Simon Follos

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Independent investigation into
the death of Mr Simon Follos,
a prisoner at HMP Stoke Heath,
on 22 August 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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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 Follos was found hanged in his cell at HMP Stoke Heath on 22 August 2023. He
was 49 years old. I offer my condolences to his family and friends.
Although Mr Follos was being managed under suicide and self-harm prevention
procedures (known as ACCT) when he hanged himself, staff underestimated his risk and
ACCT procedures were poorly managed. Staff did not check on Mr Follos for several
hours on the day he died.
We identified similar deficiencies in the way that ACCT monitoring was completed in two
previous investigations into self-inflicted deaths at Stoke Heath. We note that HM
Inspectorate of Prisons identified weaknesses in the management of ACCT procedures in
January 2023, and we have not seen evidence that the necessary improvements had been
made by the time of Mr Follos’ death.
Mr Follos had a significant history of mental health issues. The clinical reviewer concluded
that the care he received was of a good standard and was at least equivalent to that which
he could have expected to receive in the community. It is possible that Mr Follos’ anxieties
about his release might have contributed to the decision to take his life.
A number of prisoners made allegations about the way prison staff had treated Mr Follos.
The Governor told us that two of the named prison officers had been dismissed (for
unrelated matters) but there was insufficient evidence to warrant an investigation into the
actions of other officers. He told us that he tackled staff issues robustly when he had
sufficient evidence to do so. We also were not able to establish whether the allegations
were true and contributed to Mr Follos’ death. HM Inspectorate of Prisons concluded that
Stoke Heath was safe. However, we expect the Governor to continue to prioritise safety
and address concerns about staff misconduct appropriately.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2025
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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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 17
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Summary
Events
1. Mr Simon Follos had a significant history of mental health issues and had served
numerous custodial sentences. On 28 March 2023, he told the police he was
psychotic, had a broken bottle and was thinking of hurting someone. Mr Follos was
arrested and remanded to HMP Birmingham. He told his offender manager that his
actions were a “cry for help”. Mr Follos had been arrested in similar circumstances
on at least three previous occasions. While at Birmingham, Mr Follos was monitored
under suicide and self-harm monitoring procedures (known as ACCT).
2. On 18 May, Mr Follos was sentenced to ten months in prison for the possession of
an offensive weapon. On 30 May, he was transferred to HMP Stoke Heath. Prison
records noted that his behaviour was disruptive, and he remained under the care of
the mental health team. On three occasions in August, Mr Follos was monitored
under ACCT procedures, including at the time of his death. During his time at Stoke
Heath, Mr Follos raised concerns about his safety five times.
3. At around 4.30pm on 22 August, staff found Mr Follos hanged from a ligature. They
began cardiopulmonary resuscitation (CPR) and asked for emergency assistance.
At 5.03pm, a doctor confirmed that Mr Follos had died.
Findings
4. We are concerned that staff underestimated Mr Follos’ risk to himself and did not
start ACCT procedures when they should have done. ACCT monitoring was poorly
managed and was closed prematurely. Mr Follos’ ACCT care plan did not address
his concerns which meant there was little to support him and address his underlying
issues.
5. We found no evidence that Mr Follos’ concerns for his safety were investigated,
despite him raising them five times.
6. Three prisoners made serious allegations about the way staff treated Mr Follos at
Stoke Heath. We drew these concerns to the Governor’s attention. The Governor
told us that there was insufficient evidence to warrant an investigation but that he
tackled staff issues robustly.
7. The clinical reviewer concluded that the physical and mental health care that Mr
Follos received was of a good standard and was at least equivalent to that which he
could have expected to receive in the community.
Recommendations
• The Governor should ensure that prison staff manage prisoners at risk of suicide or
self-harm in line with the Prison Safety Policy Framework, including that stringent
ACCT quality assurance procedures are in place for senior managers to identify
poor practice, learn lessons and, where appropriate, provide staff with refresher
training.
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• The Prison Group Director for West Midlands should outline in the action plan the
steps she has taken to satisfy herself that effective action is being taken to improve
ACCT quality assurance at Stoke Heath.
• The Governor should ensure that staff:
• fully and promptly investigate information about bullying and intimidation;
• challenge alleged perpetrators appropriately; and
• support victims effectively and properly consider and address the possible
impact on their risk of suicide and self-harm.
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The Investigation Process
8. HMPPS notified us of Mr Follos’ death on 22 August 2023.
9. The investigator issued notices to staff and prisoners at HMP Stoke Heath informing
them of the investigation and asking anyone with relevant information to contact
him. One prisoner responded and asked to speak to the investigator.
10. The investigator obtained copies of relevant extracts from Mr Follos’ prison and
medical records and watched CCTV and body-worn video camera footage. He also
obtained ambulance service records. Mr Follos made no telephone calls during his
time at Stoke Heath.
11. NHS England commissioned a clinical reviewer to review Mr Follos’ clinical care at
Stoke Heath.
