Sean Higgins

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Independent investigation into
the death of Mr Sean Higgins,
a prisoner at HMP Rochester,
on 7 February 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Sean Higgins was found hanged in his cell at HMP Rochester on 7 February 2024. He
was 45 years old. I offer my condolences to Mr Higgins’ family and friends.
Staff monitored Mr Higgins using suicide and self-harm prevention procedures (known as
ACCT) from 6 to 30 January 2024. Throughout this time, he isolated himself, experienced
hallucinations and reported suicidal ideation. The procedures were poorly managed.
Despite his apparent symptoms of deteriorating mental health, there was very little input
from the mental health team. Support actions were ineffective and did not address some
significant issues. The procedures were closed prematurely, failing to consider evidence of
heightened risk of suicide and self-harm.
Prison managers have recognised deficiencies in the management of Mr Higgins’ ACCT
procedures. It is important that the Governor continues to review the operation of ACCT
procedures, to ensure that they provide effective, meaningful support to prisoners who are
at risk of suicide.
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 October 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
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Summary
Events
1. In June 2018, Mr Sean Higgins was remanded in custody for attempted grievous
bodily harm. He later received a sentence of 12 years in prison. Mr Higgins was
diagnosed with paranoid schizophrenia and, in his first year in prison, was
monitored under suicide and self-harm prevention procedures (known as ACCT) on
three occasions.
2. In January 2021, Mr Higgins was transferred to HMP Rochester. He was monitored
under ACCT procedures four times. Mr Higgins often self-isolated and had spent
time in the segregation unit due to beliefs that other prisoners were threatening him.
3. On 29 December 2023, Mr Higgins began to isolate, as he said that he was hearing
voices and believed that other prisoners were threatening him. He continued to
isolate for the remainder of his life.
4. On 6 January 2024, prison staff began ACCT monitoring when Mr Higgins tied a
ligature around the tap in his cell. On 26 January, Mr Higgins told staff that he felt
like barricading his cell and hanging himself due to the fear of other prisoners. On
30 January, staff closed the ACCT procedures.
5. On 7 February, staff did not complete morning routine checks. At around 11.40am,
officers found Mr Higgins hanged in his cell. At 12.07pm, paramedics confirmed that
Mr Higgins had died.
Findings
6. Mr Higgins’ ACCT procedures were poorly managed. There was no oversight by a
named case co-ordinator and, despite his symptoms and apparent paranoia, a lack
of input from the mental health team. Support actions did not sufficiently identify or
address Mr Higgins’ key issues. The ACCT procedures were closed when these
issues were unresolved and when there was clear evidence that his risk of suicide
and self-harm was raised.
7. Work to investigate and manage Mr Higgins’ isolation and the threats he said he
received was generic and not tailored to his issues and risk factors.
8. The clinical reviewer found that Mr Higgins’ clinical care was not of the required
standard and therefore not equivalent to that which would have been received in the
wider community. Mr Higgins’ poor compliance with his anti-psychotic and anti-
anxiety medication was not reviewed and he was not supported to take his
medication when isolating.
9. Staff falsified records when they recorded that they had carried out required checks
on the morning of 7 February.
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Recommendations
• The Governor should review the quality and compliance with policy of ACCT
management in the previous 12 months, identify any improvements required, and
devise a plan to deliver those improvements.
• The Governor should ensure that the ongoing review of the local Self-Isolation
Strategy includes that isolating prisoners are properly supported, and that staff are
trained in supporting prisoners towards ending self-isolation.
• The Governor should review the operation of CSIPs to ensure that staff are trained
in setting meaningful support actions, there are consistent CSIP/ACCT case
managers and prisoners’ concerns about their safety are properly investigated and
recorded.
• The Governor and Head of Healthcare should ensure that prison staff know when
and how to refer prisoners to the mental health team, including for prisoners
experiencing auditory hallucinations and being managed under ACCT procedures.
• The Governor and Head of Healthcare should ensure that prisoners who are not
taking or collecting their medication are identified and reviewed, and that prisoners
choosing to isolate are able to safely collect and take their medication.
• The Governor should review staff compliance with local roll check procedures and
identify any improvements to practice required.
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The Investigation Process
10. HMPPS notified us of Mr Higgins’ death on 7 February 2024.
11. The investigator issued notices to staff and prisoners at HMP Rochester informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
12. The investigator visited Rochester on 13 February 2024. She obtained copies of
relevant extracts from Mr Higgins’ prison and medical records, Rochester’s safety
and self-isolator policies, and staff statements.
13. The investigator interviewed one prisoner at Rochester on 13 February. She and an
assistant ombudsman interviewed eight staff members on 20 and 26 March.
14. NHS England commissioned a clinical reviewer to review Mr Higgins’ clinical care at
the prison. She conducted five joint interviews with the investigator on 27 March
and 8 April.
