Patryk Jalocha

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Independent investigation into
the death of Mr Patryk Jalocha,
a prisoner at HMP Manchester,
on 5 November 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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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 Patryk Jalocha died after being found hanged in his cell on 5 November 2024 at HMP
Manchester. He was 24 years old. I offer my condolences to Mr Jalocha’s family and
friends.
Mr Jalocha’s was the sixth apparently self-inflicted death in three years at Manchester.
Mr Jalocha was on remand and had not been in prison before. The nature of the offences
he was charged with meant he was identified as requiring the highest level of security
(category A) in prison. As a foreign national he had also received notification that, if found
guilty, he may be deported after serving all or part of his sentence. There is some
evidence that he was worried about his future and he appeared generally low in mood,
bored and frustrated with the limited activities available to him. Wing staff recognised this
and managed Mr Jalocha under Prison Service suicide and self-harm monitoring
procedures (known as ACCT) for most of the five weeks before his death.
The investigation found some deficiencies in ACCT procedures but, most seriously, an
officer did not complete the required ACCT checks immediately before Mr Jalocha was
found hanged. The Governor rightly dismissed the officer for gross misconduct but I am
conscious that this failure in duty of care will make difficult reading for Mr Jalocha’s family.
In October 2024, following an inspection of Manchester, HM Chief Inspector of Prisons
issued an urgent notification to the Secretary of State for Justice in relation to a concerning
decline in three of the four healthy prison tests. Some of the concerns HM Inspectorate of
Prisons identified are relevant to Mr Jalocha including poor ACCT care planning and lack
of purposeful activity. As a result the prison has received extra support from national
teams and taken some positive steps to improve safety. I therefore make fewer
recommendations than I might otherwise have done.
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 June 2026
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 16
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Summary
Events
1. Mr Patryk Jalocha was born in Poland and came to the UK aged 15 with his mother
and siblings in 2015. On 10 June 2024, Mr Jalocha was convicted of affray,
possession of an offensive weapon and possession of cocaine and bailed pending
sentence. On 5 August, Mr Jalocha was arrested and charged with attempted
murder, possession of a firearm and aggravated burglary.
2. On 6 August, Mr Jalocha was remanded to HMP Birmingham. It was his first time in
prison. Mr Jalocha told a nurse during an initial health assessment that he was
physically well and had no history of mental illness or substance misuse. He
strongly denied any thoughts of suicide and self-harm.
3. On 7 August, Mr Jalocha was identified as a potential category A prisoner
(indicating he presented a high risk to the public) due to the nature of his offences.
On 12 August, he transferred to HMP Manchester, a high security prison, where he
was given a cell on the landing used for younger and more vulnerable category A
prisoners away from the main category A wing.
4. On 5 September, Mr Jalocha was sentenced to eight months imprisonment for
possessing a firearm and six months imprisonment for the charges relating to the
incident on 10 June. Both sentences were to be served concurrently. He remained
on remand for attempted murder and aggravated burglary.
5. On 9 September, he was deemed a person of interest to Foreign National Offender
Returns Command (FNORC - the branch of Home Office Immigration Enforcement
that deals with foreign national offenders) as the nature of his outstanding offences
meant it was likely, if found guilty, that he would be sentenced to more than 12
months in prison and would therefore be liable for deportation after serving all or
part of his sentence.
6. On 20 September, an officer gave Mr Jalocha a notice of liability to deportation
issued by FNORC. Mr Jalocha refused to sign to confirm receipt of this until he had
spoken to his solicitor.
7. On 29 September, an officer started Prison Service suicide and self-harm
monitoring procedures (known as ACCT) after she noticed that Mr Jalocha had
become withdrawn and spent most of his time in his cell asleep.
8. Staff stopped ACCT monitoring on 15 October but re-started this on 26 October
when officers noticed superficial scratches on Mr Jalocha’s arm and that he had
again become withdrawn. The ACCT case coordinator made some progress
towards Mr Jalocha receiving education, obtaining a cleaning job and being allowed
access to the main category A unit gym.
9. On 4 and 5 November, two different members of staff noticed graffiti in Mr Jalocha’s
cell but did not examine it or question him about it. The graffiti included a drawing of
a man hanging.
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10. At about 10.55pm on 5 November, an officer discovered Mr Jalocha hanged in his
cell. Prison and healthcare staff attended and began cardiopulmonary resuscitation
(CPR). Ambulance paramedics also attended but declared life extinct at 11.45pm.
Findings
11. There were a number of weaknesses in ACCT procedures between 29 September
and 15 October including:
• Mr Jalocha was not assessed by a trained ACCT assessor within 24 hours.
• Mr Jalocha’s ACCT assessment was completed at the same time as a case
review and not separately beforehand.
• No support actions to mitigate and reduce risk were identified.
• Some sections of the document were left blank or were poorly completed
including risks, triggers and protective factors and sources of support.
• The ACCT was closed without evidence that Mr Jalocha’s risk had been
reduced.
12. The management of Mr Jalocha’s ACCT after it was re-opened on 25 October was
significantly better.
13. The night patrol officer did not complete the required ACCT checks immediately
before Mr Jalocha was discovered hanging and falsified the ACCT record to say he
had done so.
14. The night patrol officer did not radio a code blue emergency when he discovered Mr
Jalocha hanging. However, the emergency response was otherwise swift and
efficient.
15. Mr Jalocha wrote a number of things on the walls of his cell that should have been
explored with him before he died.
