Paul Cartwright

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Paul Cartwright,
a prisoner at HMP Onley,
on 12 June 2023
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 then
our recommendations should be focused, evidenced and viable. This is especially the
case if there is evidence of systemic failure.
Mr Paul Cartwright was found hanged in his cell at HMP Onley on 12 June 2023. He was
42 years old. I offer my condolences to Mr Cartwright’s family and friends.
Mr Cartwright’s death was the first self-inflicted death at Onley in almost five years.
Mr Cartwright had a history of self-harm but appeared settled in the weeks before his
death. I am satisfied that staff could not have foreseen his actions.
I make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. In January 2023, Mr Paul Cartwright was recalled to prison because of his drug use.
He was sent to HMP Dovegate on 23 January.
2. Mr Cartwright had a long history of substance misuse and mental health issues. He
heard voices and self-harmed by cutting. On 16 February, he told staff that he had
taken an overdose of paracetamol. Staff monitored him and assessed that he had
no symptoms of overdose. Blood tests initially showed a borderline result for
paracetamol and then a normal result. Mr Cartwright told staff he had done it to get
his antipsychotic medication which he had still not been prescribed.
3. On 8 March, Mr Cartwright was moved to HMP Onley. He engaged with the mental
health team and was prescribed antipsychotic and antidepressant medication. His
mood improved and he seemed to settle.
4. On the evening of 5 May, Mr Cartwright made cuts to his arm. He told staff that he
was locked up 20 hours a day, was not getting any help and would “be hanging by
the morning”. Staff started suicide and self-harm prevention procedures (known as
ACCT) but stopped them the next morning, satisfied that Mr Cartwright was no
longer at risk.
5. Staff gave Mr Cartwright a job in the kitchens. His behaviour on the wing was good,
and he got on well with staff and peers. However, on 7 June, he told staff that he
was anxious about his impending release (in six weeks’ time) because he had fallen
out with his family.
6. On 11 June, Mr Cartwright refused to go to his job in the kitchens as he said he did
not feel like it. Staff issued him with a warning but said they had no concerns about
him. He left his cell and interacted with other prisoners. However, during telephone
calls to his mother that afternoon and evening, Mr Cartwright was distressed and
said he planned to take his own life.
7. An officer carried out a routine check at 8.00pm that evening and said that he saw
Mr Cartwright sitting on his bed and had no concerns. Mr Cartwright made a phone
call to a community mental health team shortly after 9.00pm, and left a voicemail
message. That was the last call he made.
8. During a routine check at around 5.25am the next morning, an officer found Mr
Cartwright hanging. He called a medical emergency code and staff responded.
When they went into the cell, they found that Mr Cartwright was clearly dead and so
did not start CPR. The Head of Healthcare from a nearby prison verified his death.
Findings
9. We consider that staff stopped ACCT procedures prematurely on 6 May, less than
15 hours after they had started them. We note that it was another month before Mr
Cartwright took his own life, but this could have been an opportunity to properly
identify his risks and triggers and put more support in place.
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10. Mr Cartwright appeared settled in the weeks leading to his death. Staff would have
been unaware of the content of the calls he made to his mother on 11 June. We are
satisfied that staff could not have foreseen Mr Cartwright’s actions.
11. The clinical reviewer found that Mr Cartwright’s healthcare was only partially
equivalent to that which he could have expected in the community. She made
several recommendations, none of which were directly linked to Mr Cartwright’s
death, which the Heads of Healthcare at Onley and Dovegate will wish to address.
12. We make no recommendations.
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The Investigation Process
13. HMPPS informed us of Mr Cartwright’s death on 12 June 2023. The investigator
issued notices to staff and prisoners at HMP Onley informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded.
14. The investigator visited Onley and obtained copies of relevant extracts from Mr
Cartwright’s prison and medical records. He interviewed 12 members of staff at
Onley.
15. NHS England commissioned an independent clinical reviewer to review Mr
Cartwright’s clinical care at the prison. The investigator and the clinical reviewer
conducted joint interviews of healthcare staff.
16. We informed HM Coroner for Northamptonshire of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
17. The Ombudsman’s family liaison officer contacted Mr Cartwright’s brother-in-law,
who was acting as the contact point for Mr Cartwright’s mother and the rest of his
family, to explain the investigation and to ask if the family had any matters they
wanted us to consider. He did not respond.
18. We shared our initial report with HMPPS. They pointed out a factual inaccuracy
which has been amended in this report.
