Paul Smyth

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Paul Smyth,
a prisoner at HMP Altcourse,
on 12 October 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
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 Paul Smyth was found hanging in his cell at HMP Altcourse on 12 October 2024. Staff
tried to resuscitate him but were unsuccessful. He was 60 years old. I offer my
condolences to Mr Smyth’s family and friends.
Mr Smyth was the fourth prisoner to take his own life at Altcourse in 2024.
Mr Smyth had been at Altcourse for less than five days when he died. I am satisfied that
Mr Smyth gave no indication to prison staff that he was at imminent risk of suicide and that
they could not have foreseen his actions.
The clinical reviewer found that Mr Smyth, who was withdrawing from drugs, was not
properly monitored by healthcare staff, and was not offered relief for his diarrhoea and
stomach pains. She concluded that the care he received was only partially 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 August 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 7 October 2024, Mr Paul Smyth was sentenced to five months in prison for
possessing a bladed article in a public place. He was sent to HMP Altcourse. It was
not his first time in prison.
2. Mr Smyth had a history of substance misuse and tested positive for
benzodiazepines and amphetamines when he arrived at Altcourse. He said he had
no thoughts of suicide or self-harm. He was put on a benzodiazepine detoxification
programme and monitored by healthcare staff for drug withdrawal symptoms.
3. On 8 October, Mr Smyth told an officer he was not feeling well due to going through
‘detox’ but would feel better in a few days.
4. A mental health nurse conducted a routine mental health assessment the same
day. The nurse noted that Mr Smyth presented as low in mood due to his
withdrawal, but he engaged well and she found no evidence of significant anxiety or
depression. Mr Smyth said he had no thoughts of suicide or self-harm. The nurse
assessed that Mr Smyth did not need mental health support at that time and
discharged him from the mental health team.
5. On 10 October, Mr Smyth soiled himself while in bed. He complained of stomach
pains and said he felt awful. A nurse saw him but there is no record Mr Smyth was
offered any medication for his pain or diarrhoea.
6. On 11 October, a healthcare assistant noted that Mr Smyth appeared very low in
mood. She sent a task (on Mr Smyth’s electronic medical record) to the mental
health team asking them to assess him.
7. At 8.10am on 12 October, a prisoner found Mr Smyth with a belt around his neck,
tied to the ladder of his bed. The prisoner shouted to staff. Staff immediately ran to
Mr Smyth’s cell and at 8.11am, entered the cell, removed the belt, and started CPR.
Healthcare staff arrived and CPR continued.
8. At 8.26am, ambulance paramedics arrived. They assessed that Mr Smyth was dead
and at 8.28am, pronounced life extinct.
9. The toxicology report showed that Mr Smyth had amphetamines in his blood, which
indicated that he had taken amphetamines shortly before he died.
10. After Mr Smyth’s death, a prisoner told us that Mr Smyth was being bullied for his
canteen (items bought from the prison shop). Another prisoner said that they had
seen other prisoners taking items from Mr Smyth’s cell on 10 October.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
11. Mr Smyth had no significant risk factors for suicide and self-harm when he arrived
at Altcourse. Although he felt down due to his drug withdrawal over the next few
days, he did not give any indication to staff that he was at risk of suicide. We are
satisfied that staff could not have foreseen his actions.
12. The clinical reviewer concluded that the care Mr Smyth received for his physical
health and for his substance misuse was only partially equivalent to that which he
could have expected to receive in the community. She found that there was
insufficient physical health monitoring during his withdrawal and that some
healthcare staff mistakenly thought that Mr Smyth was detoxing from alcohol rather
than benzodiazepines.
13. The clinical reviewer found that Mr Smyth received good mental health care,
equivalent to that which he could have expected to receive in the community.
However, she considered that further guidance was needed for healthcare
assistants on how to escalate concerns around prisoners with very low mood.
