Roy Sinclair

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Roy Sinclair,
a prisoner at HMP Woodhill,
on 25 November 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 Roy Sinclair died in hospital of multi-organ failure, liver necrosis and paracetamol
toxicity on 25 November 2023 after taking an overdose of paracetamol at HMP Woodhill
on 22 November. He was 45 years old. I offer my condolences to Mr Sinclair’s family and
friends.
Mr Sinclair was the fifth prisoner to take his own life at Woodhill in three years.
Mr Sinclair had several risk factors for suicide and self-harm. He had no family support and
found himself in debt to other prisoners. Mr Sinclair chose to isolate in his cell for the
majority of his time at Woodhill. Although some of the support offered to Mr Sinclair was
good and aimed at resolving his issues, my investigation found that prison staff stopped
suicide and self-harm monitoring (known as ACCT) prematurely and before staff had
implemented a plan to manage his debt. Prison staff did not monitor how Mr Sinclair was
coping once the monitoring had ended.
The clinical reviewer concluded that the mental health care Mr Sinclair received at
Woodhill was not equivalent to what he could have expected to receive in the community.
Mental health nurses did not attend case reviews or complete an assessment after Mr
Sinclair seriously self-harmed.
Since Mr Sinclair’s death, and in response to an Urgent Notification issued by HM
Inspectorate of Prisons in August 2023, Woodhill has introduced measures to improve the
quality of ACCT management. The prison will need time to demonstrate the effectiveness
of these changes in preventing future self-inflicted deaths.
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 April 2025
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 7 February 2022, Mr Roy Sinclair was remanded to HMP Elmley, charged with
robbery and possession of an offensive weapon. He was sentenced to five years
and four months in prison on 25 April and moved to HMP Woodhill on 9 June.
2. Mr Sinclair had a history of self-harm, mental illness and substance misuse. He
completed a methadone detoxification programme in March 2023. Mr Sinclair was
prescribed anti-psychotic and antidepressant medication which he was not allowed
to keep in his cell.
3. Mr Sinclair was managed under the prison’s isolating individuals policy for the
majority of his time at Woodhill after he told prison staff that he was in debt, felt
anxious and wanted to remain in his cell. Prison staff created a debt support plan
and Mr Sinclair started paid in-cell education. In May, Mr Sinclair told staff he was
no longer in debt.
4. From 13 October 2023, prison staff managed Mr Sinclair under Prison Service
suicide and self-harm prevention measures (known as ACCT) after he told them
that he had taken an overdose of paracetamol because he felt anxious. On 15
October, Mr Sinclair made cuts to his wrists and was taken to hospital. He returned
to Woodhill on 23 October.
5. On 7 November, Mr Sinclair told the case review team that he was in debt again.
Safer custody staff agreed to give Mr Sinclair an advance to repay his debt and
support his application for employment. Prison staff decided to continue ACCT
monitoring because of Mr Sinclair’s outstanding issue with debt.
6. At a case review on 15 November, staff stopped ACCT monitoring because Mr
Sinclair did not have any current thoughts of suicide and self-harm. Mr Sinclair told
the case review team that he still had an outstanding issue with debt. Prison staff
did not complete the seven day post-closure monitoring form.
7. At around 1.57pm on 22 November, a prison officer went to Mr Sinclair’s cell after
he rang his cell bell. He told the officer that he had taken an overdose of
paracetamol. Prison staff started ACCT monitoring. A nurse assessed Mr Sinclair
and as staff were concerned about damage to his liver, Mr Sinclair went to hospital
for further assessment.
8. Mr Sinclair’s condition deteriorated in hospital, and he died at 9.00am on 25
November.
Findings
9. Mr Sinclair had several risk factors for suicide and self-harm. We found that ACCT
procedures provided him with some support. Mr Sinclair’s care plan did not refer to
his poor mental health or substance misuse, despite him taking an overdose of non-
prescribed medication.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
10. We found that in some respects, the support offered to Mr Sinclair through the
ACCT process was good and clearly aimed at resolving his issues, staff were too
quick to conclude that Mr Sinclair was not at risk and ended support procedures
prematurely. This was despite Mr Sinclair making the case review team aware that
his issues with debt were not resolved. Prison staff did not complete the seven day
monitoring form or make any entries in his prison record related to his welfare or
risk.
