Peter Magloire

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Peter Magloire,
a prisoner at
HMP Wormwood Scrubs,
on 3 February 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
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 Peter Magloire, a black prisoner, died from an anoxic brain injury (a lack of oxygen to
the brain) caused by asphyxiation on 3 February 2023, while a prisoner at HMP
Wormwood Scrubs. He was 65 years old. I offer my condolences to his family and friends.
Mr Magloire was taken to hospital on 29 January after he was found unconscious in his
cell, with a plastic bag tied around his head. At the time, Mr Magloire had spent 78 days in
the segregation unit and was being monitored under suicide and self-harm prevention
procedures, known as ACCT.
Mr Magloire had episodes of severe paranoia. He claimed to be under constant threat from
other prisoners and staff because, he said, they knew about his offences. Mr Magloire
harmed fellow prisoners so that he would be moved to the segregation unit as this was
where he felt safest. He asked to be transferred to a prison which catered for his offender
profile. Wormwood Scrubs should have done more to explore or facilitate this.
The clinical reviewer concluded that the overall care provided to Mr Magloire was not
equivalent to that which he could have expected to receive in the community. She was
concerned about the different perceptions among healthcare staff about the significance of
his paranoid beliefs and the lack of a plan to identify and support his deteriorating mental
health.
We identified issues with the processes for managing a prisoner subject to ACCT
monitoring in the segregation unit. There were missed opportunities to use a
multidisciplinary approach to resolve the challenges that Mr Magloire presented.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman May 2025
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 3
The Investigation Process ................................................................................................ 5
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 9
Findings ......................................................................................................................... 22
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. In January 2010, Mr Peter Magloire was convicted of serious historic sex offences.
He was sentenced on 28 May 2010 and received a discretionary life sentence, with
a minimum term of ten years.
2. Mr Magloire spent time in a number of prisons. He moved to HMP Isle of Wight on
12 April 2012, where he remained until 18 November 2021, when he was
transferred to Three Bridges Medium Secure Unit in Uxbridge (a psychiatric
hospital).
3. While at Three Bridges, medical professionals concluded that Mr Magloire did not
have a mental illness but had had a psychotic episode which had resolved.
4. On 22 June 2022, Mr Magloire was discharged to HMP Wormwood Scrubs. He
initially lived on a general wing but was later moved to the segregation unit (a small
unit where prisoners are kept separate from the general population) because of his
behaviour.
5. On 29 November, staff became concerned that Mr Magloire might try to harm
himself. They monitored him under suicide and self-harm prevention procedures,
known as ACCT. Later that day, Mr Magloire stabbed himself in the stomach and he
was admitted to hospital for treatment.
6. On 2 December, Mr Magloire returned to the segregation unit. On 9 December, staff
ended ACCT monitoring.
7. On 20 January 2023, a nurse opened a new ACCT due to concerns that Mr
Magloire felt very low.
8. On 23 January, the prison consultant psychiatrist saw Mr Magloire and diagnosed
that he was having a psychotic episode. He recommended that he should be
admitted to the prison’s inpatient unit (IPU). He also completed an urgent referral for
Mr Magloire to be re-admitted to an NHS psychiatric hospital.
9. On 29 January, Mr Magloire was found in his cell with a plastic bag over his head
which was tied around his neck. Prison and healthcare staff carried out life-saving
treatment and Mr Magloire was taken by ambulance to hospital, where he was
placed on life support.
10. On 3 February, Mr Magloire’s life support was turned off and he died at 4.20pm.
Findings
11. The clinical reviewer concluded that the care provided to Mr Magloire was not
equivalent to that which he could have expected to receive in the community. She
was concerned about the different perceptions among healthcare staff of the
significance of his paranoid beliefs and the lack of a plan to support and respond to
his deteriorating mental state.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
12. Mr Magloire expressed concerns about his safety before he returned to Wormwood
Scrubs, and the prison indicated that they would look to transfer him as soon as
possible. However, Wormwood Scrubs did not take any action to transfer him until
four months later. Once Mr Magloire became subject to a parole review, staff
considered that he could not be moved so they made no further attempts to do so.
13. Given the challenges presented by Mr Magloire, it was imperative that staff from a
number of disciplines worked together to manage the situation and identify a way
forward. Yet, Mr Magloire’s case was not always discussed at the weekly safety
intervention meeting despite him meeting the criteria for this. We found instances
where there could have been better collaboration between prison and mental health
in-reach team colleagues.
14. We identified examples where ACCT and segregation processes were not followed
and/or the paperwork was not completed properly.
15. There is no evidence that Wormwood Scrubs contributed to Mr Magloire’s funeral
expenses as they should have done.
Recommendations
• The Head of Healthcare should ensure that the segregation policy has been
developed and is implemented in line with their own action plan to include a process
for identifying the most suitable clinician to attend the Segregation Review Board.
• The Governor should ensure that there are effective quality assurance
arrangements in place so that she can be satisfied that both the Prison Safety
Policy Framework (formerly PSI 64/2011) on ACCT monitoring and Prison Service
Order (PSO) 1700 on segregation are being followed.
• The Governor should ensure that the agenda for the SIM includes consideration of
the length of time a prisoner has been segregated.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
16. HMPPS notified us of Mr Magloire’s death on 3 February 2023.
17. The investigator issued notices to staff and prisoners at HMP Wormwood Scrubs
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
18. The investigator visited Wormwood Scrubs on 4 and 5 April 2023. He obtained
copies of relevant extracts from Mr Magloire’s prison and medical records and
documents from the ambulance services.
19. NHS England commissioned a clinical reviewer to review Mr Magloire’s clinical care
at the prison.
20. The investigator and clinical reviewer interviewed ten members of staff in person on
4 and 5 April. They conducted a further nine interviews remotely by Microsoft
Teams on 18,19, 20 and 24 April and 4 May.
21. Another investigator took over the investigation in July 2024.
22. We informed HM Coroner for Hammersmith, Fulham and Hounslow of the
investigation. The Coroner confirmed the cause of Mr Magloire’s death and told us
that a post-mortem was not needed. We have sent the Coroner a copy of this
report.
23. The Ombudsman’s office contacted Mr Magloire’s brother to explain the
investigation and to ask if he had any matters he wanted us to consider. Mr
Magloire’s brother was concerned that the prison did not take the threat of harm
(from others) to Mr Magloire seriously and he wanted to know why probation staff
had notified members of the family about Mr Magloire’s death.
24. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
25. Mr Magloire’s brother received a copy of the draft report. He did not make any
comments.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Wormwood Scrubs
26. HMP Wormwood Scrubs is a category B local and resettlement prison holding
remanded and sentenced adult men and young adults (aged 18-21 years). Practice
Plus Group provides primary health care services. Barnet, Enfield and Haringey
NHS Mental Health Trust provides mental health services. The prison has an
inpatient unit.
