Sheldon Jeans

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Independent investigation into
the death of Mr Sheldon Jeans,
a prisoner at HMP Guys Marsh,
on 13 November 2022
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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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 Sheldon Jeans died from a reaction to a combination of alcohol and medication which
had not been prescribed to him on 13 November 2022 at HMP Guys Marsh. He was 32
years old. I offer my condolences to Mr Jeans’ family and friends.
Mr Jeans had a history of substance misuse. While he was in prison, he was seen
regularly by the substance misuse team and warned about the risks and dangers of taking
drugs. He attended regular support sessions, and all of his eleven voluntary drug tests
were negative for illicit and non-prescribed drugs. We are satisfied that Guys Marsh did all
they could to manage the risks associated with Mr Jeans’ substance misuse.
Regrettably, as with other prisons, the trading and misuse of drugs, including prescribed
medications, remains an intractable problem at Guys Marsh. I am satisfied that the prison
is taking reasonable steps to tackle this issue.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman August 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. On 10 January 2022, Mr Sheldon Jeans was sentenced to 31 months imprisonment
for grievous bodily harm (GBH) with intent. He was sent to HMP Winchester. He
had a history of substance misuse.
2. On 28 January, Mr Jeans transferred to HMP Guys Marsh. The next day, a mental
health nurse saw Mr Jeans, referred him for bereavement counselling and added
him to the list to be discussed at the next mental health team meeting.
3. On 1 February, Mr Jeans met a substance misuse recovery worker who told him
about the risks associated with taking substances. Over the next few months, Mr
Jeans completed multiple substance misuse workbooks, attended support groups,
and engaged positively with his recovery worker.
4. On 24 May, Mr Jeans saw a psychiatrist who arranged some additional support to
help manage his mental health. A referral for therapy was sent to the psychology
team. On 9 June, a clinical psychologist saw Mr Jeans for an initial psychology
assessment. Mr Jeans was added to the waiting list for therapy.
5. On 19 September, Mr Jeans was found under the influence of an illicit substance.
The next day, Mr Jeans admitted to drinking hooch (illicitly brewed alcohol) and said
that he was struggling after the deaths of his aunt and father. Over the next few
weeks, Mr Jeans continued to engage with his recovery worker and gave two
negative voluntary drug tests.
6. On 27 October, Mr Jeans attended his Parole Board hearing (to decide whether an
individual should be released from prison). Records note this went well and the
Parole Board told Mr Jeans that he would be given the outcome of the hearing in
two weeks’ time.
7. At approximately 5.08am on 13 November, staff noticed an alarm clock going off in
Mr Jeans’ cell. They looked through the observation panel and noticed that he was
lying on his front on the cell floor, unresponsive, in a pool of blood. They radioed a
medical emergency code.
8. Staff attended, went into the cell and found that Mr Jeans was not conscious or
breathing. They started chest compressions. At 5.39am, paramedics arrived and
took over treatment. At 5.55am, a senior paramedic arrived and pronounced that Mr
Jeans was deceased. Shortly afterwards, police attended and removed a bottle
containing orange liquid from Mr Jeans’ cell. This was later tested and found to
contain 13% ethanol.
9. The pathologist concluded that Mr Jeans died from an unusual reaction to having
consumed hooch and illicit medication which had not been prescribed to him.
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Findings
10. Mr Jeans had a history of substance misuse. While he was in prison, he was seen
regularly by the substance misuse team and warned about the risks and dangers of
taking drugs. We are satisfied that Guys Marsh did all they could to manage the
risks associated with Mr Jeans’ substance misuse.
11. Mr Jeans was able to obtain hooch and illicit medication while he was at Guys
Marsh. The prison is taking proactive steps to reduce the supply of drugs and hooch
in the prison and we make no recommendation in this regard.
12. The clinical reviewer found that the care Mr Jeans received at Guys Marsh was of a
satisfactory standard and was equivalent to that which he could have expected to
receive in the community.