16. The prison has brought in a number of measures since Mr Jalocha’s death and as a
result of an urgent notification from HM Inspector of Prisons (HMIP) in October
2024 to improve ACCT monitoring and increase the number of trained ACCT
assessors. As part of this the prison safety team has produced a directory for ACCT
case coordinators signposting sources of support for a number of different issues.
This is good practice. In April, the prison implemented a system of random CCTV
monitoring to ensure staff complete required ACCT checks.
Recommendations
• A fabric check on a cell represents an opportunity to consider wider risk factors. The
Governor should ensure that his staff are aware of this fact and take due account of
any graffiti, handwritten notes, drawings etc. and take further action where
appropriate.
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• The Governor should introduce a robust assurance process to satisfy himself that
all prison staff understand PSI 03/2013 and their responsibilities during medical
emergencies, including that staff promptly use an emergency code to communicate
the nature of an emergency effectively.
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The Investigation Process
17. HMPPS notified us of Mr Jalocha’s death on 6 November 2024.
18. The investigator issued notices to staff and prisoners at HMP Manchester informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
19. The investigator visited HMP Manchester on 26 November 2024. She obtained
copies of relevant extracts from Mr Jalocha’s prison and medical records. Further
information was obtained from North West Ambulance Service and a member of the
HMIP inspection team who inspected the prison in October 2024.
20. The investigator interviewed seven members of staff and one prisoner at
Manchester between November 2024 and February 2025.
21. NHS England commissioned a clinical reviewer to review Mr Jalocha’s clinical care
at the prison. She jointly interviewed healthcare staff with the investigator. Further
information was provided by the Head of Healthcare and the Head of the Mental
Health Team.
22. We informed HM Coroner for Manchester City of the investigation. The post-mortem
report was not available at the time of writing. We have sent the Coroner a copy of
this report.
23. The Ombudsman’s office contacted Mr Jalocha’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Jalocha’s mother
said she had no specific questions but wanted to understand all the circumstances
around her son’s death. We have sent her a copy of this report.
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Background Information
HMP Manchester
24. HMP Manchester is a high security training prison which accepts long-term
prisoners. There is a category A unit on E Wing for prisoners posing greater
security risks. Category A prisoners who are younger or are considered more
vulnerable are held on Z landing in the prison’s healthcare unit. Greater Manchester
Mental Health NHS Foundation Trust provides 24-hour mental and physical
healthcare at the prison. Delphi Medical provides substance misuse services.
HM Inspectorate of Prisons
25. The most recent full inspection of HMP Manchester was between 17 September
and 3 October 2024. Following this inspection, HM Inspectorate of Prisons issued
an urgent notification (UN, a mechanism for the Chief Inspector to raise urgent
concerns with the Secretary of State) as a result of their findings. The UN cited the
number of weapons and other illicit items found in recent months was amongst the
highest of all prisons holding adult men and those testing positive for drug use was
very high. Time out of cell was poor and the restricted daily regime left large
numbers of prisoners locked in their cells for extended periods of time.
26. Since the last inspection, there had been six self-inflicted deaths and a further three
deaths with suspected links to drug abuse. The lack of purposeful activity, drug
availability, associated debt and frustration at basic requests not being dealt with
had contributed to a steep rise in the rate of self-harm, which was the highest
amongst adult male prisons. Too little help was given to men in crisis and few men
on suicide and self-harm monitoring were engaged in purposeful activity, which did
not help their well-being. There were significant weaknesses in the ACCT process –
care plans were often very limited or non-existent and most lacked consistent case
management.
Independent Monitoring Board
27. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. The latest annual report was published in August 2022 and covered the
immediate post-pandemic period. Therefore we have not included their findings
here.
Previous deaths at HMP Manchester
28. Mr Jalocha was the sixteenth prisoner to die at Manchester since 5 November
2021. Of the previous deaths, six were self-inflicted, six were from natural causes
and three were from other causes or drug related. In three of the previous deaths, a
code blue emergency (when a prisoner has stopped or is having difficulty breathing)
was not called at the earliest opportunity.
29. Up until the end of March 2025, there had been one further self-inflicted death and
one from a cause unascertained at the time of writing.
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Assessment, Care in Custody and Teamwork (ACCT)
30. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to decide the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011. After a first assessment of the prisoner’s main concerns, levels of
supervision and interactions are set according to the perceived risk of harm. Checks
should be irregular to prevent the prisoner predicting when they will occur. There
should be regular multidisciplinary review meetings involving the prisoner.
31. As part of the process, a caremap (plan of care, support, and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which goes with the prisoner as they move around the prison. When Mr Jalocha
was at Manchester, guidance on ACCT procedures was set out in PSI 64/2011.
From January 2025, this was superseded by the Prison Safety Policy Framework, in
which the principles of how an ACCT is managed remain largely unchanged.
Foreign national offenders (FNOs)
32. Home Office Immigration Enforcement automatically considers all foreign national
offenders sentenced to 12 months or more for deportation. Remand prisoners are
identified as persons of interest and served with a notice of liability to deportation
once they are sentenced. Under the Early Removal Scheme, prisoners with a
determinate sentence can be removed from prison earlier than their half-way point
of sentence, to allow their deportation or removal from the UK. The scheme is
mandatory; all determinate sentenced foreign national prisoners who are liable to
removal must be considered. The rules do not apply to prisoners who receive life
sentences (indeterminate sentences). Prisoners who receive extended determinate
sentences can be deported once they have served a third of their sentence.