15. We informed HM Coroner for Kent and Medway of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
16. The Ombudsman’s office contacted Mr Higgins’ brother to explain the investigation
and to ask if he had any matters, he wanted us to consider. Mr Higgins’ brother said
that Mr Higgins did not receive his medication and that his mother had contacted
the prison twice (before Christmas 2023) regarding this. Mr Higgins’ family provided
copies of the correspondence Mr Higgins’ mother had sent to the prison in 2022
and 2023 which were acknowledged by the Governor and Head of Safety. HMP
Rochester responded to Mr Higgins’ mother on both occasions, providing
reassurance that Mr Higgins was being supported by staff. His brother also asked
why additional therapy that Mr Higgins had said he wanted was not available.
17. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
18. Mr Higgins’ family received a copy of the draft report. The solicitor representing Mr
Higgins’ family wrote to us expressing further information regarding the family
correspondence referred to. The report has been amended accordingly and we
have provided further clarification by way of separate correspondence to the
solicitor.
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Background Information
HMP Rochester
19. HMP Rochester is a category C resettlement prison holding adult and young male
prisoners across seven residential units. Healthcare services for prisoners are
provided by the Oxleas NHS Foundation Trust healthcare team, with an in-reach
service for mental health wellbeing.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Rochester was in October 2021 and findings
were outlined in a report published in February 2022. Inspectors reported that the
daily regime for prisoners being managed under ACCT procedures did not
adequately support well-being, and that only 22% of prisoners who had been on an
ACCT said they felt cared for. ACCT documentation was generally completed to a
reasonable standard. Inspectors also found that there was no evidence of key
workers supporting prisoners on an ACCT.
21. An independent review of progress was undertaken in September 2022, which
found that most prisoners still did not have any reliable, regular contact with a key
worker to help them address any personal well-being issues and support their
progression.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to March 2024, the IMB reported
that incidents of self-harm had increased (especially from December 2023), with
many incidents related to hopelessness or debt. The number of prisoners monitored
under ACCT arrangements was unchanged. The IMB noted that swift action by
prison staff had prevented many attempts by prisoners to take their lives.
23. The IMB also reported that levels of violence had increased, much of it gang
related, and that drug-related debt and bullying were significant elements of life at
Rochester. The IMB noted that relatively few prisoners chose to isolate themselves.
24. In their report, ‘Segregation of men with mental health needs, a thematic monitoring
report’ published in January 2024, the IMB found that prisoners with mental health
needs isolated themselves on standard prison wings. Many IMBs were concerned
that these prisoners were living in segregated conditions without the protection of
the segregation rules and the level of monitoring that would be offered in a
segregation unit.
Previous deaths at HMP Rochester
25. Mr Higgins was the fourth prisoner to die at Rochester since February 2021, and
the second man to take his own life in that time. To the end of July 2024, there have
not been any further deaths at the prison.
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26. In our investigation into the self-inflicted death of a prisoner at Rochester in 2022,
we recommended that the Governor should ensure that any concerns raised by a
prisoner about their safety are properly investigated and recorded appropriately. In
response, the prison said that all prisoners who raise a concern about their safety
will be referred to challenge, support and intervention plan (CSIP) management.
Assessment, Care in Custody and Teamwork
27. 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. 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.
28. As part of the process, support actions are put in place. The ACCT plan should not
be closed until all the actions of the support actions 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. Guidance on ACCT procedures is set out
in the Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of
harm to self, to others and from others (Safer Custody).
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Key Events
Background
29. On 4 June 2018, Mr Sean Higgins was remanded in custody to HMP Elmley,
charged with attempted grievous bodily harm. Over the following year, staff
monitored him under ACCT procedures on three occasions. (These were the only
times on which Mr Higgins was monitored under ACCT procedures before his
transfer to HMP Rochester.) Mr Higgins had a history of substance misuse and was
diagnosed with paranoid schizophrenia. On 31 May 2019, Mr Higgins received an
extended sentence of 12 years.
30. In January 2021, Mr Higgins was transferred to Rochester. During this time, he
received support from the Mental Health In-Reach Team (MHIRT). From September
2022, he was engaged with a psychologist. Mr Higgins was prescribed mirtazapine
(an antidepressant), methadone (an opiate substitute), melatonin (to treat insomnia)
and olanzapine (an anti-psychotic medication).
31. Mr Higgins often self-isolated and had spent time in the segregation unit due to
beliefs that other prisoners were threatening him. He was monitored under ACCT
procedures four times, when Mr Higgins said that he had heard voices telling him to
harm himself.
32. In November 2023, Mr Higgins did not collect his medication because he said he
was in danger from other prisoners. Staff attempted to make alternative
arrangements for him to collect his medication, however he declined.