14. Evidence obtained from two prisoners suggests that Mr Smyth was being bullied
(cell theft is a form of bullying). Following a previous death at Altcourse, we made a
recommendation to the Director that he should review the prison’s Violence
Strategy so that it provides clear guidance to staff on how to identify and support
prisoners at risk of bullying, intimidation, or violence. While a revised strategy was
issued in November 2024, we consider it inadequate as it still provides little
guidance to staff on how to identify and support victims of bullying and intimidation.
Recommendations
• The Head of Healthcare and the Merseycare Mental Health Lead should review the
process for healthcare assistants to escalate concerns about prisoners with very
low mood to a nurse.
• The Head of Healthcare should ensure that for prisoners withdrawing from drugs,
staff:
• follow a clinical detoxification care plan;
• complete physical observations, including NEWS2, to ensure timely assessment
and monitoring of patients at risk of deterioration;
• provide documented symptomatic relief (e.g., for stomach cramps and
diarrhoea), in line with NICE NG57 guidelines; and
• audit detoxification cases regularly to ensure care plans are in place.
• The Head of Healthcare should review and update the Standard Operating Policy
for managing benzodiazepine dependence within three months.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• The Director should update the prison’s Violence Strategy so that it provides clear
guidance to staff on how to identify and support prisoners at risk of bullying,
intimidation, or violence.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
15. HMPPS notified us of Mr Smyth’s death on 12 October 2024.
16. The investigator issued notices to staff and prisoners at HMP Altcourse informing
them of the investigation and asking anyone with relevant information to contact
him. Two prisoners responded.
17. The investigator visited Altcourse on 31 October. He obtained copies of relevant
extracts from Mr Smyth’s prison and medical records. He also obtained CCTV and
Ambulance Service records.
18. The investigator interviewed two prisoners at Altcourse on 31 October. In March
2025, he interviewed a member of prison staff over video call.
19. NHS England commissioned an independent clinical reviewer to review Mr Smyth’s
clinical care at the prison. In December, the clinical reviewer and investigator
conducted joint interviews with six members of healthcare staff by video call.
20. A second clinical reviewer subsequently took over and completed the clinical
review.
21. We informed HM Senior Coroner for Liverpool of the investigation. We have sent
the Coroner a copy of this report.
22. The Ombudsman’s office contacted Mr Smyth’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. Mr Smyth’s brother
raised two issues which have been answered in separate correspondence.
23. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. HMPPS and Practice Plus
Group provided an action plan which is annexed to this report.
24. We sent a copy of our initial report to Mr Smyth’s brother. He did not notify us of any
factual inaccuracies.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Altcourse
25. HMP Altcourse is a local prison in Liverpool that houses adult male prisoners and
young offenders who are either sentenced or on remand from the Cheshire and
Merseyside courts. About half of the prisoners are on remand or serving very short
sentences. Sodexo took over management of the prison from G4S in June 2023.
26. Practice Plus Group provides primary healthcare and clinical substance misuse
services seven days a week. Mersey Care offers mental health services from
Monday to Friday, 8.00am to 8.00pm. Phoenix Futures provides non-clinical
substance misuse services from Monday to Friday, 8.00am to 4.00pm.
HM Inspectorate of Prisons
27. The most recent inspection of HMP Altcourse was in November 2021. At the time of
inspection Altcourse was run by G4S.
28. Inspectors noted that prisoners’ safety was not sufficiently good and had
deteriorated since the last inspection in 2017. Eight prisoners had taken their own
lives; four in the previous 12 months. Levels of self-harm remained high and Early
Learning Reviews had not been transferred into longer term safety plans. Staffing
numbers had a detrimental impact on the development of primary and mental health
care.
29. Staff-prisoner relationships remained a real strength. Inspectors observed
supportive and caring interactions between staff and prisoners across all units. Key
work took place more frequently than in similar prisons and was of a better
standard.
Independent Monitoring Board
30. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 30 June 2024, The IMB reported
that the increased prison population had made it more difficult to safely house
vulnerable prisoners. They were concerned that many prisoners who died at
Altcourse had only been there for a few days. Substance misuse had been a
recurring factor in most deaths, underscoring the crucial role of the substance
misuse team in supporting prisoners. There had been ongoing challenges in
engaging short-term prisoners in managing substance misuse.