11. We are satisfied that since Mr Sinclair’s death, the prison has taken necessary
steps to improve the management of ACCT procedures.
12. The clinical reviewer concluded that Mr Sinclair’s mental health care was not
equivalent to what he could have expected to receive in the community. As Mr
Sinclair was unwilling to engage, he was not on the mental health team caseload
which meant that a mental health nurse did not attend case reviews. When Mr
Sinclair returned from hospital after a serious incident of self-harm, he was not
assessed by a mental health nurse.
13. Since Mr Sinclair’s death, the prison has issued an instruction which sets out the
immediate steps that staff must take if a prisoner is under the influence of illicit
substances or if they inform staff that they have taken an overdose. The prison has
also amended the local security strategy to ensure that staff are aware when a cell
search must take place and the procedure for sharing intelligence with security.
14. In June 2024, the prison implemented a debt management strategy to identify,
manage and support prisoners that are in debt. This includes a designated custodial
manager in the safer custody team with responsibility for monitoring the
effectiveness of the policy in reducing and managing custodial debt.
Recommendations
• The Head of Healthcare should review the contribution to the ACCT process from
mental health nurses for prisoners who have seriously self-harmed, including those
not on the mental health team’s caseload.
• The Head of Healthcare should investigate why a mental health nurse did not
assess Mr Sinclair when he returned from hospital after a serious incident of self-
harm.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
15. HMPPS notified us of Mr Sinclair’s death on 27 November 2023.
16. The investigator issued notices to staff and prisoners at HMP Woodhill informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
17. The investigator visited Woodhill on 15 December. She obtained copies of relevant
extracts from Mr Sinclair’s prison and medical records and viewed CCTV footage
and body worn camera footage. She also obtained the HMPPS Early Learning
Review.
18. NHS England commissioned a clinical reviewer to review Mr Sinclair’s clinical care
at the prison.
19. The investigator interviewed 11 members of staff at Woodhill between February and
April 2024. She and the clinical reviewer jointly interviewed healthcare staff.
20. We informed HM Coroner for Milton Keynes of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
21. The Ombudsman’s office wrote to Mr Sinclair’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not ask any
questions but asked for a copy of the report.
22. We shared the initial report with Mr Sinclair’s family. They did not make any
comments.
23. We also shared the initial report with HM Prison and Probation Service (HMPPS).
Central and Northwest London NHS Foundation Trust pointed out some factual
inaccuracies, and we have amended the clinical review accordingly.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Woodhill
24. HMP Woodhill is a relatively modern prison in Milton Keynes. In addition to its role
as a category B training prison, it holds several category A prisoners on remand
and operates several specialist units, making it a complex and high-risk institution.
Central and North-West London NHS Foundation Trust provides physical and
mental health services.
HM Inspectorate of Prisons
25. The most recent inspection of HMP Woodhill was in August 2023. Following the
inspection, the Chief Inspector of Prisons invoked the Urgent Notification (UN)
process because he was so concerned about conditions there. (The Urgent
Notification process allows His Majesty's Chief Inspector of Prisons to directly alert
the Lord Chancellor and Secretary of State for Justice if he has an urgent and
significant concern about the performance of a prison.) He noted that none of the
recommendations from the 2021 inspection had been achieved and many poor
outcomes previously identified had worsened in some important areas, particularly
with regard to safety. Despite this, there were many excellent, dedicated staff in the
prison who were doing their best to support the prisoners in their care. The issues
highlighted included:
• Prisoners were self-isolating in their cells in fear for their safety and the prison
had the highest rate of serious assaults against staff.
• Reported incidents of violence had risen sharply and use of force against
prisoners was amongst the highest in the adult male estate.
