two minutes. In her statement she said that she could not see
Mr Driver in his bed and then saw that he was on the floor. The OSG knocked on
Mr Driver’s cell door but Mr Driver did not respond. At around 5.11am, the OSG
radioed a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties that alerts healthcare staff and tells the
control room to call an ambulance immediately) and remained at the door trying to
gain a response from Mr Driver.
71. Another OSG responded to the code blue. Her statement says that she looked
through the observation panel and could see Mr Driver slumped against the cell
door. Both OSGs continued to knock on the door to try to gain a response from Mr
Driver while waiting for other staff to attend.
72. An officer arrived around three minutes later and entered the cell. He found Mr
Driver unresponsive, sitting against the wall and door, with a shoelace tied around
his neck and attached to the phone socket. The officer cut the ligature using his
anti-ligature knife.
73. Other officers and healthcare staff arrived. They moved Mr Driver onto the landing
and started CPR.
74. A member of staff in the control room called for an ambulance in response to the
code blue. They were unable to say if the patient was breathing. After a couple of
minutes, they transferred the call to the houseblock. An OSG confirmed to the
ambulance call handler that Mr Driver was not breathing but was unable to confirm
if CPR had started due to being located on another floor. Three minutes into the
call, the ambulance service confirmed an ambulance was being arranged.
75. At around 5.30am, paramedics arrived and applied a defibrillator which advised no
shock. Resuscitation attempts were unsuccessful and, at 5.34am, paramedics
pronounced life extinct.
Information received after Mr Driver’s death
76. A staff member contacted the investigator to inform her of a conversation with a
prisoner about Mr Driver’s death. A prisoner told the staff member that Mr Driver
was concerned about which prison he would be transferred to for his trial, due to
being told by other prisoners that they mixed vulnerable prisoners with the main
population. The prisoner told the staff member that he thought this may have
pushed Mr Driver over the edge, as he was already concerned about his trial.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contact with Mr Driver’s family
77. On 5 October, the prison appointed a family liaison officer (FLO). He and the prison
chaplain visited Mr Driver’s sister that day to break the news of his death.
78. Later that month, the FLO made arrangements for Mr Driver’s family to visit the cell
and have a meeting with the Governor.
79. The Prison Service contributed to the funeral expenses in line with national
instructions.
80. Mr Driver’s sister was concerned that the prison had leaked information about her
brother’s death as details had appeared in the public domain. We asked the prison
about this. They told us they had investigated and were satisfied that standard
procedures had been followed and there had been no unauthorised leaks. We have
provided further details in a separate letter and are also satisfied that prison staff
did not divulge any unauthorised information.
Support for prisoners and staff
81. 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.
82. After Mr Driver’s death, the Head of Security debriefed the prison and healthcare
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.
83. The prison posted notices informing other prisoners of Mr Driver’s death and
offering support. The prison also deployed Listeners to the wing to offer support.
Staff reviewed all prisoners assessed as being at risk of suicide or self-harm in case
they had been adversely affected by Mr Driver’s death.
Post-mortem report
84. The post-mortem report gave Mr Driver’s cause of death as hanging.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of Mr Driver’s risk of suicide and self-harm
85. The Prison Safety Policy Framework, implemented on 1 January 2025, which
superseded the Prison Service Instruction (PSI) 64/2011, Management of prisoners
at risk of harm to self, to others and from others (Safer Custody), requires all staff
who have contact with prisoners to be aware of the risk factors and triggers that
might increase the risk of suicide and self-harm and take appropriate action. Any
prisoner identified as at risk of suicide or self-harm must be managed under ACCT
procedures.
86. Mr Driver was supported using ACCT on three occasions during his time at Elmley.
We consider that staff managed the ACCT procedures well. They held regular
ACCT reviews, involved appropriate staff and arranged for Mr Driver to be cared for
in IPD when they became concerned about his physical health due to his food
refusal.
87. Staff stopped ACCT procedures on 26 February, after Mr Driver said he was no
longer feeling depressed and had no plans to harm himself. We consider this was a
reasonable decision. Although there are minimal records between February and
October, there was no indication that Mr Driver was at imminent risk of suicide or
self-harm. We therefore understand why he was not being monitored under ACCT
when he died.