HM Inspectorate of Prisons
27. The last inspection of HMP Wormwood Scrubs was unannounced and took place in
June 2021. Inspectors concluded that the prison was a much safer, cleaner and
better organised prison than previously. They found that levels of self-harm had
reduced substantially and were lower than comparable prisons. There had been a
significant improvement in prisoners subject to ACCT feeling cared for by staff.
Inspectors noted that discussions at the weekly safety intervention meeting about
those presenting a high risk of concern did not always consider all relevant
prisoners and the minutes lacked evidence of meaningful discussion and action.
Inspectors found that the reasons for segregation lacked detail, the behaviour
targets were often superficial and the ongoing segregation records were
observational and did not demonstrate meaningful interaction.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to 31 May 2023, the IMB reported
that staff shortages and staff turnover had adversely impacted the provision of an
effective mental health service and waiting times for routine mental health
assessments had increased.
29. The IMB also noted that recorded self-harm had increased by 22% and the
numbers of prisoners subject to ACCTs had also increased. They were concerned
that prisoners with serious mental health issues were frequently kept in segregation,
awaiting a move to the hospital wing due to a shortage of beds. They noted that
while mental health staff regularly visited the segregation unit, the restricted
conditions there made it unsuitable for those with severe mental health problems.
Previous deaths at HMP Wormwood Scrubs
30. Mr Magloire was the eleventh prisoner to die at Wormwood Scrubs since February
2020. Of the previous deaths, six were self-inflicted and four were from natural
causes. Since Mr Magloire’s death up to February 2025, a further nine prisoners
have died at Wormwood Scrubs, six from natural causes, one self-inflicted, two
drug-related and one where the cause of death remains unascertained. There were
no similarities between our investigation findings into Mr Magloire’s death and our
findings in the previous investigations.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Assessment, Care in Custody and Teamwork
31. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and 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.
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
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
Segregation
32. Segregation is when a prisoner is kept apart from other prisoners in the segregation
unit The criteria for segregating a prisoner are set out in the Prison Rules. Most
commonly, prisoners are segregated under Prison Rule 45 on good order or
discipline (where a prisoner has behaved in a way that prison staff consider would
put others in danger or cause a problem for the prison) or for the prisoner’s own
interests/protection (if the prisoner or prison staff consider they are in danger).
33. Once a prisoner has moved to the segregation unit, the Segregation Review Board
(SRB) must carry out regular reviews to assess if the prisoner should remain
segregated. The SRB comprises a governor (the Chair), a healthcare
representative, an ACCT case manager (where applicable) and the prisoner. An
IMB member must also be invited, and every effort should be made to facilitate their
attendance.
34. Prison Service Order (PSO) 1700 on segregation acknowledges the specific risks of
holding vulnerable prisoners in segregation. It notes that rates of suicide among
segregated prisoners are high, and that segregation should only be used as a last
resort. Prisoners segregated for a continuous 30 days must have a care plan to
support their mental wellbeing. If segregation goes beyond 42 and 84 days, the
prison must seek authorisation from a senior manager in the Prison Group
Director’s office.
Parole Process
35. The Generic Parole Process Policy Framework sets out the requirements and
guidance for staff involved in the parole process (the process by which the Parole
Board considers whether a prisoner is suitable for either a move to open conditions
or release). It states that prisoners may be transferred during their Parole Board
review to access a progression opportunity in line with their sentence plan or for
security reasons. If the hearing date has been listed, a prisoner should not move
unless the receiving establishment can accommodate arrangements for the
prisoner to attend the hearing.
Inpatient unit
36. The inpatient unit at Wormwood Scrubs comprises 17 beds, 12 of which are
allocated for patients with complex mental health needs. The mental health in-reach
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
team, in consultation with senior healthcare managers in the prison, maintains the
waiting list for the mental health allocation and decides who will be given a bed.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
Background
37. On 15 February 2008, Mr Peter Magloire was remanded to HMP Wormwood
Scrubs, charged with serious historic sex offences, predominantly against family
members. On 18 January 2010, Mr Magloire was convicted of the offences. On 28
May, he received a discretionary life sentence, with a minimum term of ten years.
After short spells at HMP Bullingdon, HMP Wandsworth and HMP Brixton, Mr
Magloire was transferred to HMP Isle of Wight on 12 April 2012, where he remained
for nine years.
38. During this time, he had occasional contact with the mental health team due to
episodes of paranoid and delusional thinking. This resulted in Mr Magloire
becoming agitated and wanting to self-isolate. Mr Magloire was paranoid that
family, prisoners and officers wanted to kill him because of his offences (there was
no evidence that this was the case). Between these episodes, Mr Magloire engaged
in the regime, mixed with other prisoners, and held a number of different jobs.
39. In September 2021, Mr Magloire told healthcare staff that he feared for his safety.
Staff noted that he was paranoid about other prisoners planning to hurt him. Mr
Magloire was moved to the healthcare unit for his own safety. A prison psychiatrist
assessed that Mr Magloire had psychotic symptoms and a referral to a psychiatric
hospital should be considered.
40. On 18 November 2021, Mr Magloire was sectioned under the Mental Health Act
and sent to Three Bridges Psychiatric Hospital in London.
2022
41. On 17 May 2022, Wormwood Scrubs’ Offender Management Unit (OMU) emailed a
mental health manager in the community about Mr Magloire’s imminent hospital
discharge. They said that he could be discharged to Wormwood Scrubs, and they
would try to move him on as soon as possible. The email did not give any further
information. (Under the NHS policy, prisoners being discharged from secure
hospitals are remitted to the nearest prison, unless they are a category A prisoner
requiring a high secure prison.)
42. On 30 May, the mental health manager emailed the joint Head of Reducing
Reoffending. She said that she had attended a meeting to discuss Mr Magloire’s
discharge to prison and aftercare services. She said that Mr Magloire was reluctant
to go to Wormwood Scrubs and wanted to return to Isle of Wight. Mr Magloire had
said he was worried that he would be placed on a standard wing and would be
vulnerable because of his offences. She asked the Head to confirm he was happy
for Mr Magloire to return to Wormwood Scrubs.
43. On 6 July, the joint Head of Reducing Reoffending responded and said there was
no conflict of interest. He asked if a prison with a vulnerable prisoners’ unit (VPU)
would be better given his age, offence and concerns.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
44. The Deputy Governor responded by email and said Wormwood Scrubs would take
Mr Magloire in line with the remissions protocol.
HMP Wormwood Scrubs
45. On 22 June, Mr Magloire was discharged from hospital to a standard wing at
Wormwood Scrubs. The discharge letter stated that he had had a transient
psychotic episode. He was not prescribed any medication.
46. On 30 June, a nurse from the mental health in-reach team (MHIRT) completed a
mental health assessment. She noted Mr Magloire’s mood was good, and he
presented as stable.
47. On 6 July, Mr Magloire was discussed at the MHIRT referral meeting. It was agreed
that he would receive monthly oversight from MHIRT and one of the prison’s
consultant psychiatrists would review him as a non-urgent appointment.