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Key Events
33. Mr Patryk Jalocha was born in Poland and came to the UK aged 15 with his mother
and siblings in 2015. Mr Jalocha completed his education and then gained
employment. In 2022, his GP prescribed him citalopram (antidepressant) after he
told her he felt sad and lacking in motivation. However, he had since stopped taking
this medication.
34. On 10 June 2024, Mr Jalocha was convicted of affray, possession of an offensive
weapon and possession of cocaine and bailed pending sentence. As part of the
conditions of his bail he was required to wear an electronic tag.
35. On 5 August, Mr Jalocha was arrested and charged with attempted murder,
possession of a firearm and aggravated burglary. The victim was a woman
unknown to him.
HMP Birmingham 6 -12 August 2024
36. On 6 August, Mr Jalocha was remanded to HMP Birmingham. It was his first time in
prison.
37. Mr Jalocha told a nurse during an initial health assessment that he was not on any
medication and had no history of mental illness or substance misuse. She noted on
his clinical record that he strongly denied any thoughts of suicide and self-harm,
appeared mentally stable, polite, coherent and calm. She did not use a translation
service and noted that Mr Jalocha spoke English, although his main language was
Polish.
38. On 7 August, Mr Jalocha was identified as a potential category A prisoner
(indicating he presented a high risk to the public) due to the nature of his offences.
According to local security policy he was moved to the Care and Separation Unit
(CSU – segregation unit) pending transfer to a higher security prison. On 9 August,
Mr Jalocha told staff he was sleeping a lot due to being bored. He said he was still
trying to process what had happened to him. The next day he said he had problems
sleeping and a GP prescribed him promethazine (an antihistamine used in prison
instead of more addictive and tradeable sleeping tablets) for three days.
HMP Manchester 12 August – 4 November 2024
39. On 12 August, Mr Jalocha transferred to HMP Manchester. He told a nurse at an
initial health assessment that he had no long-term health conditions. He denied any
history of or current thoughts of suicide or self-harm. Mr Jalocha said he had used
cocaine once a week in the community and denied any addiction issues.
40. A mental health nurse also assessed Mr Jalocha as part of his initial health
assessment. He said it was difficult to establish rapport with Mr Jalocha and he
spoke very little. He noted that it was Mr Jalocha’s first time in prison and he did not
have access to any of his community records to confirm his history. Mr Jalocha
denied any mental health issues, substance misuse issues or suicidal thoughts.
She referred Mr Jalocha to the mental health team. He explained at interview that it
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was prison policy to automatically refer category A prisoners for a mental health
assessment.
41. The next day on 13 August, Mr Jalocha told an officer that he had no concerns
about being in Manchester. A member of the drug and alcohol team visited him for
a standard triage assessment and he told them he was not interested in working
with them. Mr Jalocha was allocated to Z landing, a landing located in the prison
healthcare department on M Wing and used for young (under-21) or vulnerable
category A prisoners.
42. On 14 August, a nurse completed a full mental health assessment with Mr Jalocha.
The nurse said Mr Jalocha’s English was very good and he spoke openly about his
childhood in Poland and his employment prior to his arrest. He noted Mr Jalocha
was not known to mental health services and was not on any medication. Mr
Jalocha said he used alcohol and cocaine socially but denied any addiction issues.
He also denied any suicidal thoughts or history of self-harm and said he did not
understand people who self-harmed.
43. Around this time, an officer on Mr Jalocha’s landing asked Healthcare Assistant
(HCA) a Polish speaker, to speak to Mr Jalocha because he seemed to be
confused about how long he was likely to be in prison. The HCA said he had a
conversation with Mr Jalocha in Polish about why he was in prison and explained
that he might be there for some time pending his trial. He said he advised Mr
Jalocha to speak to his solicitor about his situation. He said Mr Jalocha seemed
calm but a little confused because it was his first time in prison.
44. The HCA said he did not know how much English Mr Jalocha understood because
they only spoke in Polish. He said he saw him quite regularly because Z landing
was in the same wing as healthcare and noticed him interacting with officers in
English. The HCA said Mr Jalocha was not very talkative and the fact that they
spoke in Polish did not seem to make a difference to how much he communicated.
45. On 5 September, Mr Jalocha was sentenced via videolink to eight months in prison
for possessing a firearm and six months for the charges relating to the incident on
10 June. Both sentences were to be served concurrently. He remained on remand
for attempted murder and aggravated burglary. On 9 September, he was deemed a
person of interest to Foreign National Offender Returns Command (FNORC - the
branch of Home Office Immigration Enforcement that deals with foreign national
offenders) as the nature of his outstanding offences meant it was likely, if found
guilty, that he would be sentenced to more than 12 months in prison and would
therefore be liable for deportation after serving all or part of his sentence.
46. The same day, Mr Jalocha received an email from his mother via the Email a
Prisoner scheme. He did not send a reply.
47. On 20 September, an officer the equalities officer in the safer custody department,
gave Mr Jalocha a notice of liability to deportation issued by FNORC. Mr Jalocha
refused to sign to confirm receipt of this until he had spoken to his solicitor.