Key work
88. Mr Driver was not allocated a key worker and did not have any key worker sessions
during his 14 months at Elmley. Following his discharge from IPD and the closure of
the ACCT in February, prison staff recorded no meaningful interactions with Mr
Driver.
89. In common with some other prisons, the key worker scheme had not been
operating as it should at Elmley due to staffing issues. The Deputy Head of
Residence at Elmley told us that the focus had been on delivery to priority cohorts
including prisoners in segregation, vulnerable prisoners (despite his alleged
offence, Mr Driver was not a vulnerable prisoner), self-isolators, first time in prison
and those serving Imprisonment for Public Protection (IPP) sentences. He said that
although key work delivery remained a challenge, the quality of sessions had
improved and that this was an area being quality assured with feedback provided to
officers.
90. The Deputy Head of Residence told us that since Mr Driver’s death, they had
introduced an early days in custody (EDIC) officer who will see every new arrival for
an initial key worker session. In addition, there were plans to use officers in the
workshop and in segregation to carry out key worker sessions with prisoners.
91. While we cannot be certain that Mr Driver would have shared his feelings and
concerns in a key work session, ongoing one-to-one sessions with a key worker
would have provided this opportunity, or for an officer to observe a change in his
mood or presentation. Key worker sessions are important for building good
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
relationships between staff and prisoners and prisoners at Elmley should receive
regular sessions as soon as staffing allows.
Emergency Response
92. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
says that when staff radio a medical emergency code, they must also provide
relevant information about the condition of the prisoner to the control room staff so
this can be passed to the ambulance service for the triage process.
93. When control room staff called for the ambulance for Mr Driver, they were unable to
answer the standard question, “Is the patient breathing?” or any other questions
about Mr Driver including the circumstances of the emergency. After two minutes,
the control room transferred the call to the houseblock. An OSG answered and told
the ambulance service that the patient was not breathing but when asked if CPR
had been started, they were unable to confirm and said that the patient was on a
separate floor and that the phone could not be taken there. After three minutes the
ambulance service confirmed that an ambulance was being arranged.
94. At interview, the Head of Safety told us that Elmley had recently issued guidance to
all staff reminding them of the importance of providing relevant information about
the condition of the prisoner to control room staff, so that they can pass it on to the
ambulance service for use in the triage process. She said the guidance was being
shared in daily briefings and she was in the process of developing a quality
assurance process.
95. We have raised our concerns to HMPPS in previous investigation reports about the
process for control room staff to pass vital information about a prisoner’s condition
to emergency operators. HMPPS reviewed the process in place and concluded that
the focus of action was for control room staff. We continue to have concerns that
such an approach is unlikely to drive effective change and issues such as those
which arose at Elmley will continue until HMPPS finds a more effective solution.
96. The evidence, from this case and others like it, is that the processes put in place by
HMPPS have made no difference. We have expended considerable energy trying to
drive change in this area, including holding an emergency response round table
with senior HMPPS colleagues in January 2024. We draw this issue to the attention
of the Chief Operating Officer and Chief Executive Officer of HMPPS.
Clinical care
97. The clinical reviewer found that the care provided to Mr Driver in relation to the
ACCT process and his admission to IPD was of a good standard and highlighted
exemplary care provided which was compassionate, well-coordinated and delivered
within a multidisciplinary framework. The clinical reviewer found the care provided
during this period to be equivalent to that which he could have expected to receive
in the community.
98. The clinical reviewer found that after Mr Driver’s discharge from IPD, there was no
clearly documented discharge plan and that a referral to mental health services,
which would have meant he was seen within 72 hours following his discharge, was
not completed. The clinical reviewer therefore found the care following his
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
discharge from IPD was not equivalent to that which he could have expected to
receive in the community. We recommend:
The Head of Healthcare should ensure that all prisoners discharged from IPD
following an ACCT, or who have presented with recent suicidal ideation or
significant mental health vulnerability, have a documented mental health
review prior to discharge and have a follow up appointment arranged when
returned to the residential unit.
99. The clinical reviewer found that there was no documentation to confirm that an
automated external defibrillator (AED) was used during the resuscitation attempt of
Mr Driver. He made a recommendation on this which the Head of Healthcare will
wish to address.
Inquest
100. At the inquest, held on 28 September 2026, the jury concluded that Mr Driver died
by suicide.
14 Prisons and Probation Ombudsman
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