48. On 18 July, a prison psychiatrist reviewed Mr Magloire. She noted no evidence of
serious mental illness and that his psychotic episode was in remission. However,
she concluded that given his history of psychotic episodes and his recent discharge,
MHIRT should retain oversight.
49. On 10 August, Mr Magloire said he was afraid to leave his cell as prisoners were
planning to stab him.
50. On 12 August, Mr Magloire was moved to a different wing as he felt under threat.
51. On 18 August, Mr Magloire received a letter which stated that the Parole Board
would review his case on 18 November 2022.
52. On 24 August, Mr Magloire was discussed at an MHIRT meeting. They agreed to
discharge him from their caseload.
53. In September, a number of prison officers noted that Mr Magloire was refusing to
leave his cell due to threats from other prisoners. He told officers there was a
“bounty” on his head because of his previous offences.
54. On 19 September, Mr Magloire’s brother contacted the prison. He reported that
other prisoners had threatened Mr Magloire after they found out his previous
offences.
55. On 24 September, a prison officer recorded that she thought Mr Magloire was
having a mental breakdown. She said that she had completed a welfare check after
Mr Magloire’s brother’s call. She noted she had exhausted all areas of information
to corroborate his claims but had found no evidence he was under threat.
56. At approximately 11.20am on 27 September 2022, Mr Magloire was taken to the
segregation unit after he allegedly sexually assaulted another prisoner. The matter
was referred to the police.
57. On 29 September, the Head of Residence for D & E wing recorded that Mr Magloire
wanted to stay in the segregation unit because he was at risk from people who
knew his offences.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
58. On 30 September, the Head of Residence chaired the Segregation Review Board
(SRB) to review the decision to segregate Mr Magloire. A prison officer, a nurse and
Mr Magloire attended. They recorded Mr Magloire should remain segregated
because of the ongoing police investigation and that Mr Magloire felt unsafe on the
wing.
59. Later that day, a nurse spoke to Mr Magloire who told her that the alleged sexual
assault that he had been accused of was a “blessing” as he could get off the wing.
60. On 3 October, the MHIRT discussed the referral for Mr Magloire and agreed to refer
him to the mental health team and to Improving Access to Psychological Therapies
(IAPT) for anxiety and depression.
61. On 7 October, the joint Head of Reducing Reoffending chaired the SRB. A prison
officer, nurse and Mr Magloire attended. It was noted that the police investigation
was ongoing, and Mr Magloire felt down, anxious and worried that people wanted to
hurt him.
62. That day, the Head of Residence for A and C wings and the kitchens chaired the
SRB. Mr Magloire, a nurse, prison officer and an IMB observer attended. The Head
wrote that Mr Magloire presented as paranoid and the MHIRT was aware.
63. On 21 October, Mr Magloire asked the Head of Residence for D and E wings if he
could transfer to another prison. The Head noted that segregation staff should
speak to OMU.
64. Later that day, there was an exchange of emails between Wormwood Scrubs’ OMU
and HMP Isle of Wight. Wormwood Scrubs put Mr Magloire forward for a transfer,
but Isle of Wight did not accept him on the basis that he was subject to a parole
review.
65. On 27 October, a prison paramedic saw Mr Magloire as part of healthcare’s regular
checks. Mr Magloire told her that he felt low and stressed due to threats from other
prisoners and wanted to transfer to another prison. She noted that she discussed
this with the Head of Residence for D and E wings.
66. Later that day, the Head of Residence for A and C wings chaired the SRB. The
paperwork notes that only he and Mr Magloire attended, though the medical record
shows that the prison paramedic was also there. The Head recorded that they
discussed with Mr Magloire his location and the difficulty of transferring him to
another prison because he was in the parole window. Mr Magloire was moved to
the Conibeere Unit (a detoxification/stabilisation unit) that day. The Head updated
Mr Magloire’s prison record to say that the move there was facilitated so that Mr
Magloire could engage in the regime which would support a transfer out of the
prison.
67. On 7 November, an alert was added to Mr Magloire’s prison record to state he was
on a parole hold and should not be transferred. Later that day, the Head of the
Offender Management Unit told Mr Magloire that he would try to transfer him to
another prison.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
68. At 8.00am on 9 November, a prison officer started ACCT procedures after Mr
Magloire told her he was going to die that day. She recorded that he had given the
cleaner a letter stating he would be murdered.
69. On 10 November, an ACCT case review took place. The case assessor did not
attend the meeting. The Supervising Officer (SO) recorded that Mr Magloire
engaged well and had no intention of suicide or self-harm. The SO concluded that
while Mr Magloire’s paranoia needed to be addressed, staff could stop ACCT
procedures. The ACCT post-closure review form was not completed and one of the
care plan actions was not complete.
70. On 11 November, Mr Magloire was placed on report for assaulting a prisoner.
71. On 12 November, Mr Magloire was sent to the segregation unit for the alleged
assault under Prison Rule 53 (pending a disciplinary hearing). The disciplinary
hearing was scheduled for 14 November, but it is not clear from the prison records if
it took place. The Head of Early Days in Custody authorised Mr Magloire’s
segregation. It was not recorded on the relevant form or the accompanying initial
health screen form that Mr Magloire was in the seven-day ACCT post-closure
period.
72. On 14 November, Mr Magloire’s brother contacted the prison to say that Mr
Magloire was under constant threat and asked why he had not been transferred to
another prison.
73. Later that day, the joint Head of Reducing Reoffending completed Mr Magloire’s
segregation paperwork. He changed the reason for segregation to Prison Rule 45
(good order or discipline) and noted that Mr Magloire had been segregated because
he had allegedly assaulted another prisoner and the incident had been referred to
the police. There was no reference that Mr Magloire was in his ACCT post-closure
period, and we were not given any evidence that the mandated ACCT review or a
defensible decision to segregate form was completed.
74. On 17 November, the Head of Early Days in Custody chaired an SRB review. The
paperwork noted that Mr Magloire, three other prison staff and a forensic
psychologist attended. The psychologist had been asked to complete a
psychological risk assessment for Mr Magloire’s parole review. In contrast to the
SRB paperwork, the prison paramedic made an entry in the medical records to say
that the SRB review had been held in Mr Magloire’s absence because he had
refused to attend.
75. Over the next few days, Mr Magloire repeatedly told officers that he was at risk of
harm from other prisoners, and he refused to leave his cell because he was afraid.
76. On 28 November, Mr Magloire saw a prison GP. Mr Magloire told him that there
was a conspiracy between the prisoners and officers to kill him and he asked to be
moved from the segregation unit. The GP referred him to the MHIRT.
Events of 29 November 2022
77. At approximately 10.50am, the prison paramedic saw Mr Magloire. She recorded
that he refused his medications and believed staff and officers were going to harm
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
him. He told her that he would only leave his cell if he was dead, and he showed
her two sharpened knives under his t-shirt. He said that if anyone opened his cell
door, he would stab himself before they could kill him. She noted that she told
officers this, completed a referral to the MHIRT and started ACCT monitoring.