12. The investigator and clinical reviewer interviewed 15 members of staff and three
prisoners in August, October and November 2023.
13. We informed HM Coroner for Shropshire of the investigation. He gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
14. The Ombudsman’s office contacted Mr Follos’ next of kin, his sister, to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Follos’ family had no specific questions.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
16. Mr Follos’ family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Stoke Heath
17. Stoke Heath is a category C training and resettlement prison. Shropshire
Community Health NHS Trust provides healthcare services.
HM Inspectorate of Prisons
18. The most recent inspection of Stoke Heath was in January 2023. Inspectors
reported continuing stability and assessed the prison to be safe and reasonably
respectful. Inspectors reported that leaders maintained an overall positive ethos and
that the Governor was keen to promote a positive culture.
19. Inspectors reported that staff interactions with prisoners were courteous and
professional and 64% of prisoners said they were treated with respect. However,
some prisoners reported that some staff were intimidating and some prisoners with
protected characteristics reported instances of staff using insensitive and offensive
language. Inspectors reported their concern about the number of prisoners who
said staff were intimidating and antagonistic towards them.
20. Inspectors noted that the focus on improving safety had been effective and that
large reductions in self-harm had been impressive, but the quality of ACCTs was
variable. They noted that assessment of risk was not always made clear and was
sometimes underestimated, reviews had not been multidisciplinary and care plans
lacked meaningful actions. Inspectors reported that more work was still needed to
improve the quality of ACCT case management.
21. Inspectors reported that investigations into incidents of violence were generally
timely and of good quality and that challenge, support and intervention plans (CSIP)
were used reasonably well to support victims.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to April 2023, the IMB reported that
they had observed healthy respect and interaction between prisoners and staff.
They reported that prisoners had a laptop computer and could access limited online
information, contact internal departments, select meals and place orders for goods
from the prison shop. They noted this had been positive for prisoners’ wellbeing.
Previous deaths at HMP Stoke Heath
23. Mr Follos was the third prisoner to take his life at Stoke Heath since January 2021.
We identified deficiencies in the delivery of ACCT at Stoke Heath in our previous
investigations into the self-inflicted deaths of men at the prison in December 2021
and September 2022. There have also been four deaths from natural causes at the
prison in the three years before Mr Follos’ death.
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Assessment, Care in Custody and Teamwork
24. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and self-harm. The purpose of ACCT is to try to determine the level of
risk, how to reduce the risk and how best to monitor and supervise the prisoner.
After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
25. As part of the process, a care plan (plan of care, support, and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the care-map
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.
Postvention procedures
26. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to supporting staff and prisoners 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 the prisoners
potentially most affected by a death.
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Key Events
Background
27. Mr Simon Follos had served numerous custodial sentences. He had been
diagnosed with paranoid schizophrenia, emotionally unstable personality disorder,
schizoaffective disorder and drug-induced psychosis. He had been sectioned under
the Mental Health Act and treated in several mental health hospitals.
28. Mr Follos also had a significant history of self-harm and substance misuse, and he
struggled to cope in prison. Since 2012, his prison records noted that he heard
voices telling him to kill himself. He was frequently monitored under suicide and
self-harm monitoring procedures, known as ACCT. His prison records noted that he
had both assaulted staff and prisoners and been the victim of bullying from
prisoners, likely due to his challenging and unpredictable behaviour.
29. In February 2022, following release form a mental health hospital, Mr Follos told the
police he felt psychotic. He said he had a knife and feared for other people’s safety.
Mr Follos said his actions were a “cry for help” as he wanted to be sectioned.
30. On 21 February 2022, Mr Follos was remanded into custody at HMP Birmingham
for possession of a blade and breach of a suspended sentence. In September, he
was sentenced to four months in prison, suspended for two years. In December, he
was admitted to a psychiatric intensive care unit. He was discharged in March 2023.
31. On 26 March 2023, Mr Follos went to hospital and asked to be sectioned under the
Mental Health Act. However, he was assessed as having mental capacity and was
deemed suitable for home treatment.
32. On 27 March, Mr Follos telephoned the police. He told them that he was psychotic,
had recently been discharged from a mental health hospital, had a broken glass
bottle and was thinking of hurting someone as he was struggling to cope. Mr Follos
was arrested for possession of an offensive weapon.
HMP Birmingham
33. On 28 March 2023, Mr Follos was remanded to HMP Birmingham. He said he did
not intend to hurt anyone but preferred prison as he “didn’t survive outside”.
34. On 6 April, Mr Follos wrote to his community offender manager (COM). Mr Follos
said his actions had been a “cry for help” and he had intentionally been arrested to
get help as the hospital had failed to help him. Mr Follos said he felt he posed more
of a risk to himself than others and just wanted to be heard.