13. We make no recommendations.
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The Investigation Process
14. HMPPS notified us of Mr Sheldon Jeans’ death on 13 November 2022.
15. The investigator issued notices to staff and prisoners at HMP Guys Marsh informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
16. The investigator obtained copies of relevant extracts from Mr Jeans’ prison and
medical records. The CCTV was not available due to a technical issue.
17. The investigator interviewed five members of staff at Guys Marsh in March 2023. In
April 2024, the investigation was reallocated to another investigator.
18. NHS England (NHSE) commissioned a clinical reviewer to review Mr Jeans’ clinical
care at the prison.
19. We informed HM Coroner for Dorset of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
20. The Ombudsman’s office contacted Mr Jeans’ next of kin, his mother, to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked:
• Why Mr Jeans was not considered to be a vulnerable prisoner, given his
history of self-harm?
• Why were staff not regularly checking Mr Jeans?
• Why was it left to a prisoner in the cell next door to raise the alarm that
something was not right with Mr Jeans?
21. We have answered these questions within this report and in separate
correspondence to Mr Jeans’ mother.
22. Mr Jeans’ family received a copy of the draft report. They did not make any
comments.
23. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Guys Marsh
24. HMP Guys Marsh is a medium security prison. Practice Plus Group (PPG) provides
primary and secondary mental healthcare and, at the time of Mr Jeans’ death,
commissioned the Exeter Drugs Project (EDP) to provide integrated substance
misuse services. That service is now provided by Change Grow Live (CGL).
Healthcare services are available on weekdays and at weekends from 8.30am to
6.00pm and there is a doctor on duty on Saturday mornings.
HM Inspectorate of Prisons
25. The most recent inspection of HMP Guys Marsh was in July 2022. Inspectors
reported that the prison was safer than the previous inspection in 2019, but levels of
violence were still high and there was a very significant drug problem. Staff/prisoner
relationships were strong and there was a lot of individual work with prisoners and
cross-departmental working.
26. Inspectors reported that EDP clinical caseloads were high, but joint prescribing
reviews with the prisoner and psychosocial worker were frequent. Suitable harm
minimisation advice was given to new arrivals, with comprehensive psychosocial
assessments being completed within three days. Psychosocial workers had high
caseloads and although care plans were in place, they did not always have mental
health practitioner input. A key concern was the high level of illicit drugs coming into
the prison. Although security measures had improved, inspectors found that not
enough had been done to reduce supply. 45% of prisoners said it was easy to get
illicit drugs, which was higher than in similar prisons. The use of psychoactive
substances (PS) had risen sharply in 2022 and this was a critical issue for the
prison.
27. A successful NHS funding bid was supporting innovative demand reduction
initiatives and a recovery wing was being developed. There was good cooperation
with the police. Clinical management of substance misuse was good, there was a
range of psychosocial interventions, and the high number of psychoactive
substance incidents were managed well.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year 2022 to 2023, the IMB reported that
illicit items continued to be a problem at the prison. They noted that the prison was
prone to “throwovers” due to its geographical situation. Illicitly brewed alcohol
(hooch) continued to be made on a significant scale which the prison tried to detect
through searches and preventing the materials needed to manufacture it from being
available. The IMB found that body worn video camera (BWVC) use was still low,
as it had been in previous years.
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Previous deaths at HMP Guys Marsh
29. Mr Jeans was the third prisoner to die at Guys Marsh since November 2019. Of the
previous deaths, one was drug related and one was self-inflicted. We have
previously highlighted the need for all staff to wear and turn on body worn video
cameras when responding to an incident.
30. Up to May 2024, two prisoners had died since Mr Jeans. The first of these, in July
2023, was due to drug toxicity (cocaine, psychoactive substances and non-
prescribed pregabalin). The second death, which occurred in April 2024, has no
confirmed cause of death and our investigation remains ongoing.