78. That morning, a prison manager in the segregation unit with responsibility for
disciplinary hearings authorised Mr Magloire’s segregation following the ACCT
procedures being opened. He agreed that Mr Magloire should remain in
segregation on the basis that he was displaying ongoing paranoia and had said that
he would not leave alive. No further reviews of this decision were documented.
79. Between 11.00am and 11.45am, an officer checked on Mr Magloire and recorded
he was threatening to stab himself and was seen holding cutlery to his stomach.
80. At 11.30am, a SO completed the ACCT immediate action plan and noted that Mr
Magloire should be checked every twelve minutes until he was fully assessed. In
regard to other interventions, including the removal of items that can cause harm,
the SO wrote ‘n/b’. There is nothing to explain what this meant.
81. At approximately 12.05pm, the chaplain saw Mr Magloire who told him that staff
were planning to kill him and showed him a plastic knife. The chaplain noted that he
informed segregation staff.
82. At 2.15pm, a SO completed the ACCT assessment. She noted that Mr Magloire
was paranoid and did not engage well. She said that after some time, he allowed
staff to open the door and he showed them two self-inflicted stomach wounds.
83. At approximately 2.40pm, a prison manager, a SO and the prison paramedic
completed an ACCT review at Mr Magloire’s cell door. They said he was paranoid
about staff and prisoners wanting to kill him. Mr Magloire showed staff a fresh self-
inflicted wound. They noted that Mr Magloire eventually engaged and allowed the
prison paramedic to assess his injuries. She decided he needed treatment, and he
was sent to hospital. A member of the safer custody team told us that Mr Magloire
was extremely paranoid at the time and had threatened to hurt staff if they opened
the cell door and this was why staff had not removed the items from his cell.
84. On 30 November, the hospital trauma doctor contacted healthcare staff with
concerns about Mr Magloire’s mental health.
85. Later that day, the prison held their Safety Intervention Meeting (SIM, a weekly
multidisciplinary safety risk meeting, chaired by a senior manager, which focuses on
those who are deemed to pose a significant risk of self-harm or harm to others).
There is no reference to Mr Magloire in the minutes.
86. On 1 December, officers completed an ACCT review with Mr Magloire in hospital.
Healthcare staff did not attend. Mr Magloire talked about the threat he faced in
prison. It was noted that healthcare staff would need to review him when he
returned to prison. The ACCT support plan identified an action to refer Mr Magloire
to the MHIRT.
87. At 11.40am, the prison paramedic emailed senior prison staff to say that Mr
Magloire did not feel safe in the prison and needed to live in a VPU. She said she
was very concerned that if he remained at Wormwood Scrubs, his cognitive ability
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
would deteriorate, and this would leave him at risk from others. She acknowledged
that Mr Magloire was on a parole hold but felt a transfer should be explored
because of his poor mental health. She said that prolonged periods of segregation
were damaging to health, and this was affecting Mr Magloire. She confirmed that Mr
Magloire would be added to the MHIRT’s caseload.
88. That day, the Head of Residence for D and E wings and the Head of Segregation
completed an SRB to authorise Mr Magloire’s continued segregation when he
returned to the prison. Healthcare staff did not attend.
89. At 5.47pm, the prison paramedic completed Mr Magloire’s initial segregation
healthcare screen in Mr Magloire’s absence as he remained in hospital. She noted
that mental health concerns had been raised, Mr Magloire had seen the MHIRT, he
had no mental health diagnosis, and he was considered fit for segregation.
CSU at Wormwood Scrubs
90. At approximately 9.00pm that day, Mr Magloire was discharged from hospital to
Wormwood Scrubs’ segregation unit. A nurse completed a second initial
segregation healthcare screen. She noted that Mr Magloire should have gone to the
IPU, but no beds were available. She wrote that Mr Magloire was showing signs of
being acutely unwell and/or psychotic and noted his paranoid thought disorder. She
concluded that Mr Magloire was able to cope with a period of segregation until a
bed became available in the IPU and placed Mr Magloire under constant
supervision.
91. At interview, the prison’s consultant psychiatrist told the investigator that Mr
Magloire should have been referred to the NHS for inpatient care following his
discharge from hospital. This did not happen.
92. On 2 December, the prison paramedic emailed prison colleagues about Mr
Magloire. She said he was not under the care of the MHIRT but there were
concerns about his mental deterioration and behaviour. She said that he had asked
to be on a VPU and as Wormwood Scrubs did not have one, this was harming his
mental health.
93. A forensic psychologist responded to the email. She said that Mr Magloire was due
to have a forensic psychology assessment as part of his parole process, and she
was happy to arrange for the assessment to be completed at another prison. She
concluded that the risk assessment should not be a barrier to him moving to a safer
location.
94. Later that day, the Head of Early Days in Custody chaired an ACCT case review. A
member from the MHIRT team attended. They recorded that Mr Magloire still did
not feel safe in prison. He denied thoughts of self-harm. Mr Magloire’s observations
were reduced from constant supervision to hourly during the day and half hourly at
night. They concluded that Mr Magloire was not at high risk of suicide or self-harm.
95. On 7 December, Mr Magloire was discussed at the MHIRT meeting. It was noted
that his current state resembled his previous presentation before he was admitted
to hospital. It was agreed that a psychiatrist would review him, and he would be
allocated a psychiatric nurse.
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
96. That day, Mr Magloire was discussed at the SIM. It was noted that he had stabbed
himself, he was very paranoid and remained a high risk to himself and others. The
notes said the MHIRT had reviewed him, he had no mental health diagnosis, and
his parole window was until the end of January. The psychologist noted that she
told the custodial manager that Mr Magloire did not need to stay at Wormwood
Scrubs if he needed to move for safety reasons.
97. On 8 December, a psychiatrist met Mr Magloire. She concluded that he presented
with symptoms of psychotic relapse, and he did not have any insight into his mental
condition. She noted that while Mr Magloire lacked the mental capacity to consent
to treatment, she was going to prescribe him risperidone (a medication used to treat
mental health conditions). She told the investigator that she had to try to treat him
before she could refer him to the NHS to be assessed for inpatient care. She said
he could not be transferred to the IPU as there was no space. She noted that Mr
Magloire should remain on an ACCT and his risks should be managed through the
ACCT process.
98. Mr Magloire was not listed on the IPU waiting list for 2, 9 and 23 December or 13
January.
99. On 9 December, the joint Head of Reducing Reoffending chaired an ACCT review.
A prison officer and Mr Magloire attended. No one from the healthcare team or
MHIRT were present. The Head noted that Mr Magloire had expressed no thoughts
of suicide or self-harm over the past week but said his main threat was from staff
and prisoners. They decided to end ACCT monitoring. The post-closure review was
not completed, and it is not clear what progress was made with one of the care plan
support actions.
100. On the morning of 14 December, a nurse reviewed Mr Magloire. She said that he
reported no concerns, other than that he remained paranoid and felt unsafe. She
incorrectly noted that Mr Magloire was on an ACCT and his risk remained low but
that his risk would increase if he became distressed. She concluded that he should
continue to be managed through the ACCT process and the MHIRT should review
him every two weeks. The ACCT post-closure period was due to finish the next day.