Previous deaths at HMP Altcourse
31. Mr Smyth was the nineteenth prisoner to die at Altcourse since October 2021. Of
the previous deaths, six were self-inflicted, ten were from natural causes and two
were drug related.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
32. Following a self-inflicted death in February 2024, we recommended that the prison
should review its Violence Strategy so that it provided clear guidance to staff on
how to identify and support prisoners at risk of bullying, intimidation, or violence.
The prison accepted this recommendation, with a target date of November 2024 for
implementation.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
33. On 7 October 2024, Mr Paul Smyth was sentenced to five months in prison for
possessing a bladed article in public. He was sent to HMP Altcourse. It was not his
first time in prison.
34. At reception, Mr Smyth told staff he had no mental health issues, had never self-
harmed, and did not have thoughts of suicide or self-harm. (Mr Smyth had a history
of anxiety and paranoid schizophrenia. In July 2024, he threatened neighbours and
jumped out of a window, leading to concerns about the risk he posed to himself and
others. He was taken to A&E for assessment. He had also taken an overdose 20
years earlier.)
35. Reception staff noted that Mr Smyth appeared to be under the influence of drugs
and had tested positive for benzodiazepines (used to treat anxiety and depression
but also widely abused) and amphetamines (stimulant drugs used in ADHD
treatment but also widely abused).
36. Mr Smyth told the GP at Altcourse that he used heroin daily and asked for
methadone (used to reduce heroin withdrawal symptoms but can also be abused).
Mr Smyth did not test positive for heroin, so the GP refused to prescribe
methadone. The GP prescribed diazepam (a benzodiazepine, detoxification
medication).
37. Mr Smyth was moved into a shared cell on Furlong Red, an induction and
detoxification unit.
38. On 8 October, a prison custody officer (PCO) saw Mr Smyth for a key worker
session. The PCO noted that they discussed Mr Smyth’s drug and alcohol
dependency. Mr Smyth told the PCO that he was detoxing and felt low due to
drugs. He said he had no debts. Mr Smyth said he was aware he could seek mental
health support if needed.
39. Later that morning, a nurse from the Integrated Mental Health Care Team (IMHCT)
saw Mr Smyth for a routine mental health assessment. He noted Mr Smyth
appeared low in mood. Mr Smyth told the nurse he did not have any current mental
health problems but had paranoid schizophrenia 20 years earlier and was
prescribed antipsychotic medication. The nurse noted that Mr Smyth had been
under the care of a psychiatrist in 2011 according to his medical records. The nurse
assessed Mr Smyth and found no evidence of significant anxiety or depression. He
discharged him from the IMHCT.
40. A member of Phoenix Futures, who provide psychosocial support for prisoners with
substance misuse issues, also saw Mr Smyth that day. Mr Smyth told them he
wanted to work with them for help and support with his drug misuse. They gave him
leaflets about harm minimisation and advised him to contact the team if he required
any further support.
41. At 11.16am, Mr Smyth telephoned his brother. The investigator listened to the
recording of Mr Smyth’s call. During the call, Mr Smyth sounded upbeat, and his
cellmate, could be heard in the background. Mr Smyth and his brother discussed
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
his offence, arrest, and sentence. Mr Smyth said he had two months left in prison
(his release date was 4 December) and his flat was secured for his release.
42. Mr Smyth told his brother he missed taking drugs. Mr Smyth’s brother asked about
mental health support. Mr Smyth told his brother he was too tired from coming down
off amphetamines to engage with the support offered. Mr Smyth declined his
brother’s offer to send money to him, saying he did not need it for his remaining
eight weeks in prison.
43. At 4.15pm, Mr Smyth telephoned his brother again, asking him to send £60 to a
prisoner’s prison account for a Trespass jacket and some other items of clothing.
(The prisoner received the £60 in his prison account the next day.)
44. Throughout the night, healthcare staff conducted four welfare checks on Mr Smyth,
with no concerns raised.
