Simon Dunn

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Independent investigation into
the death of Mr Simon Dunn,
a prisoner at HMP Garth,
on 26 September 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, 2026
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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 Simon Dunn was found dead in his cell on 26 September at HMP Garth. A cause of
death has not yet been established, although toxicology tests showed that Mr Dunn had
taken elevated levels of some of his prescription medication, and he left a note in which he
indicated that he intended to take his life. He was 55 years old. I offer my condolences to
Mr Dunn’s family and friends.
Mr Dunn was the sixth prisoner to take his own life at Garth since September 2021.
Mr Dunn had several risk factors for suicide and self-harm, including a history of attempted
suicide by overdose. In the time before his death, new potential triggers emerged which
were not properly addressed. While Garth has struggled to provide a consistent regime in
the face of considerable staff shortages, without regular proper engagement with
prisoners, staff are unlikely to be able to pick up on changes in mood and behaviour that
may indicate increased risk.
Mr Dunn left a note in his cell indicating that bullying contributed to him taking his life.
There were not sufficiently robust processes in place to ensure that bullying concerns were
being properly documented and addressed.
Around two months before he died, healthcare staff assessed and allowed Mr Dunn to
keep a supply of his medication in his cell to take as prescribed. The clinical reviewer
found that his history of overdose should have prompted this to have been considered
through wider multidisciplinary discussion.
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 July 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 15
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Summary
Events
1. On 13 August 2019, Mr Simon Dunn was remanded to HMP Durham for
sentencing, having been convicted of sexual offences. On 10 September, he was
sentenced to 16 years in prison. This was his first time in prison.
2. Mr Dunn had a number of physical and mental health diagnoses, including
emotionally unstable personality disorder, depression and anxiety. He was
prescribed medication for both his physical and mental health. Mr Dunn had an
extensive history of self-harm and attempted suicide, including a number of serious
overdoses of prescription medications in the community.
3. On 14 November 2019, Mr Dunn transferred to HMP Garth. While at Garth, staff
monitored Mr Dunn under suicide and self-harm prevention procedures (known as
ACCT) on nine occasions, with his most recent ACCT closed in January 2024.
4. For most of his time in prison, Mr Dunn had to collect his medication each day from
the medication hatch. In July 2024, healthcare staff undertook a risk assessment
and decided that Mr Dunn was now able to hold a supply of his medication in his
possession.
5. In August 2024, Mr Dunn plead guilty to additional charges and was committed to
the crown court for sentencing. Mr Dunn attended a court video hearing on 17
September, which was adjourned to 2 October.
6. On 19 September, Mr Dunn approached his key worker and said he needed to
speak to her and that he was not okay. His key worker was not able to speak to him
in detail but asked him if he had any thoughts of suicide or self-harm, which he said
he did not. She was then absent from work so did not return to speak to Mr Dunn.
7. A prisoner told us that, on 24 September, Mr Dunn explained, in the presence of an
officer, that he was having issues on the wing and that four people were “out to get
him”. This prisoner said that Mr Dunn said that he could not cope with this and it
was affecting his health. The officer told us that Mr Dunn only shared that he was
having issues on the wing and did not elaborate any further.
8. At around 11.36am on 26 September, staff found Mr Dunn unresponsive in his cell.
At 12.10pm, a doctor pronounced life extinct.
9. Staff found a number of empty medication packets in Mr Dunn’s cell along with a
note in which he indicated that he was being bullied and that he intended to take his
life.
Findings
10. Mr Dunn had several risk factors for suicide and self-harm, and in the time before
his death two potential triggers emerged: his impending sentencing for further
offences and concerns that he was being bullied. While it would not necessarily
have led to staff starting ACCT procedures, these potential risks and triggers were
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not explored as well as they might have been. Staff did not check Mr Dunn’s welfare
following important court appearances in the time before his death, as local and
national policy expects. Some staff were not aware of how to implement local
violence reduction procedures and there was a lack of evidence that incidents of
low-level bullying were properly recorded.
11. The clinical reviewer concluded that the physical and mental healthcare provided to
Mr Dunn was partially equivalent to that which would have been received in the
wider community. She found that the decision to give Mr Dunn his medication in
possession should have been discussed as part of a multi-disciplinary team, given
his personality disorder and extensive history of overdose.
12. Garth informed Mr Dunn’s next of kin of his death five days after he died. Initially
there were challenges in obtaining the correct address for the next of kin. However,
once the prison had obtained an updated address it took too long to attend the
address and break the news.
Recommendations
• The Governor should ensure that staff understand their responsibilities to challenge
and manage bullying and verbal abuse towards prisoners, including by:
• Reviewing the local Safer Custody Policy to ensure there are clear expectations
about what staff should do in response to bullying concerns where a perpetrator
may not be disclosed.
• Ensuring that staff receive training on CSIP and understand the referral process
and expectations of their role.
• The Governor should introduce a robust quality assurance process to ensure that
staff complete a welfare check on prisoners following a court appearance, including
those by video link, in line with local and national policy.
• The Head of Healthcare should review the Medication in Possession policy to
ensure there is a multidisciplinary approach where the prisoner has a significant
overdose history.
• The Governor should ensure that there are appropriate processes in place to inform
the next of kin at the earliest opportunity, including when the assigned family liaison
officers are off duty.