• The rate of reported self-harm was the highest in the adult male estate, there
had been 829 incidents of self-harm involving 124 prisoners.
• Illicit drug use was a serious problem.
• Staff were relatively inexperienced and lacked the confidence to challenge poor
behaviour. A chronic shortage of prison officers remained at the crux of the
prison’s difficulties.
26. Despite efforts by the safer custody team to upskill staff, there were frailties in the
ACCT process and quality assurance was absent or ineffective. Inconsistent case
management was a source of frustration for those in crisis and, if completed at all,
individual care plans often lacked proper focus. Observations were not always
conducted at the required frequency and interactions were often transactional.
Independent Monitoring Board
27. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to November 2023, the IMB
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
reported that the quality of the comments and interactions with men managed under
the ACCT process varied widely. Some comments showed a clear understanding
and concern for the men in their care, whilst others could best be described as
satisfying the requirements to fill in the paperwork. The Board was concerned that
there was no consistency of staff attending ACCT reviews.
Previous deaths at HMP Woodhill
28. Mr Sinclair was the eighth prisoner to die at Woodhill since November 2020, and
the fifth self-inflicted death. Up to the end of June 2024, there has been one death
at Woodhill since Mr Sinclair’s death, the cause of which has not yet been
established.
29. As a result of these self-inflicted deaths and the Urgent Notification issued by HMIP,
Woodhill is receiving additional support and monitoring from HMPPS regional and
national safety teams.
Assessment, Care in Custody and Teamwork
30. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011. After an initial assessment of the prisoner’s main concerns, levels of
supervision and interactions are set according to the perceived risk of harm. Checks
should be irregular to prevent the prisoner anticipating when they will occur. There
should be regular multidisciplinary review meetings involving the prisoner.
31. As part of the process, a care plan (plan of care, support and intervention) is put in
place. The ACCT should not be closed until all the actions on the care plan have
been completed. All decisions made as part of the ACCT process and any relevant
observations about the prisoner should be written in the ACCT booklet, which
accompanies the prisoner as they move around the prison.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
32. On 7 February 2022, Mr Roy Sinclair was remanded to HMP Elmley. On 25 April,
he was sentenced to five years and four months in prison for robbery and
possession of an offensive weapon. Mr Sinclair transferred to HMP Woodhill on 9
June.
33. Mr Sinclair had a long history of offending and had spent most of his adult life in
prison. He had no family contact and did not make any telephone calls or have any
visitors during his time at Woodhill.
34. Before he moved to Woodhill, Mr Sinclair was managed under Prison Service
suicide and self-harm prevention measures (known as ACCT) on 20 occasions after
making cuts (recorded as superficial) and expressing suicidal thoughts.
HMP Woodhill
35. When he arrived at Woodhill, a prison officer completed Mr Sinclair’s first night
induction interview. He noted that Mr Sinclair engaged well and was aware of the
support available to him. Mr Sinclair told staff he was not in debt. He had last self-
harmed over a year ago and said he did not have any current thoughts of suicide
and self-harm. Prison staff completed a cell sharing risk assessment (CSRA,
assesses a prisoner’s suitability to share a cell). This recorded that Mr Sinclair was
not suitable to share a cell due to previous incidents of violence against other
prisoners.
36. A reception nurse noted Mr Sinclair’s previous history of substance misuse and
poor mental health. He was diagnosed with paranoid schizophrenia (a mental
health condition where people experience things that are not real and may hear or
see things that others cannot see or hear) in October 2017. Mr Sinclair was
prescribed anti-psychotic and antidepressant medication which he was not allowed
to keep in his cell. The nurse referred him to the substance misuse service (SMS)
and mental health team.
37. A SMS recovery worker saw Mr Sinclair on 10 June. He agreed to start a
methadone detoxification programme, which he completed in March 2023. Mr
Sinclair was discharged from the SMS on 3 May.