101. Later that day, Mr Magloire was discussed at the MHIRT meeting. They noted that
his care would be handed over to another psychiatrist, as the previous one had left
Wormwood Scrubs. It was noted that Mr Magloire was at a high risk of self-harm
and harm to others which was a different conclusion to the nurse’s assessment
earlier that day. There was no record that Mr Magloire’s ACCT status was
discussed.
102. On 15 December, the IAPT team reviewed the referral made on 24 October. They
concluded that Mr Magloire was too high risk for IAPT, but he could be referred to
them once he had stabilised.
103. Later that day, the prison paramedic saw Mr Magloire. She noted that he was not
taking his antipsychotic medication.
104. At 2.15pm, the Head of Residence for D and E wings chaired the SRB meeting. Mr
Magloire, the prison paramedic, the psychologist and two prison officers attended.
They noted that Mr Magloire had stopped engaging in the regime as he was worried
Prisons and Probation Ombudsman 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
someone would kill him. The Head recorded that the MHIRT would support him,
and psychology would conduct a risk assessment as part of the parole process.
105. On 16 December, a nurse examined Mr Magloire. She updated his medical record
and incorrectly noted that he was on an ACCT and his risk should be managed
through the ACCT process.
106. On 20 December, a nurse spoke to Mr Magloire about him not taking his
antipsychotic medication. She recorded that he told her he did not need to take it as
he was not mentally ill. She noted she would refer Mr Magloire to the doctor and the
MHIRT.
107. On 21 December, the Head of Segregation completed the application to continue to
segregate a prisoner beyond 42 days. He wrote that Mr Magloire had said he would
assault another prisoner if he was returned to standard location and the best option
for him was to transfer out of Wormwood Scrubs, but this was not possible as he
was on parole hold. He also wrote that Mr Magloire was deemed unsuitable for the
IPU. There is no record to explain why he was unsuitable.
108. On 21 December, the London Prison Group Safety Lead authorised Mr Magloire’s
continued segregation.
109. On 25 December, a nurse saw Mr Magloire during segregation rounds. She
recorded that he remained paranoid and was desperate to be transferred to another
prison as he was scared for his life.
110. On 29 December, a prison manager chaired the SRB meeting. Mr Magloire, two
other prison officers and an IMB observer attended. Healthcare staff did not attend,
though the manager recorded that the prison paramedic contributed verbally
beforehand. He noted that Mr Magloire would not consider moving to another unit
and was not taking his antipsychotic medications.
111. On 5 January 2023, a nurse completed a mental health review with Mr Magloire.
She noted that his presentation had improved, and he was no longer being
monitored under ACCT procedures but continued to express paranoid beliefs. She
concluded he would be monitored through fortnightly reviews.
112. On 11 January, the psychologist met Mr Magloire in connection with his
psychological risk assessment. He was concerned for his safety and wanted to
move to a prison for sex offenders.
113. That day, a nurse met Mr Magloire to complete a mental health assessment. She
noted he appeared mentally stable and could articulate his issues. She recorded
that he was taking his medications and had no side effects. However, at this time,
Mr Magloire was refusing to take the antipsychotic medications. Mr Magloire was
discussed at the MHIRT meeting, and they concluded that he was stable and could
be seen monthly rather than fortnightly.
114. On 12 January, the joint Head of Reducing Reoffending chaired the SRB review.
The paperwork did not indicate any other attendees, though an entry from the
prison paramedic in the medical records about the SRB and the segregation daily
record noted that Mr Magloire attended. The Head recorded that Mr Magloire was
very quiet most of the time, he tried to manipulate staff to get vapes and harmed
16 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
himself by inserting objects into cuts in his arms. There is no corresponding entry
about self-harm of this nature in the segregation log or medical records and Mr
Magloire was not subject to ACCT monitoring.
115. On 15 January, a prison manager spoke to Mr Magloire during the segregation
rounds. She noted he remained very paranoid and wanted a transfer. She told him
that this depended on his parole status.
116. On 16 January, the psychologist met Mr Magloire and spoke about the police
investigation into the two alleged incidents of assault. She recorded that Mr
Magloire told her that he carried out the assaults so that he would be taken to the
segregation unit.
117. On 18 January, a senior forensic psychologist emailed the Head of OMU and other
prison staff to tell them that the previous psychologist had completed the
psychological risk assessment and Mr Magloire did not need to stay at Wormwood
Scrubs for forensic psychology purposes. The Head of Offender Management
responded by email that as he was subject to a parole hearing and further reports,
they could only move Mr Magloire if the receiving establishment could facilitate
hearings. There is no evidence that staff at Wormwood Scrubs were actively
seeking a prison that could facilitate the hearing.
118. On 19 January, the Head of Segregation chaired the SRB review. Mr Magloire, an
SO, an IMB representative and a paramedic attended. It was noted that Mr Magloire
was mostly quiet and passed notes to officers about forthcoming attacks. They
recorded their concerns about his mental health and paranoia and said they would
refer him to the MHIRT. (Mr Magloire was already under the care of the MHIRT.)
119. On 20 January, the joint Head of Reducing Reoffending spoke to Mr Magloire
during segregation rounds. She noted that he was very down, and staff had said
this was after a discussion about moving him out of segregation. Later that day, Mr
Magloire told the chaplain he would not see him the next day as staff were planning
to kill him using the showers.
120. At approximately 4.46pm, the prison paramedic started ACCT monitoring
procedures. She noted that Mr Magloire appeared very low. She told the
investigator that she felt that both prison and mental health staff dismissed her
concerns about Mr Magloire’s mental health and said there was nothing wrong with
him: “It’s Magloire, that’s how he is” or “he is not under MHIRT”.
121. At around 7.00pm, an officer completed the ACCT assessment. She noted that Mr
Magloire had said he did not feel low but displayed an irrational fear of everything.
She noted that his only expectation of the future was that he would be killed. She
noted Mr Magloire had said he had no thoughts of suicide or self-harm and he had
never harmed himself as it was against his religious beliefs.
122. At 8.15pm, the Deputy Governor chaired Mr Magloire’s ACCT case review in Mr
Magloire’s cell. The officer provided a verbal handover and a nurse attended. It was
noted that the Head of the MHIRT, the prison GP and a nurse had seen Mr
Magloire earlier and had not identified any physical or mental health issues. Mr
Magloire asked to be put under constant supervision to protect him from other
people. There is no record that any action was taken.
Prisons and Probation Ombudsman 17
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
123. The immediate action plan was not completed until 8.40pm. Observations were set
for three conversations per day, supported by the segregation observations of an
hourly check during the day and half hourly at night.
124. The joint Head of Reducing Reoffending completed the defensible decision
paperwork for Mr Magloire to remain in segregation while on an ACCT. The
document was dated 3 October but referred to his January 2023 segregation. The
Head noted that he believed that if Mr Magloire was forced to leave segregation, it
could provoke him to assault another prisoner. He said that to end his segregation,
efforts should be made to integrate Mr Magloire with other prisoners.