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The Investigation Process
13. HMPPS notified us of Mr Dunn’s death on 26 September 2024.
14. The investigator issued notices to staff and prisoners at HMP Garth informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
15. The investigator obtained copies of relevant extracts from Mr Dunn’s prison and
medical records. She also obtained CCTV, the Ambulance Service Records as well
as the HMPPS Early Learning Review.
16. NHS England commissioned a clinical reviewer to review Mr Dunn’s clinical care at
the prison. The investigator and the clinical reviewer jointly interviewed twelve
members of staff in November 2024.
17. The investigator interviewed an additional three members of staff and four prisoners
between November and December 2024.
18. We informed HM Coroner for Lancashire and Blackburn of the investigation. The
Coroner gave us the results of the post-mortem examination and toxicology report.
However, the cause of death will be determined at inquest. We have sent the
Coroner a copy of this report.
19. The Ombudsman’s office contacted Mr Dunn’s daughter to explain the investigation
and ask if she had any matters she wanted us to consider. Mr Dunn’s daughter
wanted to know the following:
• What physical and mental healthcare Mr Dunn had received?
• What drugs were in Mr Dunn’s system when he died and whether these were
prescribed or not?
• Whether Mr Dunn had his medication in possession and, if so, why this was
the case given that he had tried to overdose with medication the previous
year?
• Whether Mr Dunn was located correctly within the prison, as his note
indicated that he felt he was targeted by other prisoners?
20. We shared the initial report with HM Prison and Probation Services (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is an additional
annex to this report.
21. We also shared the initial report with Mr Dunn’s daughter. She did not make any
comments.
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Background Information
HMP Garth
22. HMP Garth is a category B training prison and holds long-term and life-sentenced
prisoners. At the time of Mr Dunn’s death, Greater Manchester Mental Health NHS
Foundation Trust provided physical health, mental health, social care and clinical
substance misuse treatment at Garth. (From April 2025, Practice Plus Group will
provide healthcare services.) Healthcare staff are on duty 24-hours a day and
seven days a week. Delphi are subcontracted to provide psychosocial substance
misuse services. Most prisoners live in single cells.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Garth was in July and August 2024. Inspectors
reported that the prison had become noticeably less safe since their last visit. They
noted that without better support from the regional team and HM Prison and
Probation Service (HMPPS), Garth would continue to be a prison of real concern.
They found that the ingress of drugs continued to be a major challenge.
24. Inspectors noted that very high levels of sickness among officers were affecting the
ability of the prison to operate effectively in many areas. The Governor had
implemented a part-time regime to reduce levels of violence, meaning that too
many prisoners were locked behind their doors for hours. There were many
inexperienced officers who had not had sufficient training or support in the role.
They reported that they saw few custodial managers or other middle managers out
on the wings.
25. Inspectors also reported that Challenge, Support and Intervention Plans (CSIPs, a
tool to help manage violence in prisons) were poor. Prisoners told inspectors of
bullying and anti-social behaviour which was either unnoticed or unchallenged by
staff. They noted that many prisoners had insufficient contact with their prison
offender managers, leave them feeling unsupported in progressing through their
sentences. Inspectors found that this was exacerbated by the lack of regular key
work sessions.
Independent Monitoring Board
26. 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
reported that constant changes to the regime had caused unrest amongst
prisoners. The Board also found that the key worker scheme was disrupted by staff
shortages and constant redeployment.
Previous deaths at HMP Garth
27. Mr Dunn was the 15th prisoner to die at Garth since September 2021, and the sixth
to take his life. Up to the end of February 2025, there have been three further
deaths from natural causes. We have previously made a recommendation about
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informing next of kin as soon as possible. Garth responded that they would brief
duty governors that the next of kin should be informed as soon as possible.
Assessment, Care in Custody and Teamwork
28. 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.
29. 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. When Mr Dunn was at Garth, guidance on
ACCT procedures was 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). From January 2025, this was superseded by the Prison Safety Policy
Framework, in which the principles of how an ACCT is managed remain largely
unchanged.
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Key Events
30. On 13 August 2019, Mr Simon Dunn was remanded to HMP Durham for sexual
offences. This was his first time in prison. On 10 September 2019, he was
sentenced to 16 years in prison.
31. Mr Dunn had diagnoses of emotionally unstable personality disorder, depression
and anxiety. He also had numerous physical health conditions. Mr Dunn was
prescribed a large amount of medication for both his physical and mental health. (At
the time of his death, Mr Dunn was prescribed 20 different types of medication for
his mental and physical health. This included amitriptyline (an antidepressant) and
aripiprazole (an antipsychotic medication).)
32. Mr Dunn had an extensive history of self-harm and attempted suicide in the
community, including a number of serious overdoses of prescribed medication. Mr
Dunn had voluntarily admitted himself to psychiatric hospitals on several occasions
before coming into prison.
33. Before transferring to HMP Garth, staff monitored Mr Dunn under ACCT procedures
on three occasions when Mr Dunn disclosed thoughts of harming himself or others.
HMP Garth
34. On 14 November 2019, Mr Dunn transferred to Garth. Staff allocated him a cell on
F Wing. (F and G Wings at Garth are for vulnerable prisoners, including sex
offenders.)
35. During his reception health screen, a nurse noted that Mr Dunn had mental health
needs and had previously seen a psychiatrist. Mr Dunn denied any thoughts of
suicide or self-harm. The reception nurse completed a medicine in-possession risk
assessment and decided, based on the score, that they would not allow Mr Dunn to
keep his medication in his possession and that he would need to collect this daily.