38. On 12 June, a mental health nurse completed a mental health assessment and did
not record any concerns. He created a mental health care plan on 19 June. This
noted Mr Sinclair’s substance misuse, mental health and self-harm history. Mr
Sinclair did not express any concerns about his prescribed medication. A GP at the
prison completed monthly medication reviews.
39. Between July 2022 and March 2023, prison staff monitored Mr Sinclair under the
prison’s self-isolation strategy (designed to monitor and support prisoners who
withdraw from other prisoners and the prison regime). Mr Sinclair told staff he had
borrowed vapes from other prisoners and was in debt but would not provide any
information about the amount of money he owed. Safer custody staff created an
isolating individuals plan which included a debt support plan. The plan said that Mr
Sinclair should start paid in-cell education to enable him to make payments towards
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
his debt and to complete the money management workbook. Staff also gave him
workbooks to manage his anxiety. Safer custody staff completed regular welfare
checks and houseblock staff completed a residential monitoring plan. Mr Sinclair
said he did not have any current thoughts of suicide and self-harm and he did not
need extra support. Staff discussed Mr Sinclair at the monthly self-isolators multi-
disciplinary team (MDT) meeting and safety intervention meeting (SIM - a meeting
to discuss prisoners with complex needs). The MDT noted that Mr Sinclair
experienced anxiety and paranoia and had received support from the SMS and
mental health team. There was no security intelligence to suggest that Mr Sinclair
was under threat from other prisoners.
40. On 18 April 2023, a GP at the prison saw Mr Sinclair because his anxiety had
increased. Mr Sinclair said that he coped with his anxiety by isolating in his cell and
asked for medication to manage it. The GP decided that Mr Sinclair did not need
medication and could benefit from anxiety management therapy. The mental health
MDT discussed Mr Sinclair on 20 April and referred him for a psychology
assessment. This did not take place before Mr Sinclair died.
41. On 3 May, prison staff created Mr Sinclair’s personal learning plan. This said that he
had no formal education and limited employment experience. Staff decided that he
should continue with education and find suitable employment once his English and
maths had improved.
42. On 11 May, Mr Sinclair started isolating in his cell again. Prison staff provided a
money management workbook and in-cell education. During a welfare check, Mr
Sinclair told the mental health team that he did not have any current thoughts of
suicide and self-harm and he did not need any support. He told the safer custody
team that he was not in debt and preferred to remain in his cell because it made
him feel less anxious.
43. Staff continued to discuss Mr Sinclair at the monthly self-isolators MDT and noted
that he had agreed to continue with in-cell education. He declined a move to
another house block and said he wanted a transfer to another prison. Records show
that the Offender, Categorisation and Assessment (OCA) unit contacted several
prisons about a transfer for Mr Sinclair, but they were unable to accept him because
he did not meet their allocation criteria.
44. On 8 and 17 September, healthcare staff gave Mr Sinclair two paracetamol after he
complained of toothache. He was prescribed two paracetamol again on 18
September and 1 October for back pain. On each occasion he received the
medication from the medications hatch dispensary. The medication is dispensed in
a clear cup and prisoners are required to drink 200mls of water (also from a clear
cup) after. A prison officer is always in attendance at the medication hatch to ensure
no medication is passed to other prisoners. Prisoners who are allowed to keep their
medication in their cells are prescribed a maximum of 16 tablets. Paracetamol is not
available to purchase on the prison’s canteen (shop) list.
45. Mr Sinclair did not attend a GP appointment to discuss his back pain on 11 October.
46. On 12 October, Mr Sinclair agreed to move to houseblock 2. Prison staff noted that
he did not have any concerns and knew how to seek support. That day, he declined
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
support from the mental health team. Mr Sinclair packed his own possessions
before he moved cells.