45. On the morning of 9 October, healthcare staff took Mr Smyth’s clinical observations,
which raised no concerns.
46. On 10 October, Mr Smyth defecated in his bed and staff noted that his cell was
covered in faeces. A healthcare staff member recorded in Mr Smyth’s medical
record that he was not assessed for withdrawal symptoms that day due to a “dirty
protest”. (A “dirty protest” is when a prisoner deliberately defecates or urinates in
their cell without using the toilet as an act of non-compliance.)
47. A nurse saw Mr Smyth in his cell. He told her he was detoxing from drugs, had
stomach pains, and felt awful. The nurse recorded that Mr Smyth was on alcohol
detoxification (which was incorrect). There was no record that she offered any relief
for Mr Smyth’s pain or diarrhoea.
48. Staff subsequently reassessed Mr Smyth as high risk for cell sharing on medical
grounds, meaning he was not suitable to share a cell. The cellmate moved out,
leaving Mr Smyth alone in the cell.
49. A prisoner and wing cleaner told us he helped clean Mr Smyth's room and delivered
new bedding. He said Mr Smyth seemed alright but did not want to discuss what
had happened.
50. On 11 October, the cellmate told us that he saw other prisoners taking noodles and
vape capsules from Mr Smyth’s cell. He said that he told wing staff. No information
related to this was recorded in Mr Smyth’s record and staff did not recall being told
about it.
51. That afternoon, a healthcare assistant, conducted Mr Smyth’s secondary health
screening. She noted that Mr Smyth appeared very low in mood and was hard to
understand. She sent a task (on Mr Smyth’s electronic medical record) to the
mental health team asking them to assess him.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Events of 12 October
52. A PCO carried out the early morning roll check on 12 October. She said at interview
that at around 5.05am, she shone her torch into Mr Smyth’s cell and saw him sitting
on the side of his bed. She said Mr Smyth turned his head to look at her.
53. At around 8.10am, a prisoner was delivering breakfast packs to cell doors. He told
us that Mr Smyth’s cell flap was open, and he could see Mr Smyth with a belt
around his neck, tied to the third rung on the bunk bed ladder. He said Mr Smyth
was leaning forward into the belt. The prisoner said he banged on Mr Smyth’s door
to try and get a response, and when no response came, he shouted for staff.
54. The investigator watched the body-worn video camera (BWVC) footage, which
showed staff responding to the prisoner’s shouting. Staff arrived at Mr Smyth’s cell
door at 8.11am and immediately entered. A PCO entered the cell first, followed by
three other prison staff. Staff removed the belt from Mr Smyth’s neck, laid him on
the floor, and started CPR. BWVC footage shows Mr Smyth was very pale with no
colour in his face.
55. Staff radioed a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties) and at 8.12am, control room staff
called an ambulance.
56. A nurse arrived. She noted Mr Smyth’s airway was clear, but he was unresponsive,
with no signs of life, no pulse, and was not breathing. The nurse took over chest
compressions. At 8.14am, more healthcare staff arrived.
57. According to the communications log, the ambulance arrived at the gate at 8.15am.
58. At around 8.16am, the nurse applied a defibrillator (a machine that can detect
electrical activity in the heart and deliver a shock to restart the heart) to Mr Smyth
(no shock was advised at any point), while another member of healthcare managed
Mr Smyth’s airways.
59. At 8.26am, ambulance paramedics arrived at Mr Smyth’s cell. They assessed Mr
Smyth and concluded that he was dead. They asked staff to stop CPR. At 8.28am,
a paramedic pronounced life extinct.
Contact with Mr Smyth’s family
60. On 12 October, the prison appointed a member of staff as the family liaison officer
(FLO).
61. Mr Smyth had not provided an address for his next of kin, his brother. At 12.00 pm,
The FLO telephoned Mr Smyth’s brother to inform him of Mr Smyth’s death and
apologised for breaking the news over the phone (Mr Smyth’s brother lived in
Northern Ireland).