Assessment, Care in Custody and Teamwork
31. Assessment, Care in Custody and Teamwork (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 irregular to prevent the prisoner
anticipating when they will occur. There should be regular multidisciplinary review
meetings involving the prisoner.
32. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of 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. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
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Key Events
33. Mr Sheldon Jeans had a history of self-harm, depression, anxiety and substance
misuse. He had diagnoses for attention deficit hyperactivity disorder (ADHD, a
condition that includes symptoms such as being restless and having trouble
concentrating), post-traumatic stress disorder (PTSD, a mental health condition
caused by a traumatic experience) and emotionally unstable personality disorder
(EUPD, a condition that affects how you think, feel and interact with other people).
34. In September 2021, Mr Jeans was released from prison on licence. In December,
he was recalled after he was suspected to have been violent towards his partner. A
warrant was issued for his arrest. Mr Jeans remained unlawfully at large until 7
January 2022, when he handed himself in to police.
35. On 10 January, Mr Jeans was sentenced to 31 months imprisonment for grievous
bodily harm (GBH) with intent. He was sent to HMP Winchester.
36. On 19 January, Mr Jeans cut his throat and required hospital treatment after being
told he was due to transfer to HMP Portland. Staff began Prison Service suicide and
self-harm monitoring procedures (known as ACCT) the same day. Mr Jeans said he
had cut himself to avoid transferring to Portland.
37. On 27 January, staff closed Mr Jeans’ ACCT and he was assessed as being
medically fit for transfer. The next day, he transferred to HMP Guys Marsh.
HMP Guys Marsh
38. On his arrival at Guys Marsh on 28 January, a nurse saw Mr Jeans for his initial
health screening and noted his mental health diagnoses. He told the nurse that he
did not have any thoughts of suicide or self-harm, but that he would like to be
referred to the Mental Health In-Reach Team (MHIRT) and to Exeter Drugs Project
(EDP) for substance misuse support.
39. The next day, a MHIRT nurse saw Mr Jeans to complete a triage assessment. Mr
Jeans told the nurse that he had anxiety and felt low in mood after the death of his
father in December 2021. The nurse referred him for bereavement counselling, and
he was added to the list to be discussed at the next MHIRT meeting. A nurse later
saw Mr Jeans for an initial substance misuse assessment. Mr Jeans said that he
would like help with his substance misuse issues whilst at Guys Marsh. The nurse
warned him about the dangers of taking psychoactive substances (PS) and noted
that he had a good understanding of the risks associated with substance misuse.
40. On 1 February, an EDP recovery worker saw Mr Jeans for a full substance misuse
assessment. Mr Jeans told her that he had had drug and alcohol problems since he
was a teenager and asked to complete substance misuse services (SMS)
programmes whilst at Guys Marsh. Mr Jeans recognised that his alcohol use was
related to his offending behaviour, and he said he wanted help to remain alcohol
free. The recovery worker told Mr Jeans about the risks associated with taking
substances and they agreed a recovery care plan.
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41. On 21 February, the recovery worker saw Mr Jeans who told her that he was
hoping to be released to supported accommodation in Portsmouth, where he would
attend Alcoholics Anonymous groups and be given additional support to remain
sober. She noted that Mr Jeans had completed his SMS workbooks to a high
standard.
42. On 11 March, Mr Jeans told a recovery worker that he used drugs and alcohol to
manage his emotions, specifically anxiety and depression. They discussed
alternative ways to manage his emotions and created an action plan to keep him
focused. The recovery worker gave Mr Jeans some additional recovery workbooks
to complete in his cell.
43. On 20 April, the recovery worker saw Mr Jeans for his 13-week review. She noted
that he presented well and engaged in the session. She gave him more workbooks
to complete. She noted that he had good insight into the problems alcohol had
caused him and recognised his triggers to substance misuse.
44. On 28 April, Mr Jeans attended healthcare for an appointment with a psychiatrist to
discuss a treatment plan for his ADHD. He waited for 45 minutes but left before he
was seen as he said he did not want to wait any longer (the psychiatrist was
delayed due to attending an emergency). Staff rebooked the appointment.