47. At around 10.45pm on 13 October, prison staff started ACCT monitoring after Mr
Sinclair said he had taken an overdose of 80 paracetamol tablets. A nurse
examined Mr Sinclair and recorded that his observations were normal, he looked
well and did not have abdominal pain. She told Mr Sinclair he would need a blood
test after 2.00am, to determine the level of paracetamol in his body. Mr Sinclair said
that he had concealed paracetamol in his cell, and he felt depressed. Staff decided
that they should monitor him five times during the night. When the nurse returned to
Mr Sinclair’s cell, he refused to have a blood test. Staff did not submit a security
information report (SIR) or search Mr Sinclair’s cell after he reported taking an
overdose and there was no investigation into how he obtained the paracetamol.
48. On 14 October, Mr Sinclair told a case review that he felt stressed about life. He
agreed to be referred to the mental health team. Mr Sinclair denied any thoughts of
suicide and self-harm. A Custodial Manager (CM) was allocated the role as case
manager. He added one action to Mr Sinclair’s caremap (designed to identify the
main areas of concern and the actions required to reduce risk), which said that he
should engage with prison staff to enable him to stop isolating. The CM assessed
Mr Sinclair’s risk of suicide and self-harm as raised and decided he should be
monitored twice an hour during the day and five times during the night. That day, a
nurse saw Mr Sinclair after he complained of abdominal pains. His observations
were normal. and he was advised to drink plenty of fluids. Mr Sinclair refused to
have a blood test. Healthcare staff observed Mr Sinclair during the night and did not
record any concerns.
49. At around 5.13am on 15 October, prison staff completing an ACCT check saw that
Mr Sinclair had made cuts to both wrists. An officer radioed an emergency code red
(which indicated that Mr Sinclair was bleeding) and the control room called an
ambulance. A nurse immediately responded and noted that he was pale, clammy
and cold to touch. Mr Sinclair had lost around 500mls of blood. Paramedics arrived
and took Mr Sinclair to hospital. He remained in hospital until 23 October.
50. A nurse saw Mr Sinclair when he returned to Woodhill and noted that hospital
doctors had prescribed him diazepam for three days when he was discharged. The
same day, Mr Sinclair told a case review that he had no current thoughts of suicide
and self-harm. Staff decided that they should monitor him once an hour and five
times during the night.
51. On 24 October, the case manager held a case review. Mr Sinclair said that he felt
stressed about life and had taken the paracetamol because he wanted to feel
sedated. He refused to provide any information about how he had obtained the
paracetamol. Mr Sinclair did not want to complete in-cell education and enjoyed
listening to his radio and watching television. He denied any current thoughts of
suicide and self-harm. The case manager decided to keep his observations
unchanged to ensure support remained in place. Mr Sinclair told staff that he was
no longer isolating.
52. On 25 October, a mental health practitioner completed a welfare check. Mr Sinclair
said that he felt better now he was taking diazepam and did not want mental health
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
support. The mental health practitioner did not record her interaction with Mr
Sinclair on the ACCT document.
53. On 27 October, Mr Sinclair told a nurse that he felt anxious and was not in the right
state of mind. The nurse gave Mr Sinclair diazepam for a further three days. There
is no record that he referred Mr Sinclair to the mental health team.
54. The case manager held a case review on 30 October. Mr Sinclair said that he felt
better, and the diazepam had calmed him down. He said he had no current
thoughts of suicide and self-harm. Mr Sinclair said he was sleeping well. The case
manager reduced Mr Sinclair’s observations to one conversation during the morning
and afternoon and three observations during the night.
55. On 7 November, Mr Sinclair told a case review that he was feeling much better and
had no current thoughts of suicide and self-harm. He was associating with other
prisoners on the houseblock, taking his medication and staff did not have any
concerns. The case manager noted that prisoners had given Mr Sinclair three
boxes of vapes and he was now unable to pay for them. Safer custody staff agreed
to provide Mr Sinclair with an advance to repay his debt and, as he was no longer
isolating, staff would support his application for employment. This would enable Mr
Sinclair to earn money to repay his debt. The case manager added one action to Mr
Sinclair’s caremap, which said that the safer custody team were creating a debt
management plan. He also gave Mr Sinclair a journal to record how he was feeling
and said he would be paid if he completed it. He noted that staff should continue
with ACCT monitoring because of Mr Sinclair’s outstanding issue with debt and to
ensure that his mood did not deteriorate.