(A medication in-possession risk assessment considers the risk of a prisoner
holding their medication in their cell to take as prescribed. It considers factors such
as their history of suicide and self-harm and whether the prisoner has been bullied
for or known to have traded medication. Prisoners who do not keep medication in
their cell are required to collect it each day, usually from a dispensary on their wing,
and take it in front of a healthcare professional. A prison officer usually supervises
the queue and dispensing.)
36. On 22 November, a mental health nurse completed a mental health assessment. In
December, staff added Mr Dunn to the mental health case load.
37. Over the next few years, Mr Dunn was monitored under ACCT procedures on six
occasions. Staff started these due to statements that Mr Dunn made to staff,
including that he was having thoughts of suicide and self-harm, he was feeling
down and that he was hearing voices. On one of these occasions Mr Dunn made a
superficial cut to his wrist, saying he was fed up with hearing voices.
38. In January 2022, Mr Dunn reported that he was being bullied for vapes by four other
prisoners. In March, as part of an ACCT case review, Mr Dunn reported that he was
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being bullied, that people were calling him “smelly” and refusing to shower after
him. Mr Dunn did not want to disclose the names of the prisoners. In April, he
reported to the ACCT case review team that the bullying had subsided.
39. On 24 June, Mr Dunn told his mental health care coordinator that he had attempted
to drown himself a few days before. There is no mention of this in Mr Dunn’s prison
records and staff did not start ACCT procedures. Mr Dunn explained that he had
still not heard from the police (about further possible charges) and this was causing
him some anxiety.
40. On 20 January 2023, a member of healthcare staff, Ms A, completed a medication
in-possession risk assessment for Mr Dunn. She noted that he had not harmed
himself or attempted suicide in the last 12 months. (This was incorrect as Mr Dunn
had attempted to drown himself.) Ms A decided that Mr Dunn was able to hold
seven days’ worth of his medication in his possession. During this conversation, Mr
Dunn shared that he had previously had issues with bullying over his medication,
but he had since moved wings and there was no longer a risk of this happening. (Mr
Dunn moved from F Wing to G Wing in December 2022.)
41. On 31 March, Mr Dunn told an officer that he had taken all or most of his in-
possession medication in an attempt to take his life. He later told staff that he took
the overdose because of recent further charges against him.
42. Staff took Mr Dunn to hospital where he stayed for four days and was treated in
intensive care. Staff started monitoring Mr Dunn under ACCT procedures.
43. On 2 April, Ms B, a pharmacy technician, conducted a medication in-possession
risk assessment and decided that Mr Dunn should not keep his medication in-cell
due to his recent overdose. On 16 May, staff stopped monitoring Mr Dunn under
ACCT procedures.
44. In June, Mr Dunn started working with Survivors Manchester (a subcontracted
service at Garth who provide psychological therapy to men who are survivors of
sexual abuse).
45. In the same month, Mr Dunn told staff that other prisoners were harassing him for
his vapes. He explained to staff that this was affecting his mental health and he was
struggling to cope. A staff member submitted an intelligence report but there is no
evidence that any further action was taken.
46. In July, staff started monitoring Mr Dunn under ACCT procedures. There is a
discrepancy about the reasons for this. Prison staff noted that they received a
phone call from the mental health team saying that Mr Dunn said he felt like taking
an overdose. In Mr Dunn’s medical records, it notes that he had tried to take his life
by making a ligature with his laptop charger. On 30 August, staff stopped monitoring
Mr Dunn under ACCT procedures.
47. In October, Mr Dunn told his key worker that he was struggling and that he got
urges to take lots of spice (a psychoactive substance). Staff began monitoring Mr
Dunn under ACCT procedures. (There is no record that Mr Dunn ever used illicit
substances in prison.)
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48. At the end of October, Mr Dunn told the ACCT case review team that some
prisoners had moved onto his wing and were hassling him for vapes. Staff
suggested and facilitated a cell move so that his cell was in sight of the staff on the
landing. There is no evidence that any further investigation took place.
49. On 15 November, staff closed the ACCT procedures as Mr Dunn said that he felt
good and had no thoughts of self-harm. He told the case review team that he was
fine now that he had moved cell and was away from the prisoners who were
bullying him.
50. On 5 January 2024, staff starting monitoring Mr Dunn under ACCT procedures due
to him saying that he felt suicidal after a therapy session and because of issues he
was having with his medication. On 30 January, staff stopped monitoring him under
ACCT procedures as he explained he felt better, was receiving good support from
Survivors Manchester and had no thoughts of self-harm.
51. On 30 January, a psychiatrist reviewed Mr Dunn with Nurse A, Mr Dunn’s care
coordinator. The psychiatrist recorded that Mr Dunn needed more specialised
psychological input. She noted that once he had finished work with psychology, he
should be discussed at a multi-disciplinary meeting with a plan to re-refer Mr Dunn
to the mental health team. (Mr Dunn was not discussed at a multi-disciplinary
meeting as planned and there was no further consideration for psychological work
once he had finished his sessions with Survivors Manchester.) On 13 February,
healthcare staff closed Mr Dunn’s case to the mental health team.
52. On 19 February, Mr Dunn had a key worker session with Officer A. He shared his
concerns about an upcoming court case. He discussed that he could be “next in
line” on G Wing to be bullied but did not give further information. Officer A told Mr
Dunn to speak to her if he had issues on the wing.