33. On 9 November, Mr Higgins was moved to the segregation unit for his own safety
as he had reported receiving threats from other prisoners. He was referred to the
Safety Intervention Meetings (SIM, a multidisciplinary meeting of different functions
and senior managers to discuss and recommend actions to reduce risk for more
complex prisoners). Prison records show that Mr Higgins had reported these issues
sporadically since arriving at Rochester.
34. On 14 November, the psychologist discharged Mr Higgins from her care and
summarised in her discharge letter that due to Mr Higgins spending significant
periods of time in segregation or self-isolation, few psychology sessions were
conducted. She noted that Mr Higgins had completed workbooks for dialectical
behavioural therapy (DBT) during his isolation periods and that she had facilitated
appointments at his door. She praised Mr Higgins for the positive changes he had
made in his ways of thinking and coping with mood changes.
35. Later that day, a mental health nurse assessed Mr Higgins and reported that he had
felt the effects of withdrawal since stopping methadone (following his non-
attendance at the medication hatch) and that he had been hallucinating and hearing
voices.
36. During his month in the segregation unit, Mr Higgins reported experiencing
hallucinations. The mental health in-reach team assessed him and booked an
appointment with a psychiatrist, which Mr Higgins did not attend (the reason for
which was not recorded). There were no further attempts to reschedule this
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appointment and as a result, Mr Higgins was not on the active MHIRT caseload.
Towards the end of his segregation, Mr Higgins stopped reporting hallucinations,
although a mental health nurse noted symptoms of low mood.
37. On 13 December, Mr Higgins returned to a cell on a standard residential wing. On
the same day, staff completed a Challenge, Support and Intervention Plan (CSIP, a
Prison Service violence reduction tool used to identify and manage prisoners at
raised risk of harming others and to protect potential victims of violence) referral,
after Mr Higgins wrote a note specifying names of prisoners from whom he said he
was under threat due to debts.
38. On 15 December, prison staff returned Mr Higgins to the segregation unit because
he had assaulted a staff member. He began to isolate and refused all activities and
refused to attend a healthcare appointment on 18 December. (The assault was
referred to the police, who investigated but did not charge Mr Higgins.)
39. On 23 December, Mr Higgins moved to E Wing, a standard residential unit.
40. On 27 December, an unnamed custodial manager (CM) conducted a CSIP
interview with Mr Higgins following the note he had given to staff on 15 December.
The CM decided to close CSIP monitoring, as Mr Higgins had engaged with the
regime since moving to E Wing, and because there had been no issues with the
one prisoner he had previously raised concerns about on that wing.
41. On 29 December, a Supervising Officer (SO) completed a new CSIP referral and
investigation form because Mr Higgins had begun to isolate again and said that he
believed that he was under threat on E Wing. She noted that staff should create
goals that would aid in reducing Mr Higgins’ self-isolation time and work with Mr
Higgins to create a safe environment.
42. On 1 January 2024, Mr Higgins told staff that he was isolating because he was
hearing voices and his head “wasn’t in the right place”. He believed that he was
being called a “nonce” (prison slang for a sex offender). Staff recorded that a CSIP
interview with Mr Higgins took place and that he was now under full CSIP
monitoring during his self-isolation.
43. There is no record of staff conducting Mr Higgins’ scheduled medication review on 2
January. (At the time, Mr Higgins was not collecting his medication.)
44. On 5 January, healthcare staff undertook a review of Mr Higgins’ mental health care
plan (for which he was not seen in person). He later declined to attend an MHIRT
appointment.
6 – 30 January 2024
45. On 6 January, staff discovered that Mr Higgins had created a ligature and tied this
around his cold water tap. He told staff that he was in a “bad way” and was hearing
voices that were telling him to kill himself. Staff began ACCT monitoring. Mr Higgins
did not attend an MHIRT appointment in the afternoon and told staff in the evening
that he was still hearing voices.
46. On 7 January, several ACCT management actions were undertaken:
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• A SO completed an immediate action plan (IAP). Mr Higgins reported that he
felt safest when he was isolating and that he was anxious at having his door
opened, so would not meet with staff. He also said that he needed to be
referred to the MHIRT. She reported in interview that she was unsure why this
IAP was completed the day after ACCT monitoring began (rather than within
one hour of the concern form being raised, as national instructions require).
• An officer conducted Mr Higgins ACCT assessment. He stated in interview
that he was given short notice and had no time to review key information to
support this assessment. When discussing immediate actions with Mr Higgins,
the officer highlighted self-isolation, MHIRT engagement and chaplaincy within
the ACCT assessment. These actions were not recorded on the Sources of
Support section of Mr Higgins’ Care Plan. (The ACCT assessment took place
over 24 hours after Mr Higgins’ ACCT was opened, contrary to national
instructions.)
• Mr Higgins’ first case review was coordinated by the SO with the officer.