125. On 23 January, a psychiatrist reviewed Mr Magloire. He noted that Mr Magloire had
a degree of thought disorder and was preoccupied that there was a conspiracy to
kill him. He noted that he planned to refer Mr Magloire to the NHS to be readmitted,
he would prescribe him olanzapine (a medication to treat schizophrenia) and
arrange for him to be moved to the IPU. He told the investigator that he was so
concerned that he completed the hospital referral straight away. In his letter, he
summarised the interactions between the healthcare team and Mr Magloire and
wrote that “some staff do not pick up on the concerns very easily, whilst others are
highly tuned into his psychosis”.
126. Later that day, the Head of Security and Intelligence chaired the ACCT review. Mr
Magloire, the prison paramedic, the prison’s imam and a prison officer attended.
The Head wrote that Mr Magloire talked about his fear of harm. He noted that the
last time Mr Magloire had been so fixated on this conspiracy, he had harmed
himself and Mr Magloire told him the feeling was “getting similar”. He kept the
ACCT open but did not think that Mr Magloire was at high risk of suicide or serious
self-harm. A further review was scheduled for 30 January and observations were
set at three conversations per hour in addition to the usual segregation
observations.
127. The prison paramedic noted that Mr Magloire told them he felt “terrible” and said,
“I've already asked God to forgive me. I hope it doesn't take too long. I know what's
coming”. She noted that Mr Magloire denied thoughts of suicide and self-harm but
said he “felt like a mouse, trapped and can't get out”.
128. That day, the Head of Segregation completed Mr Magloire’s care plan and noted
they planned to transfer him at the earliest opportunity to a long-term VPU but that
was not possible due to his parole review. He said that he would benefit from being
moved to standard location and they were looking into a phased reintegration. He
said the outcome of his forensic assessments would be integrated into his care
plan.
129. On 24 January, the Head of Segregation emailed a probation officer to ask if all
parole reports had been submitted so that Mr Magloire could be transferred. The
probation officer replied that there were no probation reports to submit but Mr
Magloire’s solicitor may need to submit his representations and the Head may need
to check with psychology services.
130. On 25 January, the psychologist recorded that there was a discussion about Mr
Magloire with the MHIRT in the SIM. It was noted that he was on an ACCT, and he
had been referred to a psychiatric hospital and put on the IPU waiting list. However,
18 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
she noted there was speculation about whether he was already on the waiting list
(he was not).
131. On 24 January, a nurse noted that Mr Magloire had refused to take olanzapine as it
was an antipsychotic, and he did not have psychosis. The nurse sent a task to the
mental health team to review him.
132. On 25 January, at the MHIRT case review meeting, it was recorded that the
psychiatrist had completed a medical review and was referring Mr Magloire to the
NHS. They said that he was to be added to the IPU waiting list and his reviews
would be increased to weekly.
133. On 26 January, a nurse reviewed Mr Magloire’s mental health care plan. She
recorded that the referral to the NHS had been done on 23 January. She concluded
his risk to self and others was low and incorrectly noted that he was not on an
ACCT as it had been closed as he had no thoughts of suicide or self-harm. (At this
point, Mr Magloire was on an ACCT.)
134. Over the next few days, Mr Magloire phoned his brother on multiple occasions to
tell him how he was going to be killed and what was being planned.
Events of 29 January 2023
135. On the morning of 29 January, officers checked on Mr Magloire at hourly intervals.
Staff noted that Mr Magloire was awake, praying in his cell. The chaplain recorded
in the ACCT document that Mr Magloire continued to talk about his anxieties.
136. At 12.40pm, a nurse saw Mr Magloire during a regular healthcare segregation
round. The nurse noted that the SO had briefed her that there were no specific
concerns about Mr Magloire. She noted no concerns about his physical or mental
health. Mr Magloire told the nurse that he was not taking his medication as he did
not have a mental illness.
137. Checks continued that day and at 4.30pm, an officer recorded that Mr Magloire was
in good spirits.
138. At 4.53pm, an officer noted that Mr Magloire had engaged with the regime and had
had a shower and medication.
139. At 8.00pm, an officer updated the ACCT record and noted that Mr Magloire raised
no issues and was a very polite prisoner.
140. At approximately 8.50pm, an Officer Support Grade (OSG) started carrying out
welfare checks. In his statement, he noted that when he reached Mr Magloire’s
door, he saw him on the floor, with a plastic bag over his head. He said he called a
code blue promptly. (This triggers the control room to call an emergency ambulance
and alerts prison staff of the incident.) A minute later, more officers arrived.
141. In his statement, Officer A said that he heard the code blue at 9.00pm and
responded immediately. He said he and Officer B were the first to arrive. He said
that they went into the cell and removed the plastic bag which was tied around Mr
Magloire’s neck. Officer A said Mr Magloire was not breathing, so he began CPR.
Prisons and Probation Ombudsman 19
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
142. Ambulance records show that the control room phoned for an ambulance at
9.01pm.
143. In his statement, a CM said that he heard the code blue and made his way to the
segregation unit. He said when he arrived, Officers A and B were already in the cell,
assisting Mr Magloire.
144. At 9.02pm, two nurses arrived with the medical emergency bags. In her statement,
one nurse recorded that she arrived within two minutes and Officer A had removed
the plastic bag. She said Mr Magloire was warm, but she could not find a pulse. She
said that they attached the defibrillator and inserted an I-gel (a tube to open the
airway) to administer oxygen.
145. The ambulance arrived at the prison at 9.10pm, but they did not reach Mr Magloire
until 9.14pm. The ambulance records noted that staff were not immediately
available to escort the crew to Mr Magloire. On arrival, the paramedics took over
resuscitation efforts. At 9.31pm, a second paramedic team arrived. Paramedics
restored Mr Magloire’s heartbeat, but he remained unconscious. He was taken by
ambulance to hospital at 10.12pm and placed on life support.
146. A paramedic told the investigator that during the medication round the next day, one
of the mental health nurses said, “He was a piece of shit anyway, doesn’t matter”
and an officer said, “Oh, do you want me to get Mr Magloire, oh, wait a minute, no I
can’t”. We were not told the name of the officer, but the Head of MHIRT told us the
nurse no longer worked at the prison.
147. On 3 February, hospital staff told healthcare staff that Mr Magloire’s life support was
going to be withdrawn. That afternoon, Mr Magloire’s brother, the Head of
Segregation and the imam visited Mr Magloire. At 4.20pm, life support was
withdrawn, and Mr Magloire died.
Contact with Mr Magloire’s family
148. At 10.35pm on 29 January, the Deputy Governor contacted Mr Magloire’s brother.
(There is no further detail about the conversation in the records.) On 30 January, a
SO was appointed as the family liaison officer, and she met Mr Magloire’s brother at
the hospital in the morning. She recorded that Mr Magloire’s brother was told that
Mr Magloire was on life support and was not expected to live. She recorded her
contact with Mr Magloire’s brother until 21 February. There are no further entries
after that date and there are no entries in the log to indicate that the prison offered
to contribute to funeral expenses.