48. On 29 September, an officer began Prison Service suicide and self-harm monitoring
procedures (known as ACCT) after she noticed that Mr Jalocha had completely
withdrawn from daily prison activities and had stopped speaking to staff. She said
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Mr Jalocha spent most of the day in bed and told her that he was struggling in
prison and worried about being deported to Poland. He said he had not spoken to
his family or friends since being in custody because he did not know what to tell
them. The officer said Mr Jalocha denied feeling suicidal but she was concerned
that his risk was raised and thought he needed extra support.
49. A Supervising Officer (SO) completed the immediate action plan. She instructed
staff to check Mr Jalocha five times an hour and record three conversations with
him a day pending assessment by a trained ACCT assessor.
50. The next day on 30 September, a SO held an ACCT review, with a nurse from the
inpatient unit, in the association room on M Wing. The SO noted Mr Jalocha had not
been assessed by an ACCT assessor within 24 hours of ACCT procedures starting
as none were available. At interview, he said that the assigned ACCT assessor for
that day had gone home unexpectedly for personal reasons and there was no one
else available. The SO offered Mr Jalocha an interpreter using a telephone
interpreting service (The Big Word) but Mr Jalocha said he did not need one. The
SO told the investigator that Mr Jalocha was not a talkative prisoner but he would
respond when asked questions and he was satisfied that Mr Jalocha understood
what he was saying to him.
51. Mr Jalocha said he was concerned about being deported to Poland and the SO said
he would contact the Offender Management Unit (OMU – the department in prison
that deals with courts and sentence planning) for him. He reduced the frequency of
checks to three per hour and the number of daily conversations with staff to two.
Staff did not complete a care plan with actions to support Mr Jalocha.
52. On 1 October, Mr Jalocha’s ACCT record showed he played pool with wing staff
and they had a conversation about Mr Jalocha’s place of birth and his interest in
martial arts. The next day, Mr Jalocha spoke to HMIP as part of their inspection for
45 minutes with an interpreter. HMIP noted in his ACCT record that she had spoken
to Mr Jalocha about his experiences of the prison’s OMU. HMIP said he seemed
calm and had laughed with her and said it was nice speaking his own language.
HMIP provided some further information for the investigator. She said in her
professional opinion, Mr Jalocha had not been distressed when they spoke but she
had concluded that he had not had any contact with anyone from OMU at that stage
and had therefore not been afforded the opportunity to ask questions regarding his
sentence or pending court case.
53. On 3, 5 and 6 October Mr Jalocha’s ACCT record showed he played pool with wing
staff and was looking forward to the X-Box in the association room being repaired.
54. On 7 October, a SO noted that Mr Jalocha was due for an ACCT review but that he
had still not had an ACCT assessment and there were no assessors available that
day. She postponed the review to the following day to ensure the ACCT
assessment took place.
55. On 8 October, the SO held a second ACCT review with Mr Jalocha, an officer and a
member of staff from the Chaplaincy team. The officer was the assigned ACCT
assessor but he did not complete the assessment before the review as he should
have done. Mr Jalocha said he had no thoughts of suicide or self-harm but just
wanted to “chill” in his cell and watch TV. The staff member from the Chaplaincy
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team asked him about his family and Mr Jalocha said he had not spoken to them
since being in prison and did not want to speak to them. He said he was frustrated
about the charges he was remanded for and “overthought” his pending court case.
He said he was in touch with his solicitor via videolink. He said he only wanted to
watch TV or go to the main prison gym as the gym on the healthcare unit was not
very good. After discussion about Mr Jalocha’s presentation, the staff present
decided to increase Mr Jalocha’s observations to five every hour and the number of
daily conversations with staff to three.
56. The officer completed the ACCT assessment paperwork after the review. He noted
that an interpreter was not needed as Mr Jalocha understood English. He said Mr
Jalocha was polite but quiet and withdrawn when asked about his family and said
he did not want to contact them. He said he just wanted to watch TV. He said he
was confused about the charges against him as he thought they did not represent
what he had done. The officer said he thought Mr Jalocha should contact his family
for support. Mr Jalocha said he did not want a well-being plan.
57. Between 9 and 15 October, Mr Jalocha’s ACCT record showed he came out of his
cell for showers, exercise and social time and often attended the landing gym. He
also often played pool with his peers. On one recorded occasion, he laughed and
joked with staff and taught them some Polish words. He appeared to sleep well and
was only noted to be awake at two of the five nightly ACCT checks in this period.
58. On 15 October, the SO held a third ACCT review with staff from the prison
chaplaincy team. Mr Jalocha said he still did not wish to contact his family. He said
he had no thoughts of suicide and did not want to be on an ACCT. He said he was
“good” and just liked watching TV. The SO and staff from the prison chaplaincy
decided to stop ACCT monitoring and set a post-closure review for 22 October.
59. On 26 October, an officer re-opened Mr Jalocha’s ACCT document after he noticed
scratches on Mr Jalocha’s arm. The officer noted on the concern and keep safe
form that Mr Jalocha had been in low mood and had stopped engaging with staff
and other prisoners. He said Mr Jalocha told him that the lack of clarity about his
future was contributing to his low mood. He refused to see a nurse about his
scratches.
60. A SO held an ACCT review the same day with a nurse. Mr Jalocha said his
scratches were old and he had not done any recently. He said he had scratched
himself out of frustration at not being able to sleep. Mr Jalocha said he had applied
to see healthcare staff about his sleeplessness (there is no record that he did this).