Initially Mr Higgins was reluctant to engage, and the review was conducted in
his cell. He reported that isolation helped him feel safe and his reason for
isolating was due to a breakup with his girlfriend six months ago. Healthcare
attendance is mandatory at the first case review but there was no
representative as the mental health team at Rochester are not contracted to
work on a Sunday (and no one from any other healthcare disciplines was
invited).
• A support action was set for Mr Higgins to engage with the MHIRT, and the
second case review was set for the following day (8 January) to enable MHIRT
to attend. In interview, both the SO and officer were unable to clarify what
steps were taken to refer Mr Higgins to the MHIRT or to request their
attendance at the second review. The SO reported that this is the
responsibility of the ACCT case coordinator, and that she was only covering
the review due to it being a weekend. (There was no case co-ordinator named
on the ACCT document.)
• The SO set ACCT observations at a minimum of one every half an hour until
the second review.
47. On 8 January, the scheduled second ACCT review did not take place. Mr Higgins
told staff that he was still hearing voices and they assured him that a full review,
including MHIRT, would happen the next day. The police notified the prison that
they would not be charging Mr Higgins’ with the staff assault (before Christmas) and
that this could be dealt with by way of prison adjudication.
48. On 9 January, SO A chaired the second case review. SO B attended and a nurse
provided a verbal contribution prior to the review, detailing that Mr Higgins’ current
paranoid beliefs had occurred on every wing at Rochester. SO A recorded that Mr
Higgins said that he had stopped taking some of his medication because he did not
think that it worked. No support actions were set. In interview, she reported that she
remembered making a referral to the MHIRT however there is no evidence that she
did. Mr Higgins’ observations were reduced to a minimum of one per hour.
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49. A Custodial Manager (CM) and a SO A discussed Mr Higgins at a CSIP review. SO
B spoke with Mr Higgins and noted his concerns regarding feeling under threat from
other prisoners in the CSIP document. SO B also noted that staff had been
monitoring prisoners and that there was no evidence to suggest any were gathering
at his door or behaving in a way to arouse suspicion. There was no evidence of
goals being created through the CSIP plan to help mitigate Mr Higgins’ self-
isolation.
50. On the same day, Mr Higgins’ prescription was stopped, seemingly because he had
stopped collecting his medication. The mental health team leader said that Mr
Higgins not taking his medication was not escalated to her. She told us that the
mental health team rely on colleagues highlighting and referring issues such as
medication refusal or deteriorating mental health to them when a patient is not on
their current caseload.
51. On 11 January, Mr Higgins told an officer that he was still hallucinating and hearing
voices. He said that he should be taking his medication and that he had not spoken
to his family because they could tell by the tone of his voice if he was feeling down.
The officer recorded this on his ACCT document.
52. On 16 January, the officer recorded that Mr Higgins said he wanted to see the
MHIRT. No one completed a referral.
53. SO A chaired an ACCT case review, which was attended by representatives from
the substance misuse and the safer custody teams. Mr Higgins did not want to
leave his cell and stated that he wished to move to A Wing (the incentivised
substance free living (ISFL) unit). The SO updated the support plan to include Mr
Smith’s wish to move to the ISFL unit. No additional support actions were set.
54. On 17 January, SO A told Mr Higgins that he did not fit the criteria for the ISFL unit
and encouraged him to participate in the regime in order to be considered for this in
the future. He agreed that he would come out of his cell when other isolating
prisoners did. However, following their conversation, Mr Higgins continued to
isolate.
55. On 18 January, Mr Higgins told staff that he wanted his sentence to end. He told an
officer that he was doing a bit better, but that the MHIRT did not attend his last
ACCT review.
56. On 20 January, Mr Higgins refused to attend an adjudication hearing relating to the
staff assault (that occurred before Christmas), which he said was due to hearing
voices and not being “in the right frame of mind”. He pleaded guilty to both charges.
A subsequent hearing was not set, and Mr Higgins’ adjudication was outstanding
when he died.
57. Over the following days, Mr Higgins continued to isolate and reported hearing
voices.
58. On 23 January, Mr Higgins told an officer that he had received a video-call that
morning from his family and that he “wasn’t in the right head space”.
59. On the same day, a SO chaired the fourth ACCT case review, with SO B also
present. Mr Higgins said that he was still hearing voices and refused to engage with
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the review. No one from the MHIRT was present and they did not provide any other
input.
60. A CM discussed Mr Higgins at a CSIP review. She noted that he continued to
isolate and that a transfer request was being explored as Mr Higgins could not be
located on another wing at Rochester.