45. On 29 April, Mr Jeans attended his first substance misuse group session. Over the
next month, Mr Jeans attended weekly sessions in which the group discussed
multiple topics such as the dangers of poly drug use (taking multiple drugs at the
same time) and harm minimisation. The group facilitator noted that Mr Jeans always
engaged in the discussions, took part in the group activities, and gave advice to
other prisoners.
46. On 24 May, Mr Jeans attended his psychiatry appointment. The psychiatrist
arranged some additional support to help manage his mental health which included
additional gym time, access to talking therapies, and prescription of Atomoxetine
(prescribed for those with ADHD). A few days later, staff discussed him at the
MHIRT meeting due to his mental health and substance misuse issues making him
more at risk of suicide and self-harm. They agreed to urgently refer him to the
psychology team.
47. On 1 June, Mr Jeans asked healthcare staff if he could have a job within the prison
as the substance misuse representative. They said they would speak to the
activities board and let him know.
48. On 9 June, a clinical psychologist saw Mr Jeans for an initial psychology
assessment. The psychologist noted that Mr Jeans said he felt settled, had no
thoughts of suicide or self-harm and that his sleep had improved. Mr Jeans said that
he would like to be referred for therapy, so the psychologist added him to the
waiting list.
49. On 11 July, Mr Jeans was given a trusted job working as a healthcare
representative. His duties included delivering appointment slips to prisoners across
Guys Marsh.
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50. On 21 July, the recovery worker gave Mr Jeans a bronze recognition award for his
positive attitude and his continued hard work with substance misuse services.
51. On 27 July, after missing a previous appointment, Mr Jeans told the recovery
worker that he no longer wanted to engage with EDP. He was discharged but
referred himself back into their service two days later. He said he would like to
continue doing voluntary drug tests, attending group sessions and engaging with
the service.
52. On 16 August, Mr Jeans moved from Anglia wing to Mercia wing. On 24 August,
EDP held a substance misuse meeting. The prison had received information that Mr
Jeans was attempting to attend group sessions on a different wing, when he was
only permitted to attend the sessions on his own wing, Mercia. As a result, the next
day, the recovery worker saw him and challenged him on this. She reiterated that
he was only allowed to attend group sessions on Mercia, and he must not attempt
to attend groups on any other wing. He subsequently complied with this.
53. On 19 September, staff suspected that Mr Jeans was under the influence (UTI) of
hooch (illicitly brewed alcohol) while he was on the wing landing. As he became
non-compliant, staff restrained him and took him to his cell. Staff were concerned
for Mr Jeans’ welfare, so they called an emergency code, and healthcare staff
attended to assess him. Mr Jeans continued to be aggressive and healthcare staff
could not fully assess him, but he was placed on a welfare log so that staff could
monitor him. Staff submitted an intelligence report documenting the incident which
involved several prisoners on the landing.
54. The next day, the recovery worker spoke to Mr Jeans to discuss the UTI incident.
Mr Jeans admitted to drinking hooch but said he could not remember anything that
had happened. He said that he was struggling after the deaths of his aunt and
father and said that he knew that using substances was not the right way of dealing
with his grief. He said that he was now refocussing on staying sober and they
discussed the possibility of him attending the chapel for help with his grief.
55. Due to being found UTI, Mr Jeans temporarily lost his trusted position as a
healthcare representative. Staff submitted a Challenge, Support and Intervention
Plan (CSIP) referral the following week. CSIP is a process used to support and
manage prisoners who are considered to pose a risk to or be a victim from other
prisoners. Guys Marsh has incorporated the CSIP process into a local system of
enhanced case management for those with serious risk issues in relation to
substance misuse. We found no evidence that this CSIP referral was actioned.
However, as this was the first time Mr Jeans had been found UTI, and there was no
evidence to suggest that he had serious risk issues in relation to substance misuse,
we are satisfied that he did not warrant the support of a CSIP at that time.