The SO said they had a long discussion with Mr Jalocha about why he did not want
to contact his family. Mr Jalocha told her he was angry about his parents’ divorce
and said it was the first time he had opened up about his family issues. They
discussed whether he had friends he could contact instead and, although Mr
Jalocha showed an initial interest in this, he then said he was not bothered.
61. Mr Jalocha said he was bored and that he had been charged with the wrong
offence. He asked to see someone from OMU to go through his situation with him.
He said he had a TV and books but found it hard to concentrate. He had also
applied to start education. The SO noted he was talkative and looked upset when
talking about his family. Mr Jalocha said he did not feel suicidal or like harming
himself. He said he wanted someone to believe him about his offence. The SO
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decided Mr Jalocha should be checked five times a day and five times overnight
because she was worried that hourly observations would disturb his sleep.
62. The nurse noted in Mr Jalocha’s clinical record that he was low in mood, was
unhappy in prison and denied his current charges. He felt let down by his family and
did not want to contact them. The nurse said he did not remember the review very
well. He remembered Mr Jalocha seemed quite low and did not particularly want to
be on ACCT monitoring. He said Mr Jalocha’s English was fluent and there was no
problem communicating with him. He said Mr Jalocha did not seem to have had
much information about his outstanding criminal case and in his experience this
was quite common. He said the SO told Mr Jalocha she would liaise with OMU
about this.
63. The SO completed a care plan for Mr Jalocha. She said she would email the
education department on Mr Jalocha’s behalf in an effort to tackle his boredom. She
noted Mr Jalocha had agreed to apply for a GP appointment to discuss his
sleeplessness.
64. The HCA said he remembered Mr Jalocha complaining about poor sleep when he
spoke to him one lunchtime around this time and had advised him to apply to see
the GP. He said he did not want to explore why Mr Jalocha was not sleeping
because they spoke on the landing and it was not a private conversation.
65. On 28 October, an officer had a key worker session with Mr Jalocha. Mr Jalocha
said he was fine but had nothing to do in his cell apart from watch TV. He thought
his poor sleep was due to frustration and boredom. The officer offered him books
and distraction packs but Mr Jalocha said he already read a lot and was still bored.
The officer said he would chase up a GP appointment for Mr Jalocha to discuss his
difficulty sleeping. He said he did not want to contact his family. He had seen
someone from the education department and was keen to start classes.
66. On 30 October, the SO completed an ACCT review with Mr Jalocha, an officer from
OMU and the Imam. She noted that Mr Jalocha was very “smiley” and engaged well
with her. The officer explained Mr Jalocha’s position regarding his sentence and
outstanding charges. Mr Jalocha said he was pleased that he had been accepted
for education classes because he wanted more money and to keep busy. TheSO
suggested he do a cleaning course so he could be considered for a job as a wing
cleaner and Mr Jalocha said he was interested in doing that. He asked for a
Polish/English dictionary as he sometimes struggled to understand words when he
watched TV. Mr Jalocha agreed to apply to have some of his friends added to his
prisoner telephone account. Mr Jalocha said he did not want anyone to visit him. He
said he had no thoughts of suicide or self-harm and staff reduced his observations
to four a day and four overnight. The SO added actions to the care plan that Mr
Jalocha would apply to add a friend to his prisoner telephone account and that she
would contact the library to see if she could get a Polish/English dictionary for Mr
Jalocha.
67. Later that day Mr Jalocha applied for his mother, stepfather and solicitor’s phone
numbers to be added to his prison telephone account. The prison correspondence
team confirmed that regulation checks on these numbers were completed on 3
November and approved for use on 4 November. Mr Jalocha did not make any calls
before he died and he did not receive any visits.
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68. According to Mr Jalocha’s ACCT ongoing record for the period 26 to 31 October, he
came out of his cell for exercise and participated in social time, playing pool and
cards with his peers. On 1 and 2 November he did not come out of his cell except to
collect his meals and spent the days watching TV or asleep in his cell. On 3 and 4
November, he came out of his cell for meals and a shower. On 4 November, an
officer recorded that Mr Jalocha asked for a pen “although he has drawn on the
walls”. The ongoing record for 1 - 4 November recorded that Mr Jalocha had
“settled” nights and was asleep most of the night on 4-5 November.
Events of 5 November 2024
69. On 5 November, a SO completed an ACCT review with Mr Jalocha in the
association room. She said she had been allocated to work on another wing that
day and had wanted to ensure she completed Mr Jalocha’s review and another Z
landing prisoner’s review first. Other staff were due to join her but did not turn up so
she decided it was preferable for her to do the reviews on her own as she knew
both prisoners rather than have someone else hold a multi-disciplinary review later
or another day.
70. When she collected Mr Jalocha from his cell she noticed graffiti on his wall and told
him to stop writing on the walls and that she would provide him with paper. She said
she, “saw scrawls everywhere” but only specifically remembered seeing “fuck the
magistrate.”
71. In the review, Mr Jalocha said he was looking forward to starting education but
wondered why he had to have so many assessments. The SO explained the
education staff needed to work out which level to start him on in each class. She
told him he would be starting the cleaning course soon too. Mr Jalocha said he was
still struggling to sleep but had a GP appointment on 12 November. The SO kept Mr
Jalocha’s observations at the same level and planned the next review for 12
November. (The Head of Healthcare confirmed that Mr Jalocha had a GP
appointment booked for that date but was unable to find out who had booked it and
when.)