56. On 8 November, a healthcare MDT meeting discussed Mr Sinclair and noted that
staff should continue to offer him support on the wing.
57. On 13 November, Mr Sinclair told a prison GP that he had difficulty sleeping and
complained of general aches and pains. As the GP was cautious not to prescribe
painkillers due to Mr Sinclair’s history of overdose, he prescribed promethazine (a
sedative).
58. On 15 November, a Supervising Officer (SO) held a case review with a nurse. Mr
Sinclair presented well and did not have any current thoughts of suicide and self-
harm. He told the SO that he still had an outstanding issue with debt for vape boxes
and the safer custody team were creating a debt management plan. The SO said
he would look into this. He and the nurse agreed to stop ACCT monitoring. They
assessed Mr Sinclair’s risk as low and considered that the actions on his caremap
were complete. The post-closure phase would end on 22 November. Prison staff
did not complete the seven day post-closure monitoring form or make any entries in
Mr Sinclair’s prison record about his welfare or risk of suicide and self-harm over
the next week.
59. On 17 November, Mr Sinclair made an application for employment in the prison
laundry, supported by his case manager.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Events of 22 November
60. On 22 November, the employment board approved Mr Sinclair’s application for
employment and noted that he would start work in the prison laundry on 27
November.
61. At around 1.57pm, Mr Sinclair pressed his cell bell, and an officer went to his cell.
Mr Sinclair said that he had taken an overdose of 75 paracetamol. The officer asked
a SO to come to Mr Sinclair’s cell. Mr Sinclair said that he wanted to die because
his family were all dead. In a written statement, the officer said that Mr Sinclair
appeared emotionless and did not show any signs of being in pain. She looked
around the cell and did not see any medication or illicit substances. As a nurse was
dispensing medication on the houseblock, the SO asked her to examine Mr Sinclair
in his cell. Prison staff started ACCT monitoring again and decided that staff should
monitor Mr Sinclair twice an hour. Staff did not submit an SIR or search Mr
Sinclair’s cell after he reported the overdose.
62. The nurse noted that Mr Sinclair was alert and sitting on his bed. He appeared well
but complained of feeling dizzy. She recorded Mr Sinclair’s national warning score
(NEWS - a tool used to assess illness severity and the risk of deterioration) as 1
(low risk). She sought advice from TOXBASE (the clinical toxicology database,
providing advice on the management of poisoned patients), who said that staff
should continue to monitor Mr Sinclair for signs of deterioration. At around 3.12pm,
another nurse and a CM decided that due to the level of concern about liver
damage, Mr Sinclair needed further examination at hospital. Two prison officers
went with Mr Sinclair and used an escort chain (a long chain with a handcuff at
each end, one end is attached to the prisoner and the other to an officer).
63. Mr Sinclair deteriorated in hospital, and he died at 9.00am on 25 November.
Contact with Mr Sinclair’s family
64. When Mr Sinclair went to hospital on 22 November, the prison appointed a family
liaison officer (FLO). As Mr Sinclair did not have any contact with his family, the
FLO asked the police for assistance. After Mr Sinclair died, police enquiries found
contact details for Mr Sinclair’s half-sister. The police visited her on 27 November
and broke the news of Mr Sinclair’s death. That day, the FLO spoke to Mr Sinclair’s
half-sister on the telephone and offered support.
65. The prison arranged and paid for Mr Sinclair’s funeral in line with national policy.
Support for prisoners and staff
66. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
67. After Mr Sinclair’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.
68. The prison posted notices informing other prisoners of Mr Sinclair’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 Sinclair’s death.
69. Safer custody staff gave prison listeners and the wing manager postvention leaflets
to share with prisoners and staff.
Post-mortem report
70. The post-mortem report concluded that Mr Sinclair died from multi-organ failure,
liver necrosis and paracetamol toxicity. The pathologist said that a previous
paracetamol overdose in October 2023, had damaged Mr Sinclair’s liver and led to
multi-organ failure.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of Mr Sinclair’s risk
71. Mr Sinclair had a number of risk factors that increased his risk of suicide and self-
harm. He had a previous history of self-harm, mental illness and substance misuse.