61. On 24 January, a SO chaired the fifth ACCT case review, with SO B also in
attendance. Mr Higgins did not leave his cell. He reported that he was still hearing
voices and that the MHIRT had done “everything they could”. The SO told us that
she believed Mr Higgins was waiting for a psychologist appointment, but she was
unsure whether this had been scheduled and that she did not take any action to
confirm or progress any MHIRT engagement. She updated the support plan to
include the following actions: for Mr Higgins to accept the regime and report any
new problems, for him to request books from the library, and for wing managers to
look into a move to another location. She reduced the level of observations to every
three hours and meaningful conversations to one in the afternoon.
62. On 25 January, the ongoing record showed no evidence of staff having any
meaningful conversations with Mr Higgins.
63. On 26 January, Mr Higgins refused to see the chaplain and declined his evening
meal. He spoke with an officer and told him that he “couldn’t take it anymore”, and
that he was being accused by other prisoners of being a “nonce”, “snitch” and
“racist”. He told the officer that he felt like barricading his cell and hanging himself.
The officer reflected in interview that Mr Higgins calmed down but that he was very
concerned about Mr Higgins’ mental health. He recorded the conversation in the
ACCT document.
64. On 27 January, Mr Higgins told the officer that he still felt the same as the night
before, but that he no longer wished to barricade his cell and hang himself. The
officer emailed a CM, SO A, SO B and the Safer Custody team, detailing this
conversation and requesting assistance to support Mr Higgins.
65. On 29 January, the officer observed that Mr Higgins was visibly shaking and
sweating. Mr Higgins told him that he could not “get out of his head”.
66. On 30 January, Mr Higgins was discussed at a SIM, where staff noted that more
information was needed from the wing and MHIRT. The Head of Safety told us that
they were waiting for more detailed information about Mr Higgins’ ACCT and that
previously an update had been requested from wing staff, but information had not
been provided.
67. Later that morning, Mr Higgins told staff that he was not in a good way and was still
hearing voices.
68. Later that day, a CM chaired the sixth ACCT case review, which was attended by
Mr Higgins and SO A. The review was conducted through Mr Higgins’ cell door as
he refused to leave his cell. The CM’s case review notes detail that Mr Higgins was
in a low mood and was convinced that other prisoners had been shouting at him
and banging on the pipes at night, which was causing him “mental torture”. He
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reported no current thoughts of suicide or self-harm and stated that he wished to
continue to isolate. Staff closed Mr Higgins’ ACCT monitoring.
69. SO A stated in interview that the decision to end Mr Higgins’ ACCT monitoring was
made on the basis that he had not expressed suicidal ideation. She confirmed that
she had reviewed Mr Higgins’ ACCT document prior to the review. She said that
she did not know about the concerns raised by the officer in his email or in the
ACCT ongoing record. We were unable to interview the CM due to her extended
absence from work.
31 January – 6 February
70. Mr Higgins continued to isolate during this period. Staff completed his seven-day
post-closure monitoring form and reported that he continued to isolate but accepted
his meals. They variously noted that Mr Higgins was “ok”, “happy” or “quiet”. There
was no evidence on any of the days of meaningful conversations or staff
encouraging Mr Higgins to leave his cell.
71. On 4 February, CCTV of E Wing shows Mr Higgins leave his cell to empty his bin.
This is the last time he was seen outside of his cell.
72. On 6 February, SO B spoke with Mr Higgins, who again reported that prisoners had
been calling him a “nonce” and had been banging on the walls either side of his cell.
The SO asked Mr Higgins if he would like to move to a therapeutic prison and he
said he would be happy to do so. A review was set for one weeks’ time to enable
staff to contact the relevant prisons. In interview, he clarified that he was unsure if
there were already plans to move Mr Higgins, but this was something he was going
to look into.
73. At 5.12pm, staff unlocked Mr Higgins’ cell and collected his dinner plate. Around an
hour later, an officer spoke to Mr Higgins through his observation panel for less than
a minute. The officer’s entry on the ACCT post-closure monitoring form details that
Mr Higgins was watching television, had had his evening meal and had no issues or
concerns.
74. CCTV shows that Mr Higgins had no further interactions with staff members that
day.
Events of 7 February
75. Shortly after midnight, CCTV shows Mr Higgins’ switched his cell light on for around
seven minutes.
76. An officer signed that she had completed an early morning routine roll check (which
should take place between 5.00am and 6.00am and is primarily a security measure
to check prisoners are in their cells), but CCTV shows that she did not do so.
Another officer was due to complete a roll check at 7.30am, but CCTV footage
shows that this did not take place. The Governor informed the PPO that a local
investigation into these officers is ongoing.
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77. At 8.00am, an officer attended Mr Higgins’ spur to unlock prisoners who had
appointments. She stated in interview that her role was to unlock prisoners for work
and since Mr Higgins’ was self-isolating, she did not check on him.