72. The SO said Mr Jalocha engaged really well in the review. Overall she said he
mixed quite well on the landing and usually came out for exercise and social time.
She said he was bored and said a number of times that he needed something to
keep him busy. He came across as restless. He was keen to start education and
was frustrated at the number of assessments that had to be completed before he
could start something. He was unhappy about the small gym on Z landing and this
had prompted her to try to get the prisoners on Z landing a session in the main
category A unit gym (something she achieved after he died). The SO said she
understood that the activity she was able to offer Mr Jalocha was not enough for
him.
73. As a category A prisoner, Mr Jalocha was subject to routine cell searches every 28
days and had to move cells every three months. After his ACCT review, he moved
from cell MZ-02 to cell MZ-04 on the same landing.
74. The investigator watched CCTV footage from the afternoon and evening of 5
November. CCTV showed Mr Jalocha mixing with other prisoners during social time
and going back and forth from his cell. At 4.34pm. he collected his evening meal
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and returned to his cell three minutes later. Another prisoner said he offered Mr
Jalocha extra food after dinner as there was some left. He said Mr Jalocha
accepted the food and seemed his usual self.
75. At 5.13pm, a SO stopped at his door and spoke to him briefly. At interview, the SO
said he could not specifically remember speaking to Mr Jalocha that day but nothing
in his behaviour had seemed different.
76. CCTV showed that at 7.05pm and 7.30pm, an officer and then a second officer
checked Mr Jalocha and recorded their checks on his ACCT document.
77. The second officer also recorded that he had checked Mr Jalocha as required by
his ACCT plan at 8.30pm and 10.00pm. CCTV showed that these checks did not
take place. At 8.30pm, CCTV showed the officer walked up the landing and refilled
his water bottle but did not stop to check Mr Jalocha as he passed his cell. The
officer was initially on sick leave and was then suspended from duty during our
investigation and was not interviewed.
Emergency response
78. In addition to watching CCTV, the investigator also watched bodyworn video
camera (BWVC) footage, listened to staff radio communications and obtained
further information from North West Ambulance Service. The following account has
been taken from all these sources and interviews with relevant staff.
79. At 10.55pm, an officer looked through Mr Jalocha’s observation panel and then ran
to the wing office, returning to the cell with two nurses. He radioed “assistance
required on healthcare” and a Custodial Manager (CM, who was he night orderly
officer (most senior officer on duty), and a SO arrived on the unit within a minute.
The CM entered Mr Jalocha’s cell and radioed a code blue emergency at 10.57pm.
Shortly afterwards at 10.58pm, the control room officer asked the CM if Mr Jalocha
was breathing and he said he was not. She rang North West Ambulance Service
promptly at 10.59pm and an ambulance was dispatched with the highest priority.
80. BWVC footage showed Mr Jalocha had made a ligature from a pair of trousers, tied
it to the frame of the top bunk bed and was slumped in a seated position on the
floor. The officer used his anti-ligature knife to cut the ligature and remove it from Mr
Jalocha’s neck. The CM put Mr Jalocha on the floor and checked for signs of life as
the nurses got the emergency equipment ready. A nurse said Mr Jalocha was not
breathing and she could not find a pulse but his skin was still warm so they decided
to start CPR. Between them, the nurses put a defibrillator on Mr Jalocha and it
advised them to start chest compressions. They gave Mr Jalocha oxygen via a bag
and mask. The defibrillator continued to analyse Mr Jalocha’s heart output and
advised staff to continue CPR. It did not advise an electric shock.
81. At 11.14pm, ambulance paramedics arrived and took over CPR with their own
equipment. At 11.45pm, they stopped CPR and pronounced life extinct.
Contact with Mr Jalocha’s family
82. The prison contacted the reverend shortly after Mr Jalocha was pronounced dead
and she arrived at the prison at 1.00am. Mr Jalocha had given a telephone number
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but no address for his mother on arrival in prison. The prison contacted the police,
but they were unable to find an address for her. The reverend and duty governor,
telephoned Mr Jalocha’s mother with a Polish speaking officer acting as interpreter
and broke the news of his death.
83. At 11.30am on 6 November, the prison appointed an officer as family liaison officer
(FLO). a senior manager and the HCA visited Mr Jalocha’s mother at her home at
1.30pm. The prison offered a financial contribution to Mr Jalocha’s funeral in line
with national policy.
Support for prisoners and staff
84. 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.
85. After Mr Jalocha’s death, duty governor 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.
86. The prison posted notices informing other prisoners of Mr Jalocha’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 Jalocha’s death.
Listeners attended Mr Jalocha’s wing in line with postvention procedures.
Writing on the walls of Mr Jalocha’s cell
87. The prison provided photographs of the graffiti in Mr Jalocha’s cell. There were five
pieces of writing:
• “Fuck cops”
• “Fuck magistrate”
• “Fuck it I can’t”
• “They can lock the locks but can’t stop the clock”
• “666”
There were two pictures – one of a stick figure hanging from some gallows and one
of a skull and crossbones.
88. After his PPO interview in January 2025, the HCA said he had visited Mr Jalocha’s
cell after he died and noticed writing in Polish on the walls. He looked at the
photographs provided to the investigator but they did not show the writing and the
cell had been redecorated by this point so the investigator was unable to see it. The
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HCA said he had written down what Mr Jalocha had written at the time. He
translated the writing as “People won’t be judging me for something I haven’t done.
I’m bored. Fuck.” He said Mr Jalocha had also written “eyes tell you truth”, “eyes”
and “reset”.