56. Over the next few weeks, Mr Jeans continued to engage with his recovery worker
and gave two negative voluntary drug tests. His Prison Offender Manager (POM)
noted that Mr Jeans received no further negative entries in his record and that he
seemed more settled and committed to staying sober. Mr Jeans regained his
trusted position as a healthcare representative as well as his enhanced regime
status (where prisoners who have shown good behaviour have access to additional
privileges).
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57. An officer worked on Mercia wing and told us Mr Jeans was a well-known and
popular prisoner. She described him as having a bubbly personality and said that
he always seemed in a positive frame of mind. She was not aware that Mr Jeans
had any issues or concerns and thought he would have approached staff if he had.
She said Mr Jeans could look after himself and was friends with some influential
prisoners on Mercia but appeared to stay out of any conflicts.
58. On 27 October, Mr Jeans attended his parole hearing with the Parole Board. Staff
recorded that this went well. Mr Jeans’ Community Offender Manager (COM)
recommended that he was suitable to be released. The Parole Board told Mr Jeans
that he would be given the outcome of the hearing in two weeks’ time.
59. On 10 November, the COM asked the Parole Board if they had made a decision
regarding his release. The caseworker told Ms Harding that he had not heard the
outcome yet, but that he would email the relevant people to find out. The next day,
the caseworker had still not been notified of the decision. The COM noted that Mr
Jeans was feeling anxious about the outcome, but that he was being patient. The
prison did not receive notification of the outcome of Mr Jeans’ parole hearing until
after his death (his release was granted).
60. An Operational Support Grade (OSG) was working overnight on Mercia wing on
12/13 November. We were unable to interview her, as she was on long-term sick
leave. In her statement, she recorded that she saw Mr Jeans and said goodnight to
him when she did her first routine check at approximately 8.45pm on 12 November.
She was not required to check Mr Jeans again during the night.
Events of 13 November
61. There was no CCTV footage for Mercia unit on 12 or 13 November (there was a
fault in the system due a generator test some months earlier that had not been
identified), nor did staff use their BWVC to respond to the emergency when Mr
Jeans was found unresponsive. The following account is therefore taken from
prison documents, staff statements and interviews and ambulance records.
62. At approximately 5.08am on 13 November, the OSG answered a cell bell two doors
away from that of Mr Jeans. The prisoner asked what the noise was, and the OSG
could hear that a loud alarm clock was going off in Mr Jeans’ cell. She looked
through his observation panel and noticed that he was lying on his front on the cell
floor in what looked like a pool of blood. She banged on the door but did not get a
response from Mr Jeans. As she realised she did not have her radio on her, she ran
back down to collect it and on the way back up to the cell, she radioed a code red (a
medical emergency code used when a prisoner has lost a significant amount of
blood). According to the control room log, this was 5.10am.
63. A Custodial Manager (CM) and an officer immediately went to Mr Jeans’ cell,
picking up an emergency response bag on their way. The officer estimated it took
him three minutes to get there. When they got to the cell, the OSG had opened the
door (having had some difficulty breaking the seal on her emergency key pouch).
They all went into the cell together. The CM said that Mr Jeans was not conscious
or breathing, his face looked swollen, and his skin was dark in colour. The officer
relayed this to the control room and requested that they called an ambulance as
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soon as possible. Control room staff noted that they called an ambulance at
5.13am.
64. The OSG went to get a defibrillator from the wing office. The officer and CM turned
Mr Jeans onto his back. In their statements, both officers described this as being
difficult, as they said Mr Jeans limbs were stiff and they believed that he had signs
of rigor mortis. They then applied the defibrillator and started chest compressions.
65. At approximately 5.39am, paramedics arrived. Staff moved Mr Jeans onto the
landing and paramedics continued resuscitation attempts. Their notes confirm that
there were signs of rigor mortis present with Mr Jeans’ arms in a fixed position.