78. At approximately 11.40am, Officer A went to serve Mr Higgins his lunch. He did not
respond when she knocked at his cell door and called out to him. She found that
she could not open Mr Higgins’ door. She looked through the observation panel, but
the cell was dark because the curtain was drawn. She could see grey material on
the floor which she thought was Mr Higgins’ legs. She was unsure whether this was
a code blue (to indicate a medical emergency when someone is not breathing) or a
barricade incident and pressed the general alarm at 11.41am.
79. Officer A turned on her body worn video camera (BWVC) and attempted to open
the door. She waved Officer B over to assist. At 11.43am, they were able to open
the cell door and found Mr Higgins hanging from a ligature, which he had tied
around the sink tap. Mr Higgins’ legs were outstretched blocking the doorway.
Officer A radioed a medical emergency code blue. Officer B cut the ligature.
Another prisoner was outside the cell and offered his assistance in carrying out
CPR. Officer B let him in, and he commenced cardiopulmonary resuscitation (CPR).
(The prisoner explained in his interview that he had recently completed CPR
training in the community.)
80. At 11.44am, the control room operator called an ambulance. The recording of the
999 call and ambulance records show that there was some confusion regarding the
reason for the call as a fight had broken out on the same wing at a similar time.
Nonetheless, an ambulance was dispatched to the prison and arrived promptly.
81. Officer B attempted to clear Mr Higgins’ airway. However, he realised that his
tongue was swollen, and his jaw was locked and purple. The prisoner continued
with CPR and Officer A gave Officer B her face shield to commence rescue breaths
in between chest compressions. Shortly after, another officer arrived and took over
chest compressions and another officer arrived with a defibrillator, which was
attached to Mr Higgins’ chest.
82. At 11.46am, healthcare staff arrived and took over the resuscitation. A nurse
requested that officers move Mr Higgins’ outside of the cell to enable more room for
the response.
83. At 12.00pm, paramedics arrived and, after assessing Mr Higgins, identified that
rigor mortis had set in. They concluded that there were no signs of life and
resuscitation efforts ceased. At 12.07pm, the paramedics confirmed that Mr Higgins
had died.
84. Mr Higgins left a note in his cell, in which he wrote that he could not carry on and
that his mental health symptoms had become too much for him to manage.
Contact with Mr Higgins’ family
85. A senior manager informed us that at the time of Mr Higgins’ death, there were no
family liaison officers (FLOs) available at Rochester because they were either
involved in the emergency response or waiting to be trained. The Head of Safety
requested regional support to provide a FLO, but none was immediately available.
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To avoid further delay, Rochester asked the police to inform Mr Higgins’ family of
his death, which they did later on 7 February.
86. On 8 February, a FLO from HMP Elmley visited Mr Higgins’ family. Rochester
contributed towards Mr Higgins’ funeral costs in line with national guidance.
Support for prisoners and staff
87. After Mr Higgins’ death, a senior manager and the Head of Healthcare 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.
88. The prison posted notices informing other prisoners of Mr Higgins’ 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 Higgins’ death.
89. The prisoner told us that he was supported by staff from a variety of disciplines. He
said that he had a good relationship with wing staff and was able to talk to them
about Mr Higgins’ death.
Post-mortem report
90. The Coroner concluded that the cause of Mr Higgins death was hanging.
Toxicology results did not identify any illicit substances.
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Findings
Managing the risk of suicide and self-harm
91. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), contains requirements for staff
using Assessment, Care in Custody and Teamwork (ACCT) procedures. Staff are
required to use ACCT when they identify that a prisoner is at risk of suicide and
self-harm, based on identified risk factors and triggers. The PSI says 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. Support actions must be tailored to meet the
individual needs of the prisoner, be aimed at reducing the prisoner’s risk to
themselves and be time-bound.
92. Mr Higgins was monitored under ACCT procedures between 6–30 January 2024.
Staff appropriately started the procedures when Mr Higgins’ was discovered with a
ligature in his cell. However, we are concerned that the procedures were very
poorly managed and did little to support Mr Higgins.
Starting ACCT monitoring
93. PSI 64/2011 requires that when ACCT procedures are started, the immediate action
plan (IAP) should be completed within one hour of the concern form being raised,
and the ACCT assessment should be conducted within 24 hours. Both Mr Higgins’
IAP and ACCT assessment were completed more than 24 hours after the
procedures were started, outside the timeline set out in policy. A SO told us that
when ACCT procedures are started, the duty manager (orderly officer) contacts a
wing manager to ask them to complete the IAP. She said that she could not
recollect why Mr Higgins’ IAP (and therefore his assessment) were completed late.
ACCT management and case review attendance
94. PSI 64/2011 instructs that a case co-ordinator must be appointed at the first case
review, who is responsible for arranging and chairing case reviews. It states that
that healthcare staff must always be invited to attend, or provide a written
contribution to, the first case review and any subsequent case reviews where they
are relevant to supporting the prisoner.