62. The FLO maintained contact with Mr Smyth’s brother over the following weeks,
offering support and advice.
63. The prison contributed to the costs of Mr Smyth’s funeral in line with national policy.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Support for prisoners and staff
64. After Mr Smyth’s death, a prison manager 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.
65. The prison posted notices informing other prisoners of Mr Smyth’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 Smyth’s death, and
prison carers were deployed on the wing to support prisoners if needed.
Post-mortem report
66. We have not received the post-mortem report. However, the toxicology report found
evidence of amphetamines in Mr Smyth’s blood.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of Mr Smyth’s risk of suicide and self-harm
67. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), which was in force at the time of
Mr Smyth’s death, set out the procedures (known as ACCT) that staff should follow
when they identified that a prisoner was at risk of suicide or self-harm. It set out the
risk factors and triggers that could indicate increased risk. (The policy has since
been superseded by the Prison Safety Policy Framework though ACCT procedures
remain broadly the same.)
68. Mr Smyth did not have any significant risk factors for suicide and self-harm when he
arrived at Altcourse. A mental health diagnosis, such as schizophrenia, is a risk
factor, but Mr Smyth was not open about this. Even if had told the reception nurse
about his diagnosis, we do not consider that this in itself would have merited ACCT
procedures being started for Mr Smyth. Likewise, his suicide attempt happened a
long time ago, and so would not have been a significant risk factor when he arrived
at Altcourse.
69. A few days after arriving at Altcourse, a nurse noted that Mr Smyth appeared low
and he told her that he was withdrawing from drugs and felt awful. He gave no
indication that he was at risk of suicide or self-harm and so there was no reason to
start ACCT monitoring. We are satisfied that staff could not have foreseen Mr
Smyth’s actions.
Illicit drug use
70. The toxicology report noted that Mr Smyth had amphetamines and diazepam in his
blood. Mr Smyth had been prescribed diazepam but not amphetamines.
Amphetamines can typically be detected in the blood for about 12 to 24 hours after
use. The exact duration can vary depending on factors such as the individual's
metabolism, the dosage taken, and their overall health. Mr Smyth was at Altcourse
for over four days, so this suggests that he took amphetamines while in prison. This
could also explain why Mr Smyth’s condition worsened and he soiled himself on 10
October (a nurse told us that taking illicit substances while on detoxification
medication could have this effect).
71. We presume that Mr Smyth obtained amphetamines while at Altcourse, rather than
that he brought any in secreted on his person.
72. The Acting Head of Safety told us that prisoners on Furlong Red are more likely to
seek illicit substances, and that while illicit substances were available on Furlong
Red, they were not a huge problem. She outlined current strategies such as
searches and drug screenings but noted challenges posed by prisoners who know
the system.
73. In their most recent inspection, HMIP noted that prison managers at Altcourse had
identified drugs as a key threat. Random mandatory drug testing (MDT) had been
reintroduced, with 19% of prisoners testing positive for drugs. Measures to disrupt
drug supply included body scanners, enhanced searches of staff and visitors, and
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
scanning incoming mail. However, suspicion-led drug testing had not resumed, and
frequent staff redeployment reduced the security team's capacity for intelligence-led
cell searches.
74. We recognise that illicit substances are endemic across the prison estate. As
Altcourse appears to be appropriately tackling this issue, we make no
recommendation.
Clinical care
75. The clinical reviewer found that Mr Smyth’s physical health care was only partially
equivalent to that which he could have expected to receive in the community. She
found that clinical welfare checks were not consistently completed daily as part of
monitoring Mr Smyth’s withdrawal. There were four checks on the night of 8/9 but
this was not repeated on other nights and there were none on the first night. Staff
recorded that they did not complete a welfare check on 10 October due to Mr
Smyth’s “dirty protest”. The clinical reviewer said that this was an inappropriate term
as it was more likely the effect of loose bowels and a symptom of Mr Smyth’s
withdrawal. Although a nurse saw Mr Smyth later that afternoon, she did not assess
his withdrawal status or clinical deterioration, nor offer relief for his diarrhoea and
stomach pains.