53. Over the next few months, Mr Dunn continued to have sessions with Survivors
Manchester, which he completed at the end of April. Mr Dunn also had monthly
sessions with his key worker until July. Staff and prisoners told us that Mr Dunn
generally spent a lot of time on his own and did not often socialise with peers.
54. In April, Mr Dunn signed up to have a buddy on the wing. (The Buddy Programme,
managed by Recoop, is a peer support programme. Prisoners on the wing act as
buddy support workers and provide additional support for prisoners with health and
social care needs.)
55. On 25 May, Mr Dunn sent an application to the mental health team setting out that
he was struggling with his mental health due to recent events. Nurse A visited Mr
Dunn, who raised concerns about inaccuracies in his OASYS report (a tool used by
probation and prison services to assess the needs and risks of offenders). She
encouraged him to speak to his key worker about these concerns.
56. On 29 May, Mr Dunn approached his keyworker, Officer A, and said that he felt
worried about things on the wing and was paranoid about what his peers thought.
Officer A noted down that she had contacted the mental health team. (Officer A said
at interview that she generally contacted the mental health team by phone but there
is no record of this in Mr Dunn’s medical records and no-one went to see him.)
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57. On 29 June, Mr Dunn approached Ms C, a healthcare assistant, and explained that
he wanted to get a job in the workshops and asked if this would be possible given
that he was on sick leave from his current role (due to his physical health
conditions). He also asked whether staff would allow him to have his medication in-
possession. Mr Dunn explained that he had no thoughts of suicide or self-harm and
said that he was confident that if he felt in crisis he would reach out to the
appropriate people.
58. Ms C sent a message to Nurse A explaining that Mr Dunn wanted to review some
parts of his care plan and asked her to look at the entry she had made. Nurse A
responded explaining that the mental health team had discharged Mr Dunn a few
months before but that he was still under the care of the psychiatrist so any
concerns should be discussed with her. (The psychiatrist did not see Mr Dunn from
January 2024 onwards. We understand that Mr Dunn remained open to the
psychiatrist for an annual medication review.)
59. On 10 July, Officer A held a key worker session with Mr Dunn. She recorded that he
sometimes got paranoid about his surroundings on the wing and spent most, if not
all, of his time in his cell. She noted that Mr Dunn was progressing well and
engaging with the mental health team. (Mr Dunn was no longer on the mental
health case load at this time.)
60. That day, Mr Dunn sent an application on his prison laptop to healthcare saying that
he wanted to have his medication in possession as he wanted to go back to work.
61. On 22 July, in response to Mr Dunn’s application, Ms B reviewed Mr Dunn’s
medication in-possession risk assessment. She noted that he was settled and did
not have any thoughts of suicide or self-harm. Ms B assessed that Mr Dunn was at
low risk and decided to allow him to hold seven days’ worth of his medication in-
possession. She set an appointment to review this in early October.
62. At interview, Ms B told the investigator that she discussed the decision to allow Mr
Dunn to have his medication in-possession with Nurse A. (Nurse A did not recall
this conversation and there is no entry about it in Mr Dunn’s medical records.)
63. On 26 July, a staff member from the offender management unit, visited Mr Dunn.
They discussed that Mr Dunn had been charged with further offences. He
expressed concerns that he may have to move prison for his court appearance and
that his mental health would decline. Mr Dunn explained that he intended to plead
not guilty to these charges.
64. There are no case notes, except for one concerning a move to an accessible cell,
recorded for Mr Dunn on his prison record for the entirety of August and September.
65. On 19 August, Mr Dunn attended a video court hearing for additional charges. Mr
Dunn pleaded guilty and the case was transferred to crown court for sentencing in
September.
66. On 26 August, Prisoner A, a prisoner on G Wing, took over as Mr Dunn’s buddy. He
told us that Mr Dunn’s friends on the wing had noticed that he was retreating more
into his cell and not coming out. Prisoner A said that he spent a lot of time in Mr
Dunn’s cell talking to him and helping him with different things. He told us that,
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following his court appearance, Mr Dunn said that he was facing more charges and
that he noticed a change in his demeanour. Prisoner A explained that when Mr
Dunn came back from his court appearance, he said he had now decided to plead
not guilty. Around that time, Mr Dunn asked Prisoner A to help him write a letter to
his solicitor. (There is no evidence that Mr Dunn formally changed his plea before
he died.)
67. That day, Mr Dunn wrote to his prison offender manager, explaining that he had
pleaded guilty. He asked to attend his next court appearance by video link as he
was very worried about it upsetting his routine.
68. Officer A told the investigator that there would be times where Mr Dunn would stay
in his cell and lock his door as he explained that he did not feel safe on the wing.
There is no record of this in Mr Dunn’s prison record.
September 2024
69. On 4 September, Mr Dunn told his buddy that he was worried about his upcoming
court date. (Mr Dunn was next due in court on 17 September.)
70. Officer A said that at some point in the weeks before he died, Mr Dunn told her that
he was worried about his upcoming court case. She said that his worries were
mainly about being transferred to a prison other than Garth, rather than the
outcome of his court case. Mr Dunn asked her to contact his community offender
manager as he wanted to change his plea. She told us that she did not have time to
do this and that she told Mr Dunn that she had not been able to. (There is no
evidence that Mr Dunn submitted an application to speak to his community offender
manager or anyone else in HMPPS about wishing to change his plea.)