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Background Information
HMP Onley
19. HMP Onley is an adult male category C prison (the lowest security prisons that are
not open prisons) in Northamptonshire. It holds approximately 740 adult male
prisoners.
20. Practice Plus Group provides healthcare services, including mental health services.
Phoenix Futures provides substance misuse services. A wide range of primary care
services are available each day, including weekends. A GP is on duty during normal
working hours. There is no 24-hour healthcare cover, and out-of-hours support has
to go through the NHS 111 telephone line.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Onley was in May and June 2022. Inspectors
reported that there were serious staffing problems. Despite this, staff and
management had worked to reduce the supply of drugs and reduce the levels of
violence, making a significant improvement in safety. The level of self-harm was
25% lower than the average for similar jails and had continued on a downward
trend throughout the previous 12 months. Prisoners who were under ACCT
management at the time of the inspection told inspectors that they were generally
satisfied with the level of care and support they received.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 28 February 2023, the IMB
reported that the health and wellbeing requirements of prisoners were generally
being met. Staff shortages had an impact on the regime.
Previous deaths at HMP Onley
23. Mr Cartwright’s death was the first death at HMP Onley since August 2018.
Assessment, Care in Custody and Teamwork (ACCT)
24. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
25. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
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ACCT plan should not be closed until all the actions of the caremap have been
completed.
26. All decisions made as part of the ACCT process and any relevant observations
about the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction (PSI) 64/2011.
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Key Events
27. On 18 November 2022, Mr Paul Cartwright was released on licence after serving
half of his 16-month sentence for arson. On 18 January 2023, probation staff
decided to recall Mr Cartwright because he was using drugs (heroin, cocaine, and
psychoactive substances (PS)) and alcohol. He had failed to engage with drug
treatment services and had been evicted from his accommodation for drug misuse.
On 23 January, he was arrested and taken to HMP Dovegate.
HMP Dovegate
28. At his initial health screen, Mr Cartwright told the nurse that he heard voices, which
worsened when he used drugs. He said that he normally took quetiapine (an
antipsychotic). The nurse noted that Mr Cartwright had a history of self-harm but
had no current thoughts of harming himself. She referred him to the mental health
and substance misuse teams.
29. Mr Cartwright was subsequently prescribed medication to treat drug and alcohol
withdrawal symptoms, along with medication for some of his physical health
conditions.
30. On 31 January, Mr Cartwright had a mental health assessment. He said that he was
feeling well and had no thoughts of harming himself, but was concerned that if he
did not take his medication he could deteriorate. He said that he heard voices and
had done for many years. He asked for quetiapine or another stronger medication
as he said he had been struggling mentally since returning to prison and had not
been sleeping. The mental health nurse noted that Mr Cartwright needed a
psychiatry appointment.
31. On 13 February, a mental health nurse saw Mr Cartwright for a review. The nurse
noted that Mr Cartwright was fixated on seeing a psychiatrist so that he could be
prescribed quetiapine. The nurse noted that Mr Cartwright showed no symptoms of
psychosis but had a diagnosis of mixed personality disorder. She noted that Mr
Cartwright was making veiled threats to try to expedite a psychiatrist appointment
and reported this to the security and safer custody departments.
32. A GP at Dovegate saw Mr Cartwright and noted that he was on quetiapine and
mirtazapine during his last prison sentence but not since then. The GP noted that
he had been caught concealing mirtazapine in a previous prison and that she would
need to discuss this prescription with the psychiatrist when Mr Cartwright was
assessed for quetiapine.
33. On 16 February, Mr Cartwright asked the pharmacist if he could have some
paracetamol to take when he needed them. He said that he had headaches each
day but did not want to constantly bother staff. The pharmacist told him that he
could buy paracetamol from the canteen but if he had frequent headaches then he
should book an appointment to have this investigated.
34. That afternoon, healthcare staff discussed Mr Cartwright at a multidisciplinary team
meeting (MDT). They noted that he wanted quetiapine and was threatening to
“kettle someone” if he was not seen soon. They made a routine psychiatry referral.
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(We understand that at that time, the waiting time to see a psychiatrist was 76
days.)
35. On Monday 27 February, Mr Cartwright told a member of the substance misuse
team that on the previous Friday, 24 February, he had taken six boxes of
paracetamol. He told a nurse that he had taken an overdose because he had not
got his quetiapine. Healthcare staff monitored him and noted no symptoms of
paracetamol overdose. Staff sent off blood tests and the results showed a
borderline result for paracetamol. The blood tests were repeated, and the results
were normal. Staff did not begin ACCT procedures.