Prison investigation into falsification of records on 5 November
89. In December 2024, the Governor, commissioned an investigation into whether an
officer’s final entries on the ACCT document on the evening of 5 November
amounted to making false statements. As a result of the investigation, the Governor
held a disciplinary hearing on 11 March 2025. He found the charges proved and
dismissed the officer for gross misconduct.
Post-mortem report
90. The post-mortem and toxicology reports were not available at the time of writing in
April 2025. Given the circumstances in which Mr Jalocha was found on 5 November
and the absence of any evidence to suggest illicit drug use, we have investigated
this death as apparently self-inflicted. The cause of Mr Jalocha’s death will be
determined at the Coroner’s inquest.
Coroner’s inquest
91. One 1 May 2026, the Coroner’s Inquest concluded that Mr Jalocha died by hanging.
The jury returned a narrative verdict and said that at the time he hanged himself it
was not possible to determine whether Mr Jalocha had formed the necessary intent.
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Findings
Assessment and management of risk of suicide and self-harm
92. At the time of Mr Jalocha’s death, Prison Service Instruction (PSI) 64/2011,
governed staff responsibilities regarding ACCT suicide and self-harm prevention
procedures. It required 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 and self-harm
must be managed under ACCT procedures.
93. In November 2024, a revised Prison Safety Policy Framework was issued, which
was fully implemented on 1 January 2025. It states that all staff have responsibility
for ensuring that ACCT procedures are started if they believe a prisoner to be at risk
of suicide or self-harm. Both PSI 64/2011 and the Prison Safety Policy Framework
contain guidance and mandatory instructions on using ACCT procedures to
manage prisoners at risk of suicide and self-harm.
94. Mr Jalocha had a number of risk factors and potential triggers for suicide and self-
harm including that it was his first time in prison and he faced the prospect of a
significant prison sentence and deportation to a country he had not lived in for many
years. He was evidently often low in mood, spent a significant amount of time in his
cell and frequently said he was bored and frustrated by a lack of things to do.
Despite these risk factors, there is nothing in Mr Jalocha’s record to indicate that an
ACCT should have been opened before 29 September. On arrival at Manchester,
he appeared calm and a full mental health assessment on 14 August did not identify
particular concerns. He was allocated to a small wing with a more settled staff
group and more regular time out of cell than other wings.
ACCT monitoring, 29 September – 15 October 2024
95. We consider staff opened an ACCT appropriately on 29 September when an officer
noticed that Mr Jalocha was withdrawn and was spending most of his time in bed.
The officer’s actions demonstrate good professional curiosity. However, we have
identified a number of deficiencies in the management of Mr Jalocha’s ACCT during
this period.
96. PSI 64/2011 requires that an assessment is completed by a trained ACCT assessor
within 24 hours of the ACCT being opened. While we understand that the
designated assessor was called away from the prison suddenly on 30 September,
Mr Jalocha had still not received an assessment by 7 October when a SO noticed
the omission and arranged one for the next day. This was an unacceptable delay.
97. The assessment eventually took place at the same time as the second case review
and was not completed separately beforehand as it should have been. The
assessment was missing some sections required under PSI 64/2011 and the Safety
Framework including areas of support, and the risks, triggers and protective factors
section was only partially completed.
98. The ACCT assessment plays a key part in identifying support actions to mitigate
and lower risk that should be set at the first case review. No support actions were
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set at the first case review as required by PSI 64/2011 or at any point before the
ACCT was closed on 15 October.
99. The identification of support actions to mitigate and reduce is risk is fundamental to
the ACCT process. PSI 64/2011 states that an ACCT can be closed when the risk
of harm has been reduced to a level where it is no longer considered raised and all
support actions have been achieved. It is self-evident that ACCT documents should
not be closed without support actions on the care plan.
100. At the reviews on 30 September and 8 October, Mr Jalocha said he was worried
about being deported to Poland, “overthought” his pending court case and was
confused about his sentence. A SO said on 30 September that he would get
someone from OMU to speak to Mr Jalocha, but this did not happen. Mr Jalocha’s
concerns about potential deportation and his questions about his court case and
sentence should have been added to his care plan and addressed before the ACCT
was closed. In the absence of identified risks and actions to reduce them, the ACCT
process fails in its fundamental purpose and it is understandable why Mr Jalocha
saw little point in being on one.
ACCT re-opened 26 October 2024
101. Mr Jalocha’s ACCT was appropriately re-opened on 26 October and was very well
managed by a SO. She identified support actions and measures to address them
within an identified time period. The SO ensured the attendance of a member of
OMU to answer Mr Jalocha’s questions and put him on the path to attending
education classes and obtaining a cleaning job. She also began lobbying for the
prisoners on Z Landing to have their own weekly session in the main category A
wing gym because Mr Jalocha was keen to use it. Something sadly only achieved
after he died.
102. PSI 64/2011 and the Safety Framework require ACCT reviews to be multi-
disciplinary and the fact that the SO held the review on 5 November on her own is
not ideal. However, we understand that other staff who were expected did not turn
up and we understand her desire as the dedicated case coordinator to complete
them herself. On balance, we agree that it was probably better that she undertook
them on her own rather than someone unfamiliar with each case.
103. Overall, we are satisfied that there was nothing to indicate to staff that Mr Jalocha
was at heightened or imminent risk of suicide on the day he died. At his review, he
appeared keen to start education and work as a cleaner and after dinner on 5
November he accepted the offer of extra food from another prisoner.