71. On 10 September, his prison offender manager responded to Mr Dunn’s application
explaining that they were looking into whether his court appearance would be in
person or via video link and would keep him updated. Two days later, Mr Dunn
followed this up with another application saying he was getting very anxious about
next week and his “mental” was getting worse. He said he needed to know if he
could attend court via video link as he had already pleaded guilty. (On 17
September, Mr Dunn rejected this application himself before it was answered.)
72. On 17 September, Mr Dunn attended a court hearing by video link where the case
was adjourned to 2 October.
73. On 18 September, Mr Dunn told Prisoner A that he was still worried about court.
74. Prisoner B, a prisoner on the wing, explained that in the lead up to his death, Mr
Dunn had told him that he was looking at more charges and another 12 years or
more in prison for historical crimes.
75. On 19 September, Mr Dunn approached Officer A and asked her for a key work
session. She explained that she could not do this as she was going home. She
asked him if there was anything she could do right then to which he replied that
there was not but that he really needed to talk to her at some point. She explained
that he could speak to other staff on the landing. Officer A told the investigator that
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Mr Dunn denied any thoughts of suicide or self-harm. (Officer A was then away
from work until after Mr Dunn had died.)
76. On the same day, Nurse B, head of the long-term conditions team, saw Mr Dunn.
Nurse B recorded that Mr Dunn said that he was well in himself but struggling with
breathlessness.
77. On 20 September, Prisoner A recorded (in a buddy support form) that he had
helped Mr Dunn respond to his solicitor’s letter and that they had posted the letter.
78. On 21 September, Prisoner A recorded that Mr Dunn had spoken to a Listener.
There is no record of this in Mr Dunn’s prison record.
79. On 24 September, Mr Dunn moved into an accessible cell on G Wing. (Mr Dunn
used a wheelchair and staff moved him into an accessible cell when this became
available.) Staff gave him his medication for the next seven days.
80. Prisoner B told the investigator that, on 24 September, he, Prisoner A and Officer B
were in Mr Dunn’s cell. He explained that Mr Dunn said that four people were “after
him” and were “going to kill him”. Mr Dunn said that he could not cope with this and
that it was affecting his heart and health. Prisoner B said that Mr Dunn did not know
who the four people were. Prisoner B described Mr Dunn as being distraught during
this conversation.
81. Prisoner B said that he told Mr Dunn that he did not need to isolate and that officers
would keep an eye on him. Prisoner B said that Officer B responded saying, “You’ll
be alright, don’t worry about it, [the officers are] only down there”.
82. Prisoner B explained that he said to the officer that he thought an ACCT document
needed to be opened and that Officer B said that Prisoner B did not need to tell him
what to do. Prisoner A recalled Mr Dunn saying that he thought people were after
him and picking on him and that he wanted to self-isolate. Prisoner A recorded that
Mr Dunn had spoken to an officer regarding his concern about bullying on the wing
and that he wanted to self-isolate.
83. Officer B recalled a very short conversation in which Mr Dunn said he was having
issues on the wing. Officer B told the investigator that Mr Dunn would not elaborate
any further on this. He explained that he asked him questions about the issues and
that Mr Dunn would not open up any further. He said that Mr Dunn did not say that
he was having issues with four prisoners. Officer B said that if he had known this he
would have asked everyone in that cell to leave and had a longer conversation. He
said that Mr Dunn did not say that he wanted to self-isolate.
84. Officer C said that she spoke to Mr Dunn after he moved cell and he seemed happy
with his new cell and did not raise any concerns.
85. CCTV shows that at around 8.15am on 25 September, Mr Dunn came to the
doorway of his cell. He did not leave his cell all day. Prisoner A told the investigator
that he collected food for Mr Dunn and explained that he seemed positive and told
him he had had a good night’s sleep.
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86. That morning, Officer D went to Mr Dunn’s cell for 20 seconds. He said that he had
asked Mr Dunn about his new cell and that Mr Dunn had smiled. Mr Dunn did not
raise any concerns with him.
87. At 5.23pm, Mr Dunn sent an application to F/G Wing saying that he wished to talk to
his key worker urgently about locking himself behind his door. At 8.57pm, Mr Dunn
rejected this application himself before it was answered.
26 September
88. The following account has been drawn from CCTV footage, staff statements,
interviews, and ambulance service records. (None of the initial responding officers
switched on their body worn video cameras.)
89. At around 5.00am on 26 September, the night patrol officer, conducted a routine
check of all prisoners. At around 6.45am, Officer E conducted another routine
check. They did not note anything of concern.
90. At 8.09am, Officer C conducted welfare checks on the wing. She opened Mr Dunn’s
observation panel and looked into the cell for around a second. She could not
remember what she saw when she looked into Mr Dunn’s cell.
91. At around 11.30am, Officer F began unlocking prisoners to come out for food. At
around 11.35am, Officer F opened Mr Dunn’s observation panel and saw him laid
on his bed without a cover over him. She could not see any movement and
therefore opened his door and attempted to get a response.
92. Officer F then shouted to Supervising Officer (SO) A for assistance and, at 11.36am
radioed an emergency code blue (used to indicate when someone is unresponsive
or not breathing). Officer F found that Mr Dunn’s body was cold and started CPR.