149. The prison was unable to confirm if they had contributed to Mr Magloire’s funeral
expenses. They told the investigator that they always contribute to the funeral if the
family want them to.
Support for prisoners and staff
150. After Mr Magloire’s death, the Deputy 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. The prison
20 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
posted notices informing other prisoners of Mr Magloire’s death and offering
support. Staff reviewed all prisoners assessed as at risk of suicide or self-harm in
case they had been adversely affected by Mr Magloire’s death.
Post-mortem report
151. The hospital established that Mr Magloire died from an anoxic brain injury (a lack of
oxygen to the brain) caused by asphyxiation. The Coroner accepted the cause of
death, and a post-mortem was not completed.
Inquest into Mr Magloire’s death
152. The inquest into Mr Magloire’s death was held on 26 January 2026 and a verdict of
suicide was recorded.
153. The coroner concluded that Mr Magloire’s death was due to anoxic brain injury
caused by asphyxiation.
Prisons and Probation Ombudsman 21
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of risk of suicide and self-harm
154. Prison Service Instruction (PSI) 64/2011 on safer custody (in place at the time of Mr
Magloire’s death and since replaced by the Prison Safety Policy Framework) states
that ACCT case reviews should be multidisciplinary where possible, that a support
plan should be completed at the first review, and that it must reflect the prisoner’s
needs, level of risk and the triggers of their distress.
155. Mr Magloire had clear risk factors for suicide including a history of serious mental
health concerns, a history of self-harm and long term segregation. He was
monitored using ACCT procedures on three occasions, including at the time of his
death. We identified concerns about the quality of the ACCT. In all three ACCTs, Mr
Magloire’s care and support plans were poor and under-developed and where
actions were identified, not all of them were completed before the ACCT was
closed. There was no post-closure review completed for Mr Magloire’s first two
ACCTs, the ongoing record was not always completed in full, and the supervisor
checks were not consistently carried out. Given Mr Magloire’s presentation and
behaviour, we would have expected more input from MHIRT at his ACCT case
reviews. While the issues identified are unlikely to have contributed to Mr Magloire’s
death, we make a recommendation about ACCT later in this report.
Segregation
156. At the time of Mr Magloire’s death, he had been segregated for 83 days and the
prison had carried out ten SRBs. PSO 1700 on segregation acknowledges the risks
of holding vulnerable prisoners in segregation. It notes that rates of suicide among
segregated prisoners is high, and that segregation should only be used as a last
resort. Prisoners monitored under ACCT procedures can be segregated but only
when they are such a risk to others that no other suitable location is appropriate and
where all other options have been tried or are considered inappropriate.
157. The PSO sets out the process for a prisoner to move from segregation and the
different pathways available, which include a return to standard location, a transfer
to a VPU or to another establishment. PSO 1700 states that the SRB’s role is to
carefully consider all evidence and “all relevant issues” about extending segregation
or removing the prisoner from segregation.
158. Following Mr Magloire’s second period of segregation on 12 November 2022, there
is little evidence in the SRB paperwork that the prison was considering all Mr
Magloire’s potential pathways out of the segregation unit. A care plan should have
been created for him on 14 December, setting out how his mental health was being
supported while in segregation. This was not completed until 23 January, even
though concerns had already been raised about the impact of segregation on his
mental health.
159. We found numerous issues with the segregation paperwork, including errors and
omissions about who attended the meetings on 27 October, 17 November, 1
December 2022 and 12 January 2023. It was not recorded that Mr Magloire was in
ACCT post-closure on 14 November and the ACCT case manager was not involved
22 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
in the SRB on 1 December. While healthcare staff attended the SRBs, the MHIRT
did not once attend. Given Mr Magloire’s psychological issues, this should have
happened. We make the following recommendation:
The Governor should ensure that there are effective quality assurance
arrangements in place so that she can be satisfied that both the Prison Safety
Policy Framework (formerly PSI 64/2011) on ACCT monitoring and PSO 1700
on segregation are being followed.
Transfer to another establishment
160. When Mr Magloire was discharged from hospital, he was sent to Wormwood Scrubs
in line with HMPPS and NHS policies on the transfer and remission of adult
prisoners. These state that the patient returning to prison will return to the nearest
reception prison (unless the prisoner needs to be located in the high security
estate). Mr Magloire expressed concern about returning to Wormwood Scrubs. He
said he felt vulnerable due to the nature of his offences and that Wormwood Scrubs
did not have a VPU. OMU were made aware of this and said they would look to
move him on straight away. Mr Magloire repeatedly told staff that he wanted to be
transferred to another prison and he told staff that he had assaulted other prisoners
in order to be sent to the segregation unit.
161. We asked OMU to give us the details of all contacts or records relating to their
attempts to transfer Mr Magloire. They provided us with emails sent in October
2022, four months after Mr Magloire arrived at Wormwood Scrubs. This request
was refused by the other prison on the basis that Mr Magloire was on ‘parole hold’.
162. Following his hospitalisation in November 2022, the mental health manager emailed
colleagues about her concerns for Mr Magloire. She stated that it would be
detrimental to him if he remained at Wormwood Scrubs, and she flagged the
negative impact of someone remaining in segregation for a long period of time. The
forensic psychologist responded to say that the necessary reports (for the parole
process) could be completed at another prison, and this should not be a barrier to
Mr Magloire moving to a safer location.
163. The investigator contacted HMPPS’ Offender Flows and Configuration Team. They
told the investigator that the National Allocation Protocol states: ‘Transfers are
possible while determinate and indeterminate sentence prisoners are in a parole
review, however, they should only be pursued if it is considered to be in the best
interests of their progression and does not interfere significantly with the parole
process.’
164. The Generic Parole Process policy framework states, “prisoners may be transferred
during their Parole Board review to access a progression opportunity only in line
with their sentence plan or for security reasons”.
165. We recognise that the situation with Mr Magloire was complex, especially given his
mental health issues, his location in the segregation unit and being within the parole
window. However, we are concerned that the prison did not try to move him either
during his first four months – despite having said they would try to do so
straightaway - and more crucially, when it became obvious that the decline in his
behaviour and the deterioration in his mental health was largely attributable to his
Prisons and Probation Ombudsman 23
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
fear of remaining in Wormwood Scrubs. It is evident that the staff involved in Mr
Magloire’s care, and indeed in other prisons where transfer was explored in 2022,
all incorrectly believed that there was no option to transfer him due to his parole
review.
166. We contacted HMPPS about our concerns that prison staff were not aware that a
prisoner could be considered for a transfer in the parole window. They told us that
they had already identified that this was a knowledge gap among prison staff and
had issued guidance to all staff working in OMU and planned to issue further
communications to include other HMPPS staff. We therefore make no
recommendation.