66. At approximately 5.55am, a senior paramedic arrived and pronounced that Mr
Jeans had died. A blanket was placed over Mr Jeans’ body for dignity purposes,
and screens were placed around him to limit the amount of people that were able to
see him. Staff later returned Mr Jeans’ body to his cell, with the agreement of senior
prison managers.
67. Police searched Mr Jeans’ cell and found a bottle which contained an orange liquid.
It was tested and found to contain 13% ethanol.
Contact with Mr Jeans’ family
68. The prison appointed a senior prison manager as family liaison officer (FLO). The
prison had received information to say that Mr Jeans’ mother had been notified of
his death via a prisoner using an illicit mobile phone. The Governor agreed that, in
the circumstances, the FLO should contact Mr Jeans' mother as soon as possible
by telephone. At 7.15am, the FLO spoke to her.
69. The FLO also attempted to contact Mr Jeans' partner because he had listed her as
his next of kin on arrival at Guys Marsh. She eventually managed to speak to Mr
Jeans' partner at 11.15am and discovered she was on holiday abroad. Mr Jeans'
partner agreed that his mother should be the point of contact for the prison. The
FLO and a prison chaplain visited Mr Jeans' mother, sister and brother at 11.50am.
70. Mr Jeans’ mother subsequently visited the prison to see her son’s cell. The prison
offered a financial contribution to Mr Jeans' funeral in line with national guidance.
Support for prisoners and staff
71. After Mr Jeans’ death, the Head of Security 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 and Trauma Risk Management
(TRiM) team also offered support.
72. The prison posted notices informing other prisoners of Mr Jeans’ death and offering
support.
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Post-mortem report
73. The post-mortem report concluded that Mr Jeans died from an idiosyncratic
response (a rare and unpredictable reaction) to a combination of alcohol and
prescription drugs.
74. The toxicology report found that alcohol, dihydrocodeine (a painkiller), mirtazapine
(an antidepressant) and pregabalin (an anticonvulsant) were present in Mr Jeans’
system at the time of his death. None of these drugs were prescribed to Mr Jeans.
The pathologist noted that all of these substances are respiratory depressants to
some degree, and each was present in either a moderate amount (alcohol) or at a
therapeutic level. All three drugs together in the presence of alcohol may have
caused a significant degree of respiratory depression in Mr Jeans. As Mr Jeans was
found face down when under the influence, the pathologist noted that partial
postural asphyxia (when an obstruction to the airway causes interference with
breathing) was a contributing factor in his death.
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Findings
Substance misuse support
75. Mr Jeans had a history of substance misuse. While he was in prison, he was seen
regularly by the SMS team and warned about the risks and dangers of taking drugs.
He attended regular support sessions, completed in-cell packs and had eleven
voluntary drug tests, all of which were negative for illicit and non-prescribed
substances. We are satisfied that Guys Marsh did all they could to manage the risks
associated with Mr Jeans’ substance misuse and support him.
Availability of illicit drugs, hooch and mobile phones
76. Mr Jeans died from an unusual reaction to hooch and illicitly obtained prescription
medication. We have considered what Guys Marsh is doing to prevent the brewing
of hooch and trading of illicit medication in the prison.
Illicit medication
77. Prescribed medications hold a value and the trading of them creates an illicit
market. These medications can either be brought into the prison illegally or obtained
from other prisoners to whom they have been prescribed. After his death, the prison
received information that Mr Jeans had told his friend the morning before he died
that he had got some hooch, pregabalin, dihydrocodeine and Subutex (an opioid
substitute used to help people stop misusing opioids) and that he intended to have
a party that evening in relation to his parole. The prison also received information to
suggest that Mr Jeans used his role as a healthcare representative to transport illicit
substances around the jail. The information did not reveal whether Mr Jeans
obtained the prescription medication from prisoners to whom it had been
legitimately prescribed, or by a throw over from outside the prison walls.