95. Mr Higgins’ ACCT procedures were not managed by a single case co-ordinator to
ensure consistency. In total, Mr Higgins’ six ACCT reviews were chaired by six
separate case co-ordinators.
96. No one from the healthcare team attended Mr Higgins’ first case review. We
appreciate that the mental health team at Rochester are not contracted to work at
the weekend, but there is no evidence that staff from other healthcare disciplines
were invited or considered. This is important as staff in other healthcare disciplines
can advise, signpost or refer as required for additional services or support. As well
as this, no one referred Mr Higgins to the mental health team despite both his
request to speak to them at the first case review and his behaviour evidencing a
potential need for referral and assessment. Mr Higgins was told that a member of
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the mental health team would attend his second case review, but this did not
happen.
97. Despite there being concerns around Mr Higgins’ mental health (including auditory
hallucinations) and his refusal to take medication, healthcare staff did not attend
any of the case reviews and there was no subsequent referral to the mental health
team. On one occasion, the MHIRT provided a verbal contribution.
98. General practice at Rochester is for healthcare staff to only attend ACCT reviews
when that individual is on their current caseload. In interview, the Head of
Healthcare and the mental health team leader stated that they did not receive any
communication from prison staff regarding Mr Higgins’ condition nor any requests
for healthcare staff to attend his ACCT reviews.
Support actions
99. PSI 64/2011 states that during case reviews, the case review team must set and
review support actions to mitigate risk. ACCT user guidance says that support
actions are one of the most important parts of the care plan. They must contain
meaningful actions with clear outcomes and owners and must identify all immediate
and longer-term risks and actions taken to mitigate them.
100. Support actions could have been set to address issues that affected Mr Higgins’
risk, including his isolation and medication concerns. Despite a support action being
set for Mr Higgins’ to engage with the MHIRT, there is no evidence to suggest that
staff made any attempt to refer or help him to engage with the MHIRT. The mental
health team leader reported that the MHIRT received no information regarding Mr
Higgins throughout his ACCT. She stated that typically support actions regarding
engagement with the MHIRT are only passed on when the MHIRT attend reviews.
101. Other support actions on Mr Higgins’ ACCT were not meaningful and supportive.
There is little evidence that staff considered the effectiveness of these support
actions at case reviews and whether anything else could be done to better support
Mr Higgins.
ACCT Closure
102. PSI 64/2011 states that an ACCT can be closed when the risk of harm has been
reduced to a level where this is no longer considered raised, and all support actions
have been completed with their intended outcome achieved. It notes that some
risks may be long term and may not be fully resolved when the decision is made to
close the ACCT, however the ACCT can still be closed if these have been
sufficiently reduced and support has been established to help the prisoner manage
these.
103. Mr Higgins’ ACCT monitoring was ended prematurely. There is no evidence that Mr
Higgins’ risk of self-harm had reduced or that his support actions had been
completed. Mr Higgins continued to isolate from the regime, had few interactions
with staff or other prisoners and had no involvement with the MHIRT despite
continuing to say that he heard voices, including just a few hours before the ACCT
procedures were closed.
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104. Mr Higgins had also expressed suicidal intent a few days before staff ended his
ACCT monitoring. An officer documented this conversation on his ACCT document
and prison record, and emailed a CM, SO A, SO B and the Safer Custody team. SO
A told us that at the final ACCT review she reviewed Mr Higgins’ ACCT document
but that she did not have knowledge of his recent suicidal ideation. She stated that
had she been made aware of this, it would have changed the decision to close Mr
Higgins ACCT monitoring that day.
105. We are satisfied that there was sufficient information provided on Mr Higgins’ ACCT
record, prison record and email communication for the CM and SO A to have been
aware of these concerns and of Mr Higgins’ ongoing issues. Closing Mr Higgins’
ACCT at this time was not in line with PSI 64/2011.
106. Following Mr Higgins’ death, the Governor conducted a disciplinary investigation
into the CM and SO A’s closure of Mr Higgins’ ACCT procedures. We have been
informed that the disciplinary investigation for the CM Meehan has concluded and
resulted in a written warning. The disciplinary investigation for SO A is ongoing.
Early Learning
107. Since Mr Higgins’ death, the Head of Safety and the Head of Healthcare have
undertaken work to improve healthcare attendance at ACCT reviews by introducing
an ACCT booking system. The Head of Safety told us that he has introduced a
singular case manager system (from 1 April) that ensures a consistent case co-
ordinator throughout the entirety of an ACCT. The Head of Healthcare highlighted in
the 72-hour review that self-isolators should have regular interactions with
healthcare staff and, to facilitate this, self-isolators will now be discussed at local
healthcare delivery meetings.