93. Around a minute later, Nurse C arrived at the cell. She instructed Officer F to stop
CPR while she completed her observations. She noted that there were no signs of
life and that rigor mortis had started to set in. (Rigor mortis is a condition which is
unequivocally associated with death.) Additional healthcare staff arrived shortly
after and agreed with the decision not to re-commence CPR.
94. At around 11.55am, paramedics arrived at the cell and noted that rigor mortis and
hypostasis (when the blood stops circulating and falls to its lowest point) were
present. At 12.10, Dr B pronounced life extinct.
95. Mr Dunn left a note in his cell. He wrote that two prisoners knew who the bullies
were. He explained that he could hear wing cleaners and laundry workers laughing
at him. He noted that wing staff had not seen his cry for help or did not understand
his mental health or had just turned the other cheek. He wrote that bullies had
“helped him in his quest” and that they had won.
96. Nurse D found a bag which had 15 empty medication packets in Mr Dunn’s
cupboard. All were dated 20 September or later. (All were medications prescribed to
Mr Dunn.)
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Contact with Mr Dunn’s family
97. The prison appointed two family liaison officers (FLO). At 1.45pm, they contacted
HMP Northumberland to ask them to attend Mr Dunn’s daughter’s address (due to
the distance that she lived from Garth). Northumberland did not have any trained
FLOs on duty. They then contacted staff at HMP Durham, who attended the
address but found that this was not Mr Dunn’s daughter’s current address.
98. CM A and Ms F then contacted Mr Dunn’s community offender manager, solicitor
and the police to find an updated address. CM A explained in interview that the
police provided an updated address on the Friday afternoon (27 September) but he
was not aware of this until the following Monday (30 September) when he returned
to duty. Ms F also said that she was not aware of the new information until the
Monday.
99. CM A and Ms F then decided to attend the address themselves in person the
following day. CM A explained that they were not able to attend on 30 September
due to adverse weather conditions and it being too late in the day.
100. On 1 October, CM A and Ms F attended Mr Dunn’s daughter’s address and
delivered the news of his death.
101. The prison contributed toward the cost of Mr Dunn’s funeral in line with national
policy.
Support for prisoners and staff
102. 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. 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.
103. After Mr Dunn’s death, an operational manager, debriefed the prison and healthcare
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. One of the initial responding officers told us that she did not feel supported
in the first few days following the incident as no one contacted her until the following
week. Another responding officer told us that the TRiM team were at the debrief and
said they would reach out the following week but had not done so.
104. Garth posted notices informing other prisoners of Mr Dunn’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 Dunn’s death. Listeners were
deployed the following morning on the wing. A few prisoners we spoke to told the
investigator that they were not offered any support following Mr Dunn’s death. Mr
Dunn’s buddy told the investigator that he was offered sufficient support.
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Post-mortem report
105. Mr Dunn was subject to a digital autopsy (when the autopsy is conducted by a scan
rather than the physical examination of the body). The post-mortem author did not
have the results of the toxicology tests at the time of writing but concluded that
given the circumstances surrounding Mr Dunn’s death, the most likely cause of
death was drug overdose.
106. The toxicology identified the following above the therapeutic range: amitriptyline,
metformin, diltiazem and paracetamol (although the latter may have been due to re-
distribution post-mortem). The toxicology also identified use of aripiprazole,
atorvastatin, omeprazole and ranolazine in the hours prior to death but it notes that
these have low or no association with acute toxicity. Mr Dunn was prescribed all of
these medications.
107. Mr Dunn left a note which suggested he intended to take his life.
108. The cause of Mr Dunn’s death will be established by the Coroner at inquest.
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Findings
Identifying risk of suicide and self-harm
109. Prison Service Instruction (PSI) 64/2011, on safer custody, which was in place at
the time of Mr Dunn’s death, required staff who have contact with prisoners to be
aware of the risk factors and triggers that might increase the risk of suicide and self-
harm and take appropriate action. Any prisoner identified as at risk of suicide or
self-harm must be managed under suicide and self-harm procedures (known as
ACCT). From January 2025, PSI 64/2011 was superseded by the Prison Safety
Policy Framework, in which the principles of how risk is identified and the action that
should be taken as a result remain largely unchanged.
110. Mr Dunn had a number of risk factors for suicide and self-harm: he had a mental
health diagnosis and an extensive history of self-harm and suicidal behaviour. In the
time before his death, Mr Dunn expressed concerns about his impending court
appearance and the additional charges he was facing. He also said that he was
being bullied by other prisoners.
111. While he had these risk factors and potential triggers, we are satisfied that there is
not any compelling evidence that staff should have started ACCT procedures in the
time before Mr Dunn’s death. However, there were some potential risks and triggers
that were not explored as well as they might have been.
Bullying
112. There is minimal evidence that prison staff had meaningful contact with Mr Dunn for
the last two months of his life. From the note that Mr Dunn left in his cell, it is
apparent that there was more going on for him at the time of his death than officers
were aware of and that one of the drivers for taking his life was that he perceived
that he was being bullied.
113. A PPO publication in October 2011, Violence reduction, bullying and safety, noted
the links between bullying and violence and self-inflicted deaths of prisoners of all
ages. In our PPO thematic report into self-inflicted deaths in 2013 - 2014, we found
that reports or suspicions that a prisoner is being threatened or bullied need to be
recorded, investigated and responded to robustly.