36. On 3 March, Mr Cartwright underwent an ECG (a test to check the heart’s rhythm)
with a view to starting him on quetiapine. (It is standard procedure to carry out an
ECG before commencing antipsychotic medication. The GP reviewed the ECG
result on 8 March but noted that no further action was needed as Mr Cartwright had
been moved to another prison.)
37. Mr Cartwright told his key worker that he took the paracetamol because he did not
feel mentally stable. When the key worker saw him again on 6 March, he said that
he felt much better. He was settled on his wing, had no thoughts of harming himself,
and was taking courses to help him move forward.
HMP Onley
38. On 8 March, Mr Cartwright was moved to HMP Onley. At his initial health screen,
he told the nurse that he heard voices and had psychosis. He was concerned that
his mirtazapine and quetiapine had been stopped. He also mentioned his
paracetamol overdose. The nurse referred him to the mental health team.
39. On 9 March, a GP at Onley prescribed Mr Cartwright’s medication for his physical
health conditions. On the same day, he was sent an invitation letter to engage with
the Forward Trust (a drug and alcohol recovery service). We understand that he did
not respond.
40. On 23 March, a mental health nurse saw Mr Cartwright. The nurse noted that Mr
Cartwright appeared low and was tearful. Mr Cartwright asked for quetiapine and
mirtazapine to be re-prescribed to him. The nurse noted that Mr Cartwright should
be added to the mental health caseload and that he needed a GP and psychiatry
referral.
41. On 28 March, a GP at Onley saw Mr Cartwright. Mr Cartwright said that he had
recurring thoughts of self- harm. He said that his mental health improved when he
took quetiapine. The GP agreed to prescribe quetiapine and mirtazapine.
42. On 6 April, an officer held a key work session with Mr Cartwright. He said that he
did not have any pressing problems. His conduct on the wing was good, and he
interacted well with both staff and peers. He was awaiting spaces on the courses he
wanted to attend, but did not want any support while not working in the meantime.
He was in touch with friends and family through his in-cell telephone.
43. On 8 April, the mental health nurse saw Mr Cartwright. The nurse noted that he
engaged well. He said that he still heard voices. He was fairly positive, looking to
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and planning for the future. He regularly spoke to his family and his partner. He was
trying to organise his remaining time in prison to complete courses to help him on
release. He had been engaging with the Chaplaincy Department, who had put him
in contact with organisations to support him after release. He was keen to work with
the substance misuse team, who had helped him in the past. The nurse formulated
a care plan.
ACCT – 5 to 6 May
44. At 8.00pm on 5 May, Mr Cartwright pressed his cell bell. An officer responded and
found that Mr Cartwright was very agitated. He complained about being locked in
his cell for 20 hours a day (because he was not employed or engaged in education)
and said he could not do it anymore. He showed her that he had made cuts to his
arm. He said he was hearing voices, that he was sitting in his cell cutting himself
and nobody was doing anything to help him. He said he would “be hanging by the
morning”.
45. The officer contacted a custodial manager (CM) who attended with another CM. Mr
Cartwright said that he had received some documentation relating to his release
that day but said that he had fallen out with his sister and was having family issues
and problems with his partner. He was concerned that prisoners thought he was a
sex offender who shared the same name (there are no sex offenders in Onley). He
did not want to engage with the mental health team anymore, and just wanted an
increase in his medication to stop the voices. During the conversation he calmed
down and handed over a razor blade and assured staff that he had no plans to
harm himself further.
46. Staff started suicide and self-harm procedures (known as ACCT) and immediately
carried out the assessment interview followed by the first case review. A CM
chaired the review, which was attended by another CM, an officer and Mr
Cartwright. Mr Cartwright was initially distressed but calmed down during the
review. He talked about problems with his family relationships, his fears about other
prisoners, and the voices he could hear. He said that he had recently tied a ligature
(a belt) to his light to try to electrocute himself. He said that he had no further
feelings of wanting to harm himself. Staff removed his belt and set observations at
one an hour.
47. At 11.00am the next morning, a CM chaired another ACCT review. Mr Cartwright
and the mental health nurse attended. In interview, the nurse said that she had not
had the opportunity to read the ACCT document before the review. Mr Cartwright
said that he felt in a better place and had no intention of harming himself again. He
said that he had only used drugs once since arriving in Onley and he would not do
so again. He talked about the support he would need after his release, and said he
was considering moving in with his mother but disengaging from people who had a
negative impact on him. Mr Cartwright said that he did not need ACCT support and
had no intention of harming himself. The case review team agreed to close the
ACCT.