108. While we appreciate that the Head of Safety has recognised deficiencies in the
management of ACCT procedures at Rochester and taken steps to improve the
practice since Mr Higgins’ death, we are concerned by the extent of the ACCT
failures we identified. We make the following recommendation:
The Governor should review the quality and compliance with policy of ACCT
management in the previous 12 months, identify any improvements required,
and devise a plan to deliver those improvements.
CSIP and self-isolators
109. Rochester has a Self-Isolation Strategy, dated 2019, which states that CSIP should
be used to work with isolating individuals towards an agreed set of actions, to aid
them in progressing away from isolation. It says that these actions should be
meaningful and tailored to the individual.
110. PSI 64/2011 requires that where both ACCT and CSIP monitoring is in place, there
should be a single case manager. Rochester’s Safety Strategy, dated 2023-2024,
states that ACCT reviews and CSIP reviews will be completed by the same
designated case manager, and this will be measured through the quality assurance
process.
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111. Mr Higgins had regularly reported that he was isolating due to fearing for his own
safety. Staff reported in interview and in prison records that these were concerns Mr
Higgins had expressed since arriving at Rochester in 2021. However, there is very
little detail regarding the specific action taken by staff to monitor these concerns,
despite Mr Higgins sometimes providing the names of prisoners from whom he said
he was under threat.
112. While CSIP was used to manage Mr Higgins’ isolation, this was not tailored towards
his specific concerns, and included general actions such as “to engage with the
regime”. There is no evidence that staff considered exploring incremental goals to
help Mr Higgins gradually adjust to the regime. There was also no designated joint
CSIP/ACCT case manager.
113. The Head of Safety told us that Rochester’s Self-Isolation Strategy is currently
under review. He reported that he had recognised that CSIP practice at Rochester
was inconsistent and key actions identified did not always happen. SO B reported in
interview that there was little training regarding how to manage CSIPs. Despite the
local policy referencing several sources of support for self-isolators, it does not
appear that any of these were explored with Mr Higgins.
114. We make the following recommendations:
The Governor should ensure that the ongoing review of the local Self-
Isolation Strategy includes that isolating prisoners are properly supported,
and that staff are trained in supporting prisoners towards ending self-
isolation.
The Governor should review the operation of CSIPs to ensure that staff are
trained in setting meaningful support actions, there are consistent CSIP/ACCT
case managers and prisoners’ concerns about their safety are properly
investigated and recorded.
Mental health care
115. Mr Higgins had complex needs and displayed symptoms of distress in the weeks
leading up to his death. The clinical reviewer concluded that there was a lack of
insight and awareness into Mr Higgins’ risk factors of hallucinations and self-
isolation. His poor compliance with medication was not acted upon and there were
significant breakdowns in communication between prison staff and healthcare staff.
Mr Higgins’ medication was stopped without any review of the reasons why he had
stopped collecting it or any consideration of how he might be supported to continue.
116. The clinical reviewer concluded that there were several omissions and missed
opportunities to provide Mr Higgins with the support he needed and, as a result, the
clinical care he received was not equivalent to that which he would have received in
the wider community. We make the following recommendations:
The Governor and Head of Healthcare should ensure that prison staff know
when and how to refer prisoners to the mental health team, including for
prisoners experiencing auditory hallucinations and being managed under
ACCT procedures.
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The Governor and Head of Healthcare should ensure that prisoners who are
not taking or collecting their medication are identified and reviewed, and that
prisoners choosing to isolate are able to safely collect and take their
medication.
Roll checks
117. On the morning that Mr Higgins died, two members of staff failed to complete roll
checks. One staff member signed that they had completed their roll check, but
CCTV shows that they did not do so.
118. The Governor informed us that a local investigation will be conducted into these
events.
119. The Governor has also issued staff notices to remind staff of local policy and of the
importance in ensuring roll checks are carried out adequately. Nevertheless, it is
concerning that two separate staff members failed to complete roll checks and one
staff member seemingly falsified records about this issue. The Governor will wish to
ensure that this issue is not widespread and that these important checks are
conducted properly in future.
The Governor should review staff compliance with local roll check
procedures and identify any improvements to practice required.
Family liaison
120. PSI 64/2011 instructs that, wherever possible, the family liaison officer (FLO) and
another member of staff must visit in person the next of kin to break the news of the
death. It says that time is of the essence, to try to ensure that the family do not find
about the death from another source.
121. There was no FLO available at Rochester when Mr Higgins died, and none at any
of the other prisons in the region. Prison staff therefore asked the police to break
the news to Mr Higgins’ family.
122. Since Mr Higgins’ death, a regional process for requesting FLO support has been
established to prevent there being delays in appointing a FLO. Additional staff at
Rochester have also been identified to complete FLO training.
Inquest
123. The inquest of Mr Higgins’ death was opened on 16 February 2024 and concluded
on 17 February 2025. The conclusion was that there were multiple failings in the
management of Mr Higgins’ mental health and that his death was due to suicide.
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