114. The Garth Safer Custody Policy notes that the Challenge, Support and Intervention
Plan (CSIP, a tool used to investigate and manage violence in prisons) process can
be used to support vulnerable individuals. The strategy notes that actions to take
following a verbal and physical incident of violence include: (i) reporting this on a
prisoner’s record (ii) submitting an intelligence report (iii) including an entry in the
observations book and (iv) completing a CSIP referral.
115. Mr Dunn’s key worker said that she thought Mr Dunn had a couple of issues on the
wing but that he was always vague about the details. On occasions, she heard
people making “snarky” comments to him on the landing. She explained she did not
record these instances and challenged prisoners about this in the moment.
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116. Two days before he died, a prisoner told us that he had a conversation with Mr
Dunn with Officer B present. The prisoner explained that Mr Dunn said that people
were out to get him, that he could not cope and that this was affecting his heart and
health. Officer B recalled Mr Dunn saying that he was having issues on the wing but
that he would not elaborate any further on this.
117. A number of staff members told the investigator that they were aware of wider
bullying which occurred on the wing. (Except for Mr Dunn’s keyworker, none had
witnessed any evidence of him being bullied.) SO A said he would expect staff
members to submit an intelligence report, do a referral for CSIP, record this in the
observations book and put this in a prisoner’s record.
118. Most of the staff we spoke to explained that they would challenge bullying in the
moment, but we found a lack of evidence that they would properly record this. A
prisoner told us that he sometimes raised bullying with staff members but they did
not do anything “because of the paperwork”. An officer told the investigator that the
reason for not referring anyone to CSIP was that he did not have anyone to show
him how to do it and was just told to keep an eye on prisoners when there were
bullying concerns.
119. In their most recent inspection, HMIP found that CSIP was poorly used. They
highlighted concerns from prisoners that bullying and anti-social behaviour was
unnoticed or unchallenged by staff.
120. We found that more should be done to ensure that staff are recording and
investigating suspicions of bullying, however low level they may perceive them to
be. In addition, we found that there was little understanding from some officers on
CSIP and the associated processes.
We make the following recommendation:
The Governor should ensure that staff understand their responsibilities to
challenge and manage bullying and verbal abuse towards prisoners,
including by:
• Reviewing the local Safer Custody Policy to ensure there are clear
expectations about what staff should do in response to bullying
concerns where a perpetrator may not be disclosed.
• Ensuring that staff receive training on CSIP and understand the referral
process and expectations of their role.
Key work
121. Mr Dunn had a key worker and until July 2024 had almost monthly sessions with
them. These entries were generally detailed and suggested that Mr Dunn was able
to share any concerns he had. However, from July onwards, Mr Dunn did not
receive any recorded sessions. Mr Dunn’s key worker told the investigator that he
would often approach her but that she would not always record the conversations in
his prison record. She said she was not aware of his history of suicide attempts and
self-harm.
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122. Several officers told us that, while they are scheduled to have key worker sessions,
because of staffing levels or being cross-deployed to other areas in the prison, they
are often not able to complete these. We understand from one officer that most key
work sessions are done on the landing, rather than in a private space.
123. Around a week before Mr Dunn died, he approached his key worker and explained
that he really needed to speak to her at some point. (We know from a number of
prison and healthcare staff that Mr Dunn was generally good at asking when he
needed help.) He told his key worker that he was not okay but denied having
thoughts of suicide or self-harm. Mr Dunn’s key worker did not have the time to
speak to him before she went home but said that he could speak to another
member of staff on the landing. We consider that she should have asked wing staff
to check on him or noted this down in the observation book.
124. Key work is important and gives an opportunity for prisoners to speak about
concerns. We understand that to run key work successfully, prisons need to be
properly staffed. The Head of Safety, explained that in August 2024, due to staffing
levels, Garth introduced an emergency regime which impacted the ability to deliver
key work.
125. We acknowledge that Garth is planning to introduce key work for priority prisoners.
Mr Dunn would not have fallen into the category of “priority prisoner” according to
Garth’s criteria (which includes IPP prisoners, those on ACCT documents, isolators
and those in debt). The Governor will want to consider how prisoners who do not
meet these criteria have the opportunity for regular meaningful interactions.
Video link court appearances
126. Shortly before he died, Mr Dunn attended two video link court hearings. We
understand that during the first hearing, in August 2024, he pleaded guilty to
additional charges. In the second, on 17 September, his case was adjourned to 2
October.
127. PSI 64/2011 lists a number of triggers which may increase risk of suicide and self-
harm. This includes court appearances, especially the start of a trial and
sentencing. The Prison Safety Policy Framework sets out that there are times in a
prisoner’s experience of custody when they are likely to be at increased risk of
suicide and self-harm. One of these is a court hearing (including a family court or
video link court hearing). It notes that it is important that prisons identify and
manage the risks to self and others during these times and put appropriate support
in place to manage any identified risk.
128. Garth’s Safer Custody Policy sets out that as court appearances, further charges
and change in status can all be potential triggers, when an individual returns from
court they should be spoken to ensuring any increased risk is noted and any
necessary action taken. It sets out that there is an expectation that key workers are
aware of when their prisoners appear at court and should discuss this with them
prior to and after appearing at court. It notes that it is important such conversations
are recorded on a prisoner’s record.