76. The clinical reviewer found Mr Smyth received good mental health care, equivalent
to that which he could have expected to receive in the community. However, the
clinical reviewer considered that rather than submitting a task to the mental health
team when Mr Smyth appeared to have very low mood, the healthcare assistant
should have consulted with a nurse who could have decided on the best course of
action. The lack of escalation to a nurse meant that there was no senior clinical
oversight to consider Mr Smyth’s thoughts in relation to low mood, including his risk
of suicide and self-harm and whether ACCT procedures were needed.
77. The clinical reviewer found that Mr Smyth’s substance misuse care was partially
equivalent to that which he could have expected to receive in the community. He
was appropriately assessed, and a treatment plan was put in place on 7 October.
However, she found that the rationale for Mr Smyth’s detoxification was not clearly
documented and there were some clinical entries that indicated some staff thought
Mr Smyth was on alcohol detoxification rather than benzodiazepine detoxification.
She found that Mr Smyth did not have a detoxification care plan in place and that
the Standard Operating Policy for managing benzodiazepine dependence needed
updating as it did not specify the frequency of monitoring.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
78. We recommend:
The Head of Healthcare and the Merseycare Mental Health Lead should review
the process for healthcare assistants to escalate concerns about prisoners
with very low mood to a nurse.
The Head of Healthcare should ensure that for prisoners withdrawing from
drugs, staff:
• follow a clinical detoxification care plan;
• complete physical observations, including NEWS2, to ensure timely
assessment and monitoring of patients at risk of deterioration;
• provide documented symptomatic relief (e.g. for stomach cramps and
diarrhoea) in line with NICE NG57 guidelines; and
• audit detoxification cases regularly to ensure care plans are in place.
The Head of Healthcare should review and update the Standard Operating
Policy for managing benzodiazepine dependence within three months.
Emergency response
79. Ambulance service records show that the ambulance was held at the prison gate for
two minutes. It then took around nine minutes for paramedics to get to Mr Smyth’s
cell. The prison has told us that there was no delay and that the time taken was due
to the distance and the fact that the ambulance had to pass through three gates,
which had to be opened and closed in turn before the ambulance could pass
through each one.
80. The time taken made no difference to Mr Smyth who was dead when found.
However, it could make a crucial difference in future cases if ambulances are taking
over ten minutes to get from gate to cell. We bring this to the Director’s attention.
Allegations of bullying
81. A nurse told us that when Mr Smyth had soiled himself, his cellmate, was unkind to
him about it, and she challenged this behaviour. The cellmate said Mr Smyth was
embarrassed about soiling himself.
82. After Mr Smyth had died, a prisoner said that other prisoners had been taking items
from Mr Smyth’s cell. He said he reported this to staff, though there is nothing in Mr
Smyth’s prison record to corroborate this. Another prisoner said he had heard that
Mr Smyth was being bullied for his canteen (items bought from the prison shop).
83. There was nothing in Mr Smyth’s prison record about the events of 10 October
when he soiled himself. We would have expected a record to have been made
about this, but it was not. It is therefore possible that reports of potential bullying
(cell theft is a form of bullying) from his cellmate, were also not recorded by prison
staff. However, we cannot say for sure whether staff were made aware. We also
cannot say what impact, if any, this had on Mr Smyth.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
84. Following an investigation into a self-inflicted death at Altcourse in February 2024,
we recommended that the prison should review its Violence Strategy so it provided
clear guidance to staff on how to identify and support prisoners at risk of bullying,
intimidation, or violence. The prison accepted this recommendation, with a target
date of November 2024 for implementation.
85. An updated Violence Strategy, dated November 2024, was shared with us.
However, it still has very little guidance on identifying and supporting victims. We
recommend:
The Director should update the prison’s Violence Strategy so that it provides
clear guidance to staff on how to identify and support prisoners at risk of
bullying, intimidation, or violence.
Inquest
86. At the inquest held from 6 to 8 July 2026, the jury concluded that Mr Smyth 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