(Additionally, the toxicology results from Mr Jeans’ post-mortem examination were
not available until a year after his death. In the meantime, the prison took measures
to address PS use in the prison, assuming that his death was linked to their use.)
78. The HMPPS Drug Diagnostic Team (DDT) provide practical advice and offer
suggestions to help regional drug strategy leads and establishments develop,
implement, and embed their drug strategies. In January 2023, the DDT completed a
targeted diagnostic visit to help Guys Marsh identify knowledge gaps and good
practice. They found that medication diversion remained a constant risk, and they
recommended an immediate review of the medication queue management to
support staff and vulnerable men collecting their medication.
79. As a result, Guys Marsh reviewed the queue system and introduced a light system
for the medication hatch. There can be no more than one prisoner at the hatch at
any given time (behind a closed door), with the light on the outside turning green
when the hatch is free. Additionally, medication is administered wing by wing, with
controlled drugs being given first which limits the number of prisoners waiting in the
queue. The prescribers check the prisoners’ mouths to ensure that medication has
been swallowed, and medication held ‘in possession’ (in the prisoner’s cell) is
regularly checked and counted by healthcare staff. Finally, there is a dedicated
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officer to manage the medication queue and a substance misuse prison officer was
introduced to improve the submission of intelligence reports to support the
intelligence picture.
80. One of our investigators interviewed the temporary Deputy Governor in January
2024, about a subsequent death due to drug toxicity (including non-prescribed
pregabalin) at the prison. She said that the demand for illicit drugs was high and
that the prison’s rural location and finite resources made it more difficult to
effectively stop drugs coming into the prison. She said that drugs being thrown over
the perimeter wall and drones dropping them over were a major problem as the
prison was surrounded by open fields. She had ensured that trees and hedges had
been cut back to improve CCTV coverage and portable fences were used to fence
off areas where throw overs were coming in so that prisoners could not retrieve the
items.
81. The temporary Deputy Governor said that Guys Marsh had also introduced a code
orange radio call to be used by staff if anyone was seen attempting to throw
something over the wall. There was an agreed protocol that then followed this.
Hooch
82. We recognise that hooch can be made by prisoners using items that are readily
accessible to them in prison, and that it can be brewed in a matter of days. This
makes reducing the supply of hooch more challenging. Since the death of Mr
Jeans, Guys Marsh has taken steps to manage the control of ingredients and
equipment used to make hooch, including removing certain items from the prison
shop. They have also taken measures to improve accommodation fabric checks
and cell searches through reinforcing information and training to prison staff. Finally,
Guys Marsh continue to complete targeted cell searches upon receiving intelligence
that suggests the presence of illicit items.
83. After the death of Mr Jeans, the Governor issued a notice to prisoners stating that
there may be drugs and alcohol circulating illegally in the prison which might put
their life at risk. He reminded prisoners to speak to a member of staff if they needed
help with their substance misuse issues so that they could be signposted to an
appropriate support service.
Mobile phones
84. Staff told the investigator that a prisoner used an illicit mobile phone to record a
video of Mr Jeans’ body after he was moved out of the cell and posted it to social
media sites. We are satisfied that staff acted appropriately in following paramedics’
instructions in moving Mr Jeans. Clearly such a video being put online is both
undignified for Mr Jeans and extremely distressing for those who knew him. A
prisoner also used an illicit mobile phone to tell Mr Jeans’ mother about his death.
85. The temporary Deputy Governor acknowledged the issue of illicit mobile phones in
the prison. Guys Marsh does not have enhanced gate security which includes
additional equipment and staff to stop illicit items coming into the prison. However,
the Deputy Governor outlined the measures they are taking in searching staff,
visitors and prisoners coming into the prison when resources allowed. The prison
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was also introducing a clear bag policy which it was hoped would limit the illicit
items brought in. There were also robust measures in place for checking post and
parcels.
86. We recognise the huge challenges inherent in preventing drugs and other illicit
items entering Guys Marsh. The prison is attuned to these challenges and taking
proactive steps to try to address them. We therefore make no recommendation.