129. Mr Dunn’s key worker told the investigator that she is not informed when one of her
caseload appears at court. She was not aware that there was an expectation to
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have a conversation after someone has appeared at court. There is no evidence
that anyone else checked Mr Dunn’s welfare following the court appearances in the
time before his death. We make the following recommendation:
The Governor should introduce a robust quality assurance process to ensure
that staff complete a welfare check on prisoners following a court
appearance, including those by video link, in line local and national policy.
Clinical care
130. The clinical reviewer concluded that the clinical care Mr Dunn received at Garth was
partially equivalent to that which he could have expected to receive in the
community.
131. The clinical reviewer found that Mr Dunn had timely mental health assessments and
allocated case managers to oversee and monitor his mental health up until he was
discharged from the team in February 2024. Staff did not discuss him again at a
multi-disciplinary meeting to determine his care pathway, as they had planned to
do.
132. Mr Dunn was provided with his own medication in possession in July 2024 and was
dispensed seven days medication at a time. (There is no evidence that Mr Dunn
had hoarded previously prescribed medication. The empty medication packets in
his cell were all dated from the week before he died.) While this decision was made
in line with the Greater Manchester Mental Health Foundation Trust (GMMH)
operating procedure, the clinical reviewer found that it would have been worthwhile
to discuss this decision as part of a multidisciplinary team, given Mr Dunn’s long
history of overdose and his last overdose when awarded IP status.
133. We make the following recommendation:
The Head of Healthcare should review the Medication in Possession policy to
ensure there is a multidisciplinary approach where the prisoner has a
significant overdose history.
Emergency response
Welfare checks
134. PSI 75/2011, on Residential Services, requires all prisons to have a clearly
understood system in place for staff to assure themselves of the wellbeing of
prisoners during or shortly after unlock.
135. In January 2024, the Governor issued an order on welfare checks. This instructed
that a welfare check should involve staff members opening the observation panel
and satisfying themselves of the individual’s wellbeing, giving the prisoner the
opportunity to report any concerns. It went on to say that best practice during a
welfare check was for staff to ensure they have full sight of the prisoner and gain a
verbal response from them.
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136. Officer C conducted the welfare check at around 8.00am on the morning of 26
September. Given that Mr Dunn had rigor mortis when found at 11.30am, it is
unlikely that he was well when Officer C checked him. She could not remember
what she saw but told the investigator that if she had thought anything was wrong
she would have gone into the cell. Garth has conducted a local investigation into
this incident and gave Officer C a 12-month written warning.
137. Officer C told the investigator that she had not seen the Governor’s Order at the
time. She explained that now she makes sure that, when conducting welfare
checks, she gets a verbal response. She told us that Governor’s Orders were often
sent by email and that many people do not check their emails. SO A was not able to
remember whether he had seen the Governor’s Order and said these were only
sent by email.
138. Garth have revised the Governor’s Order to make it clear that staff must receive a
response, rather than this being best practice. The Governor re-issued this in
December 2024. The Governor will want to ensure that Governor’s Orders are
appropriately disseminated, in a variety of means, so that all staff are aware of the
content of these. He will also wish to consider the need for a robust quality
assurance process to ensure that this measure has been embedded.
Body worn video cameras (BWVC)
139. The Prison Service Body Worn Video Cameras Policy Framework states that staff
responding to an incident should start recording at the earliest opportunity. This
includes incidents involving injury or illness to a prisoner.
140. None of the initial responding officers switched on their body worn video cameras.
This means that we have not been able to accurately confirm what happened upon
finding Mr Dunn. The first responding officer explained in interview that she had
“tunnel vision”. She explained that this was not her regular wing and at that point
needed another officer to go in and help her. The second responding officer
explained that he forgot to switch his BWVC on.
141. The Governor will wish to assure himself that staff are reminded of the importance
of activating body worn video cameras, in line with national policy.
Informing Mr Dunn’s family of his death
142. PSI 64/2011 says that, wherever possible, the family liaison officer (FLO) and
another member of staff must visit in person the next of kin or nominated person to
break the news of the death. It notes that time will be of the essence in order to try
to ensure that the family do not find out about the death from another source. It sets
out that where the prisoner is a long distance from their next of kin, consideration
must be given to requesting the assistance of a FLO from the nearest prison.
143. Mr Dunn’s next of kin was not informed until five days after he died. We understand
that the address noted in Mr Dunn’s prison record was not correct and the FLOs
therefore sought assistance from the police to find an up-to-date address. This was
given to them the following afternoon (Friday 27 September).
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144. In interview, one of the FLOs told the investigator that they had not received this
address until the following Monday, as he and the other FLO were not on duty over
the weekend. On the Monday, they decided to attend the address the following day
due to extreme weather conditions and the fact that it was already late in the day.
The lead FLO told the investigator that this decision was supported by the duty
governor.
145. It is important that the news of a death is broken to a prisoner’s family at the earliest
opportunity. There should have been a process in place to ensure that action was
taken on receipt of Mr Dunn’s correct family address details in the absence of the
lead and deputy FLO and it is disappointing that senior leaders did not consider
how to prioritise this over the weekend and, indeed, on the Monday when the
address was available. It would also be sensible to appoint a lead and deputy FLO
who are not expected to be absent from work at the same time in the days after a
death.
146. We make the following recommendation:
The Governor should ensure that there are appropriate processes in place to
inform the next of kin at the earliest opportunity, including when the assigned
family liaison officers are off duty.
Inquest
147. The inquest into Mr Dunn’s death concluded on 22 May 2026, and recorded a
verdict of suicide.
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