Safety Intervention Meeting
167. PSI 64/2011 details that some prisoners supported through ACCT who have
particularly challenging needs may need to be referred to the SIM. The policy states
that when a prisoner in the segregation unit is monitored under ACCT procedures,
the case must be referred to the SIM.
168. The prison gave us copies of the five meetings in which Mr Magloire was discussed.
However, he was not discussed in three meetings between November 2022 and
February 2023, even though he was in the segregation unit, was subject to ACCT
and on two occasions, had recently harmed himself. While they discussed Mr
Magloire on 7 December 2022, the SIM did not discuss him again before he died
and, in this period, he passed the 42 days in segregation point and was nearing the
84-day point.
169. Given the complexity of Mr Magloire’s situation and the length of time he spent in
segregation, he would have benefitted from the SIM discussing his case more
regularly. We identified instances of confusion between healthcare and prison staff,
for example, about whether Mr Magloire was suitable for the IPU or if he was on the
waiting list. We therefore make the following recommendation:
The Governor should ensure that the agenda for the SIM includes
consideration of the length of time a prisoner has been segregated.
Clinical care
170. The clinical reviewer concluded that the care provided to Mr Magloire was not
equivalent to that which he could have expected to receive in the community.
171. She said that in a community setting, a person discharged from hospital would
return to their ordinary residence (where they lived before being admitted). In this
case, Mr Magloire did not return to Isle of Wight, where he had lived for many years,
and instead, was sent to Wormwood Scrubs. The clinical reviewer concluded that
healthcare could not be equivalent in this respect.
172. The clinical reviewer identified that while the mental health team were very busy
due to limited resources, she was concerned about the differences in staff
perception about the significance of Mr Magloire’s paranoid beliefs. She identified
that the absence of a therapeutic relationship with him and an allocated nurse, the
lack of a plan to identify and respond to his deteriorating mental state and the
24 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
limited support to move him to a more suitable environment meant that the care
provided was not effective.
173. The clinical reviewer said that some staff saw Mr Magloire’s behaviour as normal for
him, while others were concerned that his mental health was deteriorating. The
psychiatrist’s referral to the NHS highlighted that some staff had not identified his
concerns, while others were highly tuned to his psychosis. The prison paramedic
told the investigator that she felt that mental health staff dismissed the concerns she
raised about Mr Magloire’s mental health, and they had concluded there was
nothing wrong with him.
Inpatient unit
174. Following Mr Magloire’s discharge from hospital on 1 December when he was
described as acutely unwell and when he had symptoms of a psychotic relapse on
8 December, healthcare staff could not transfer him to the IPU as there was no
space and Mr Magloire had to remain segregated.
175. The healthcare team was unable to provide the admissions criteria for IPU and all of
the IPU waiting lists for the period under consideration. Of the four lists they
provided, Mr Magloire was not listed as needing a bed.
176. While we cannot know if a bed would have become available in time or that this
would have led to a different outcome, we are concerned that Mr Magloire was not
added to the waiting list once it was identified that he needed that level of care or
indeed prioritised for a bed given his mental state and that staff considered he could
not be transferred to another prison.
Joint working and communication
177. Good communication and liaison between prison and healthcare staff is critical and
ACCT and segregation processes need staff to work effectively together.
178. Healthcare staff did not attend Mr Magloire’s ACCT reviews on 1 and 9 December.
On 9 December, the decision was made to close the ACCT but just the day before,
the psychiatrist had concluded that Mr Magloire was still at risk of suicide and self-
harm and should be managed through the ACCT process.
179. In most instances, the prison paramedic attended the SRB meetings. While there
are advantages in having the same person attending the meetings, the discussions
focused on Mr Magloire’s psychological issues rather than his physical health. It
would therefore have been beneficial for someone from the MHIRT to have
attended these reviews.
180. Communication broke down between prison and healthcare staff about Mr
Magloire’s ACCT status. On 14 and 16 December, when a nurse noted that Mr
Magloire should continue to be managed under ACCT procedures, Mr Magloire was
either in the ACCT post-closure period or not on an ACCT at all. She was also
unaware that Mr Magloire was on an ACCT when she saw him on 26 January. We
note that the healthcare team’s operating procedure has since been revised to
ensure that the most relevant clinician always attends an ACCT. This should mean
Prisons and Probation Ombudsman 25
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
that the healthcare team will now be aware of a prisoner’s ACCT status, and we
therefore do not make a recommendation.
Action taken since Mr Magloire’s death
181. After Mr Magloire’s death, Practice Plus Group and Barnet, Enfield and Haringey
Mental Health Trust commissioned a patient safety incident investigation. They
produced a report which identified areas for improvement which were converted into
an action plan. In an update provided to the Ombudsman in November 2024, they
confirmed that all actions have been completed.
182. The investigator asked healthcare staff to provide a copy of the revised operating
procedures for healthcare’s involvement in ACCT reviews and their new
segregation policy. Staff were unable to provide a copy of their own segregation
policy and they were unclear if it existed. We therefore make the following
recommendation:
The Head of Healthcare should ensure that the segregation policy has been
developed and is implemented in line with their own action plan to include a
process for identifying the most suitable clinician to attend the Segregation
Review Board.
183. Wormwood Scrubs confirmed that following Mr Magloire’s death, all IPU referrals
are now screened and co-ordinated through multidisciplinary team meetings and
prioritisation is dynamic and based on the needs of the service user. For mental
health admissions, decisions are made between the consultant psychiatrist,
inpatient team leader and the mental health team leader and there is a process in
place for referrals made out-of-hours. The healthcare team told us that a new role of
Service Lead for Quality, Performance, Safety Transfer and Remissions has been
implemented to support the patient flow from the IPU into NHS establishments.
Governor to note
Inappropriate comments
184. A paramedic told us that a mental health nurse and an officer made highly
inappropriate, offensive and unprofessional remarks about Mr Magloire following his
death. The clinical reviewer reported this to the Head of the MHIRT at the time and
was told that the nurse had been spoken to and had since resigned. We do not
know what investigations were made into the comments allegedly made by the
officer, but we bring this to the Governor’s attention.
Response to self-harm on 29 November
185. PSI 64/2011 states that staff must be aware that the preservation of life is the first
priority when managing at-risk prisoners. Justifiable decisions on when to go into a
cell where life is endangered should be documented. However, there were three
occasions when officers were told that Mr Magloire was threatening to harm himself
with cutlery, and indeed he was able to make self-inflicted wounds requiring hospital
attention. No action was taken to remove items from him, and no record was made
to explain why the decision was made not to intervene.
26 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Family liaison and record keeping
186. The family liaison log only documented contact up to 21 February. It did not contain
any information about the payment of Mr Magloire’s funeral expenses or any
subsequent contact with his next of kin. The prison was unable to confirm if they
had made a financial contribution to the cost of Mr Magloire’s funeral but told us that
they always contributed to the cost of the funeral if a family wanted them to. The
family liaison log should have covered this.
IMB representation at SRB meetings
187. An IMB representative only attended two of the SRB meetings.
Prisons and Probation Ombudsman 27
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