Clinical care
87. The clinical reviewer found that the care Mr Jeans received at Guys Marsh was of a
satisfactory standard and was equivalent to that which he could have expected to
receive in the community. She made two recommendations, not related to Mr
Jeans' death, which the Head of Healthcare will wish to address.
Resuscitation
88. We found that when staff found Mr Jeans unresponsive, they attempted CPR
despite noticing clear signs of death. The European Resuscitation Guidelines 2015
state that resuscitation is inappropriate when there is clear evidence that it will be
futile. We understand that staff act with the best intentions in emergencies, but they
should be reminded that they are not required to attempt or continue CPR when
there is rigor mortis or other clear signs of death.
89. Following learning from deaths in custody, the prison and PPG introduced the
custody officer immediate life support (COILS) training, to ensure a proportion of
managers were trained in emergency first aid. As part of internal learning after Mr
Jeans’ death it was identified that the night orderly officer had not received a recent
Custodial Office Immediate Life Support (COILS) refresher training session. The
prison has taken steps to ensure that COILS training is delivered to all CMs and
introduced a new protocol to ensure that a certain percentage of night staff on duty
on any given night will be COILS trained.
Availability of CCTV
90. The investigator asked Guys Marsh for CCTV footage of the events surrounding Mr
Jeans’ death. A CM is the security hub manager at Guys Marsh. Following the
death of Mr Jeans, she attended Mercia Unit in order to download and secure the
CCTV from 12/13 November. When she looked at the CCTV terminal there was an
error message displayed. She logged in and the system successfully reset,
however no footage from the previous several days was available to view or
download as the system had been offline. As a result, there was no footage of the
events surrounding Mr Jeans’ death. Engineers identified that the prison had
undertaken a generator test on 9 March that had involved the generator being
switched off and on again. This was likely what caused the CCTV to malfunction.
91. Since Mr Jeans’ death, Guys Marsh has introduced a new system to ensure that the
CCTV is working on all units. Unit supervising officers (SOs) are required to check
their CCTV is working twice a day and sign a document to that effect. We therefore
make no recommendation.
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Governor to Note
Emergency response
92. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
states that when a member of staff finds a prisoner unresponsive, they should alert
the control room of this using a medical emergency code, without delay. This is to
ensure timely, appropriate, and effective response to medical emergencies and to
maximise the likelihood of a positive outcome for the prisoner. The control room
should then automatically call an ambulance.
93. When the OSG found Mr Jeans unresponsive in his cell, she did not have her radio
on her to alert the control room. This resulted in a short delay between her finding
Mr Jeans, and her radioing an emergency code. Furthermore, control room staff did
not immediately telephone an ambulance but waited a further three minutes to do
so. As Mr Jeans was likely to have been deceased for several hours before he was
discovered, we do not consider this delay as having any impact on the outcome for
Mr Jeans. However, it may do in another situation. The Governor will want to
consider how to ensure staff are aware of the importance of always carrying their
radios and their responsibilities in a medical emergency.
Body Worn Video Cameras (BWVC)
94. Prison Service Instruction (PSI) 04/2017, Body Worn Video Cameras (BWVC),
requires prison staff to use BWVCs during any reportable incident. The PSI says
that on attending an incident involving medical intervention, BWVC users must
consider any sensitivities of the circumstances. This may involve turning their
cameras away from the incident to capture only an audio recording.
95. Staff did not turn on their BWVCs when they found Mr Jeans unresponsive. We
recognise that during an emergency event staff might forget to switch on their
cameras, but someone managing the incident should have reminded staff this was
necessary. We have also found this to be an issue in a previous investigation and
the IMB have commented on the low use of BWVCs at the prison. The Governor
will wish to ensure staff activate BWVCs when responding to an incident.
Inquest
96. The inquest into Mr Jeans’ death concluded on 23 July 2025 and found that he died
as a result of misadventure.
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