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May to June
48. On 12 May, the mental health nurse saw Mr Cartwright. He was settled and after
having some worries about his partner’s health was pleased to have received good
news from her. He told the nurse that the only occasion that he had used PS was
approximately eight weeks previously. The nurse said that she appreciated Mr
Cartwright’s honesty and stressed the danger of using illicit substances while taking
antipsychotic medication.
49. On 14 May, an officer held a key work session with Mr Cartwright. He said that he
had no pressing concerns. The officer offered a wellbeing plan, but Mr Cartwright
said he did not need one. His behaviour on the wing had been good, and he got on
well with staff and peers. He had started working in the kitchen and was pleased to
be doing so. He remained in telephone contact with friends and family. The officer
noted that she had no concerns for his welfare.
50. In his ACCT post-closure interview that day, Mr Cartwright said that he was in a
much better place, as the issues that had upset him had been resolved. He felt
supported by wing staff and had learned to communicate when he felt low. He felt
that he had family support and could talk to his key worker. Staff kept the ACCT
closed.
51. On 18 May, an officer had a key work session with Mr Cartwright. He said that he
had no issues to raise. When offered any further support he politely declined.
52. On 4 June, the mental health nurse saw Mr Cartwright. He presented as well and
settled. He was stable in his mental health, was taking his medication, and reported
no issues.
53. On 7 June, an officer had a key work session with Mr Cartwright. He was still
working in the kitchens. He had applied for enhanced status under the Incentives
and Earned Privileges scheme (IEP, designed to reward and encourage good
behaviour). During the session, Mr Cartwright was upset, saying that he was due for
release in six weeks, and he was anxious about it. He had fallen out with his family,
with whom he was going to live. He said that he had no thoughts of harming
himself, and while aware of how to access support did not need anything at that
time. In interview, the officer said that by the end of the session Mr Cartwright’s
mood was back to normal and she had no concerns about him. The officer spoke to
staff working on the wing and asked them to keep an eye on Mr Cartwright. Later
that afternoon she noted that he had collected his meal and was socialising with
other prisoners.
54. On 8 June, a pharmacy technician carried out a medication in-possession risk
assessment and concluded that Mr Cartwright could hold 28 days’ worth of
medication in his own possession. The technician incorrectly recorded that Mr
Cartwright had no history of self-harm and no issues with drugs or alcohol. (Mr
Cartwright was not given any in-possession medication before he died and
continued to collect it up to his death.)
55. On 11 June, Mr Cartwright refused to attend work. An officer asked him why, and
he said that he did not feel like it. She told the kitchens and then told Mr Cartwright
that she would have to give him an IEP warning. She asked him if there was
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anything further behind his refusal, and he told her that he “could not be bothered”.
The officer gave Mr Cartwright an IEP warning. She told us that he did not appear
to be upset or frightened, and left his cell and interacted with other prisoners.
56. In the afternoon and evening of 11 June, Mr Cartwright made several telephone
calls to his mother. He was distressed and told her that he planned to take his own
life. His last call to his mother was at 7.35pm.
57. During a routine check at 8.00pm, an officer saw Mr Cartwright sitting on his bed
and had no concerns. There was no reason to check on Mr Cartwright again during
the night and he did not press his cell bell at any point.
58. Mr Cartwright made his final phone call shortly after 9.00pm. He called a community
mental health team and left a message for three people who he said had previously
counselled him. He said, “Thank you for nothing”.
Events of 12 June
59. During a routine check at around 5.25am, an officer found that Mr Cartwright had
blocked the observation panel in his cell door. The officer looked through a small
gap and thought he saw Mr Cartwright hanging. He called a code blue (a medical
emergency code used when a prisoner is unconscious or having difficulty
breathing). The control room called an ambulance.
60. Staff responded to the code blue. A CM tried to open Mr Cartwright’s door, but he
had put some furniture behind it. The CM forced the door. She found that Mr
Cartwright was hanging by a ligature attached to the ceiling light. The CM used an
anti-ligature knife to cut the ligature and lowered Mr Cartwright to the floor. There
was blood on the floor, which had come from cuts Mr Cartwright had made to his
leg. (He had carved into his leg the words, “The jail has to pay. Don’t let truth be
lies.”)