Mr Sinclair chose to withdraw from the prison regime for the majority of his time at
Woodhill, he had no support from friends or family, made no phone calls and
received no visits.
72. Mr Sinclair was supported by ACCT procedures after he told staff he had taken an
overdose of paracetamol on 13 October. We consider that the ACCT procedures
provided some support to Mr Sinclair. His ACCT case manager held regular case
reviews which appropriately assessed his risk. Prison staff added actions to Mr
Sinclair’s caremap which reflected that he was isolating and was struggling with
debt. However, Mr Sinclair’s caremap did not refer to his poor mental health or
substance misuse issues, despite him taking an overdose and obtaining medication
that he was not prescribed.
73. We consider that the ACCT was closed prematurely and before a significant action
on the caremap was complete, despite Mr Sinclair telling the case review team that
the issue related to debt was still outstanding. The ACCT was closed by a member
of prison staff who was not Mr Sinclair’s case manager and who had limited
knowledge of his support needs. Safer custody staff had not implemented the debt
management plan and Mr Sinclair had not started work, both issues that were
causing Mr Sinclair anxiety.
74. Mr Sinclair was in the post-closure phase of ACCT monitoring when he took a
second overdose. Staff did not complete the post-closure monitoring form and there
were no entries on his prison record during the post-closure phase. This meant that
staff did not assess how Mr Sinclair was coping without support or monitor if his risk
was increasing.
75. Since Mr Sinclair’s death, Woodhill has introduced various measures to improve the
quality of ACCT management, including additional staff in the safer custody team,
quality assurance and additional case management training for operational staff.
HMPPS has provided more extensive guidance and resources to support the safer
custody team. Keywork (which provides prisoners with an allocated officer that they
can meet regularly to discuss how they are and any day-to-day issues they would
like to address) has also been reintroduced, initially targeted at the most vulnerable
prisoners, including those in the induction unit and prisoners subject to ACCT
monitoring. We appreciate that the prison will need time to demonstrate the
effectiveness of these supportive measures, we therefore make no
recommendation.
Mental health
76. The clinical reviewer concluded that Mr Sinclair’s mental health care was not
equivalent to what he could have expected to receive in the community. Mr Sinclair
had a diagnosis of paranoid schizophrenia and was prescribed an antipsychotic
medication. A mental health nurse created a mental health care plan shortly after he
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
arrived at Woodhill, but this was not implemented or reviewed. As Mr Sinclair
regularly told mental health nurses that he did not need their support he was
discharged from their care. A mental health nurse did not attend case reviews and
there was no discussion about how his poor mental health may have contributed to
his decision to self-harm. In addition, the lack of input from the mental health team
into the ACCT process meant that Mr Sinclair was not offered mental health support
after serious incidents of self-harm. We recommend:
The Head of Healthcare should review the contribution to the ACCT process
from mental health nurses for prisoners who have seriously self-harmed,
including those not on the mental health team’s caseload.
77. When Mr Sinclair returned from hospital on 22 October after a serious incident of
self-harm, he was not assessed by a mental health nurse. The assistant practitioner
who saw Mr Sinclair did not record her assessment on Mr Sinclair’s ACCT
management plan to ensure that the case review team had the necessary
information to appropriately assess his risk. We recommend:
The Head of Healthcare should investigate why a mental health nurse did not
assess Mr Sinclair when he returned from hospital after a serious incident of
self-harm.
Under the influence policy
78. Mr Sinclair was able to take an overdose of a significant amount of paracetamol on
two occasions despite being assessed as unsuitable to have medication in his cell.