ACCT checks on the evening of 5 November
104. The officer did not make the required ACCT checks on Mr Jalocha as he should
have done and falsified the record to say that he had. While we cannot say that had
he made those checks he would have been able to prevent Mr Jalocha’s death, this
was a serious failure in his duty of care and will be particularly upsetting for the
family given the time Mr Jalocha was discovered hanging that night.
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105. Had the prison not undertaken an investigation into the officer’s conduct we would
have recommended they do so. We are satisfied that the Governor has considered
the matter and taken appropriate action.
Measures taken by the prison since Mr Jalocha’s death
106. We have read the Secretary of State’s response to HM Chief Inspector of Prisons’
urgent notification and the associated action plan to address the issues identified.
The Head of Safer Custody told us that a number of measures had been brought in
as a result of issues identified by HMIP and as a result of learning from Mr
Jalocha’s death. These include:
• Compilation of a local directory of services available in the prison to support
prisoners with a variety of issues that ACCT case coordinators can use to
ensure care plans are more meaningful and prisoners receive targeted
support.
• Intensive support sessions for ACCT case coordinators delivered by the
National Safety Team and focussing on recognising risks and triggers and
making more effective care plans.
• Recruitment of two supervising officers to act as floor walkers to provide
hands-on help for ACCT case coordinators.
• Training of eight more ACCT assessors.
• Implementation of random CCTV monitoring to ensure required ACCT
checks are conducted. (At the time of writing this was scheduled for mid-April
2025.)
107. The Head of Safer Custody said that staff had also been reminded to re-visit and
update ACCT care plans at every review and that ACCTs should never be closed
with no actions on the care plan. He was also in the process of reviewing ACCT
assurance models to ensure effective management oversight of the process.
108. In recognition of these measures and the significant amount of support provided to
Manchester to improve the standard of ACCT monitoring following the urgent
notification we make no recommendation.
Writing on the walls of Mr Jalocha’s cell
109. Mr Jalocha wrote a number of things on the walls of his original cell on Z landing in
both English and Polish that indicated he was ruminating on his current and future
circumstances. Most tellingly he appears to have drawn a figure hanging. The
records indicate that the fact he had written on his cell walls was noticed by the
officer on 4 November and by a SO on 5 November.
110. Identifying the risk of suicide is extremely difficult and risk assessment is not an
exact science. It is therefore vital that all potential indicators of risk are identified
and explored. All closed prisons are required to conduct fabric checks to ensure the
physical integrity of each cell. Cells in Manchester are checked daily. Fabric checks
are necessary for the security of the establishment, for gathering intelligence and
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help to ensure cells are kept in a decent state. Graffiti should be identified and steps
taken to remove it as part of this process. We are also aware that there was writing
on the walls of a self-isolating prisoner who died in March 2025. Closer inspection
of Mr Jalocha’s walls should have raised concerns about his risk, especially
because he was subject to ACCT monitoring. This was a missed opportunity to
explore Mr Jalocha’s risk to himself. We make the following recommendation:
A fabric check on a cell represents an opportunity to consider wider risk
factors. The Governor should ensure that his staff are aware of this fact and
take due account of any graffiti, handwritten notes, drawings etc. and take
further action where appropriate.
Emergency response
111. Prison Service Instruction (PSI) 03/2013 on medical emergency response codes
requires that the Governor must have a medical emergency response code protocol
in place which ensures that an ambulance is called automatically in a life-
threatening medical emergency. The protocol gives guidance on efficiently
communicating the nature of a medical emergency, ensuring that staff take the
correct equipment to the incident and that there are no delays in calling an
ambulance. It explicitly states that all prison staff must be made aware of and
understand the protocol and their responsibilities during medical emergencies.
112. As is usual, Manchester use code blue to indicate an emergency when a prisoner is
unconscious, or having breathing difficulties, and code red when a prisoner is
bleeding. Calling an emergency code should automatically trigger the control room
to call an ambulance.
113. When the officer discovered Mr Jalocha hanging he did not radio a code blue.
Fortunately the CM was in close proximity to the scene and radioed a code blue
one minute 40 seconds later once he had entered Mr Jalocha’s cell. We cannot say
whether this delay made a difference to the outcome for Mr Jalocha but in cases of
hanging the swiftest possible response is necessary. We note that in three of the
previous deaths at Manchester since November 2021, the first on scene has not
radioed a code blue.
114. In the first of these deaths (in February 2022) we recommended the Governor
remind staff of the importance of using emergency codes and in the second and
third deaths (in April and July 2024) we have not yet produced our initial reports due
to the investigations being suspended pending the results of toxicology tests. Given
that Mr Jalocha’s was the third death in 2024 in which the first officer on scene did
not radio a code blue we make the following recommendation:
The Governor should introduce a robust assurance process to satisfy himself
that all prison staff understand PSI 03/2013 and their responsibilities during
medical emergencies, including that staff promptly use an emergency code to
communicate the nature of an emergency effectively.
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Clinical care
115. The clinical reviewer found that the clinical care that Mr Jalocha received at
Manchester was equivalent to that which he could have expected to receive in the
community.
Good practice
116. The compilation of a local directory of services available in the prison to support
prisoners with a variety of issues that ACCT case coordinators can use to ensure
care plans are more meaningful is good practice.
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