61. In interview, the CM said that Mr Cartwright’s body was cold and stiff, and it was
clear to her that he had died. The CM went to the office to telephone the control
room to update them. An officer had also responded to the code blue. In interview,
he said that Mr Cartwright was not breathing, had no pulse, and was cold and stiff.
He used his radio to tell the control room that Mr Cartwright was dead. An
Operational Support Grade (OSG) was in the control room and passed this
message onto the Ambulance Service who cancelled the ambulance.
62. A nurse arrived for work at 7.10am, and was asked to go to Mr Cartwright’s cell.
She noted that Mr Cartwright had rigor mortis and was clearly dead, but she was
not trained to verify death. She was unsure why she had been called to attend.
None of the medical staff at Onley who are qualified to verify death were on duty
that day. The Head of Healthcare at neighbouring HMP Rye Hill is a paramedic and
qualified to verify death so staff asked him to attend. He did so, and at 9.55am,
confirmed that Mr Cartwright had died.
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Contact with Mr Cartwright’s family
63. The prison appointed a family liaison officer. The family liaison officer and the
Governor went to Mr Cartwright’s mother’s address and informed her of her son’s
death. In line with HMPPS guidance, Onley made a contribution to the cost of Mr
Cartwright’s funeral.
Support for prisoners and staff
64. After Mr Cartwright’s death, managers and the staff care team spoke to staff
involved in the emergency response to ensure that they had the opportunity to
discuss any issues and to offer support. A senior manager later held a debrief
session.
65. The prison posted notices informing other prisoners of Mr Cartwright’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 Cartwright’s death.
Post-mortem report
66. The post-mortem report concluded that Mr Cartwright died from hanging. There
were no illicit substances found in his system.
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Findings
Management of Mr Cartwright’s risk of suicide
67. Staff at Onley correctly started ACCT procedures for Mr Cartwright on the evening
of 5 May, when he cut his arm and said that he would “be hanging by the morning”.
However, they closed it less than 15 hours later, when Mr Cartwright said he felt
better and no longer required the support of ACCT. We acknowledge that it was
another month before Mr Cartwright took his own life but nevertheless, we consider
that the closure of this ACCT was premature. In our view, too much emphasis was
placed on what Mr Cartwright said, rather than his risk factors and recent behaviour.
68. The mental health nurse, who was a member of the case review team who closed
the ACCT, said at interview that she had not read the ACCT document and was
unaware that Mr Cartwright had recently said that he had attached a ligature to the
light fitting to try to electrocute himself. It is important that staff attending case
reviews know about the individual’s recent behaviour, and particularly recent self-
harm attempts, so that they can make well-informed judgements about the need for
ongoing ACCT support and the level of observations required.
69. We bring these issues to the attention of the Governor and Head of Healthcare.
70. Mr Cartwright appeared to be more settled in the weeks before his death. On 11
June, he refused to attend work but continued to interact with other prisoners, so
staff had no concerns. The contents of his telephone calls to his mother that
afternoon were clearly concerning, but staff would have been unaware until after his
death. We accept that staff could not have foreseen Mr Cartwright’s actions.
Clinical care
71. The clinical reviewer concluded that Mr Cartwright’s care was partially equivalent to
that which he could have expected to receive in the community.
72. The clinical reviewer made recommendations to Onley about medication in-
possession risk assessments, physical health monitoring following the prescription
of antipsychotic medication, provision of substance misuse services, long-term
condition monitoring and healthcare involvement in supporting those being
monitored using ACCT. None of these issues were directly related to Mr
Cartwright’s death but the Head of Healthcare at Onley will wish to address them.
73. The clinical reviewer made recommendations to Dovegate about responding to
paracetamol overdoses, handovers to other prisons and long-term condition
monitoring. Again, none of these issues related to Mr Cartwright’s death but the
Head of Healthcare at Dovegate will wish to address them.
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Head of Healthcare to note
Verification of death
74. Onley do not have 24-hour healthcare cover, so there were no medical staff present
when Mr Cartwright was found hanged at 5.25am. When the nurse came on duty at
7.10am, she was asked to go to Mr Cartwright’s cell. It is unclear why, as it was
already clear that Mr Cartwright was dead, and the nurse was not able to verify
death. Mr Cartwright’s death was not verified until a qualified member of staff from a
neighbouring prison attended, some hours after he had been found. The Head of
Healthcare may wish to consider whether they need a clearer process for verifying
death.
Inquest
75. At the inquest, held from 8 to 10 December 2025, the jury concluded that Mr
Cartwright died by suicide.
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