He told staff he had hidden the medication in his cell but did not provide any
information about how he managed to obtain it. The investigation found that staff
did not submit a SIR after he told staff he had taken the first overdose shortly after
he moved cells and they did not investigate how he had obtained such a large
quantity of paracetamol. This meant that the security team did not search his cell or
investigate how he had obtained the medication. The Head of Security told the
investigator that at the time of Mr Sinclair’s death, Woodhill did not have a specific
‘under the influence’ instruction to staff. We have not uncovered any evidence to
indicate where Mr Sinclair obtained the paracetamol.
79. On 8 May 2024, the Governor issued a notice to staff to ensure they were aware of
the immediate steps that they must take if a prisoner is suspected of being under
the influence of illicit substances or if they inform staff that they have taken an
overdose. This includes completing welfare checks every 15 minutes in addition to
ACCT checks, recording the incident in the unit observation book, prison record and
submitting a SIR. Staff should also ensure that healthcare staff make appropriate
referrals to the SMS and mental health team.
80. On 21 May, Woodhill amended their local security strategy on searching techniques
and cell searches. This states that on discovery of a prisoner who is under the
influence, staff must conduct a cell search immediately or as soon as it is safe to do
so. Staff must make the security team aware of the outcome of the search.
Prisoners who staff suspect are under the influence or who are obtaining
medication illicitly will also be subject to intelligence led searches.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
81. We are satisfied that since Mr Sinclair’s death, Woodhill has put in place an
appropriate under the influence instruction and cell searching strategy.
Self-isolation strategy
82. Woodhill’s Isolating Individuals Strategy (updated in July 2023) says that prisoners
identified as self-isolating for longer than 72 hours should be referred to the safer
custody team and entered on the challenge, support and intervention plan database
(a process used to manage difficult prisoners and victims of violence or threat).
Prisoners who are confirmed as self-isolating should be allocated a liaison from
safer custody to understand why they are isolating, to seek a solution and signpost
to other support.
83. Mr Sinclair was first identified as self-isolating in July 2022, when he told prison staff
that he wanted to remain locked in his cell because he was in debt to other
prisoners. A prison officer completed an isolating individuals referral form. Safer
custody allocated a prison officer as Mr Sinclair’s safer custody liaison officer to
ensure that Mr Sinclair was appropriately monitored while he was self-isolating.
Staff discussed Mr Sinclair at the monthly self-isolators meeting and safety
intervention meeting.
84. Safer custody staff spoke to Mr Sinclair to investigate why he did not want to
participate in the normal wing regime and to ensure Mr Sinclair understood the self-
isolator regime. Mr Sinclair was reminded of the support available from Listeners
and the Samaritans. Mr Sinclair continued to receive support from the safer custody
team and staff explored a transfer to another prison. Mr Sinclair agreed to move to
another houseblock and was not isolating when he died.
85. We are satisfied that prison staff took appropriate action when Mr Sinclair was
identified as self-isolating.
Management of Mr Sinclair’s debt
86. When Mr Sinclair told prison staff he was in debt they created a debt management
plan and provided money management workbooks. Mr Sinclair’s debt management
plan identified that he was unable to pay for vapes because he had had no family
support and needed to earn money. Staff created an individual learning plan to
support Mr Sinclair with completing paid in-cell education while he was isolating and
to improve his employment prospects.
87. At the time of Mr Sinclair’s death, Woodhill did not have a specific debt
management policy. Prisoners in debt were managed under the prison’s Isolating
Individuals Strategy.
88. In June 2024, the prison implemented a debt management strategy which includes
a designated CM in the safer custody team with responsibility for overseeing the
actions that safer custody staff must take when a prisoner is in debt. The strategy
enables prison staff to understand why prisoners get into debt, to prevent it
happening and to respond appropriately to prisoners who are in debt. It provides
specific guidance to ensure staff effectively manage prisoners who are in debt and
to support collaborative working with prisoners to prevent future debt.
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
89. We are satisfied that Woodhill has an appropriate strategy to manage and support
prisoners who are in debt.
Inquest
90. At the Inquest held between 16 and 19 March 2026, a jury returned a verdict of
misadventure.
Prisons and Probation Ombudsman 15
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