35. On 18 April, Mr Follos told staff he was hearing voices. Staff started ACCT
monitoring. Concern about the effectiveness of his antipsychotic medication was
listed as a trigger. Three days later, Mr Follos harmed himself by putting a plastic
bag over his head and swallowing a vape capsule. He said he had done this to be
moved to the prison’s healthcare unit. He denied being threatened or in debt and
said he felt better supported in prison.
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36. On 8 May, Mr Follos tied his television aerial around his neck. He said voices had
told him to do it. He said his depot injections of paliperidone (an antipsychotic used
to treat schizophrenia) were becoming less effective. Staff noted that his cell was
untidy which appeared normal for him. Four days later, Mr Follos tied a telephone
cable around his neck. He told staff to remove his telephone and trainers from his
cell to prevent him harming himself. Over the following days, Mr Follos consistently
misused his emergency cell bell and disrupted the wing regime.
37. On 18 May, Mr Follos was sentenced to ten months in prison. It was noted that he
was more settled knowing that he was soon to be released from prison.
38. On 26 May, Mr Follos’ ACCT was closed. He was noted to be in high spirits and
had apologised for his recent behaviour. Mr Follos said that he felt his medication
was working and his mental health had improved. Mr Follos said he was looking
forward to being transferred to another prison and to his release.
HMP Stoke Heath
39. On 30 May, Mr Follos was transferred to HMP Stoke Heath. At an initial health
screen, a nurse noted Mr Follos’ mental health history, that he had been given his
depot injection and noted his other prescribed medications. Mr Follos denied
thoughts of suicide and self-harm. An officer noted his history of ACCT monitoring.
Mr Follos was given a single cell as his risk to others was considered high.
40. On 2 June, a mental health nurse assessed Mr Follos. He noted his mental health,
substance misuse and self-harm history. He noted that Mr Follos’ communication
was unpredictable. The nurse referred him to the prison’s psychiatrist and created a
care plan which included monitoring Mr Follos weekly in case he needed changes
to his care plan.
41. On 5 June, a recovery worker from the substance misuse team spoke to Mr Follos.
Mr Follos said that his substance misuse worsened his mental health, and his goal
was abstinence.
42. On 9 June, a psychiatrist and a mental health nurse reviewed Mr Follos. He told
them he had hallucinated and heard voices since he was nineteen and found it
difficult to sleep. Mr Follos told them he felt most stable on paliperidone. Mr Follos
said he was hopeful for the future as he had plans for his release. He denied
thoughts of suicide and self-harm. The psychiatrist noted that there would be no
change to Mr Follos’ medication.
43. That day, Mr Follos was moved to A wing, a standard wing. He applied for
education and was told that pre-release support would be available.
44. On 15 June, Mr Follos told a mental health nurse that voices in his head had told
him to kill himself, that the psychiatrist had done nothing to help him and that he
wanted to be sectioned. The nurse told him that he would discuss his case with the
psychiatrist.
45. On 20 June, a Supervising Officer (SO) noted that concerns had been raised about
Mr Follos’ mental health after he had been sexually inappropriate in front of an
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officer. Mr Follos told staff that his behaviour was a result of his mental health and
that he had been smoking a teabag. Staff noted that it smelt like an illicit substance.
46. The SO told the investigator that Mr Follos’ behaviour on A wing was “quite bizarre”
and became more so over time but sometimes, he laughed and joked with staff,
appeared comfortable and apologised after inappropriate behaviour. She said there
was no indication that Mr Follos was being bullied. She said that the mental health
nurse told her that Mr Follos’ behaviour changed when he was due his depot
injection or used illicit substances. She noted that staff should remain vigilant
around Mr Follos, challenge inappropriate behaviour and issue him with incentives
warnings (a method for rewarding good behaviour by allowing additional privileges,
which can be removed or reduced for poor behaviour), when appropriate.
47. That day, the mental health nurse reviewed Mr Follos. He noted that Mr Follos
appeared calmer, blamed his recent behaviour on his mental health and that he had
accidently smoked an illicit substance. (The nurse noted that Mr Follos’ medical
records indicated that when he had previously taken substances, his behaviour had
become more unpredictable and violent.) He noted Mr Follos displayed no signs of
psychosis.
48. On 21 June, Mr Follos was given two incentives warnings for not attending his art
class and for vaping in a communal area. The SO downgraded his incentives level
to basic (one result of which was the removal of Mr Follos’ in-cell television). It was
noted that over the following days, Mr Follos was disruptive, spoke inappropriately
to staff, ignored instructions, had tried to annoy other prisoners, and had misused
his emergency cell bell.
49. Officers told the mental health nurse that Mr Follos’ behaviour continued to be
inappropriate. The nurse noted that he had been told that Mr Follos had defecated
himself and had called officers paedophiles. The nurse noted that it was possible
that Mr Follos’ depot injection had not been holding him for four weeks.
50. On 26 June, Mr Follos sent an application to the Offender Management Unit (OMU)
asking for a new cell key as prisoners were stealing from his cell when he was not
there.
51. Mr Follos was given an incentives warning for making inappropriate comments. He
also told staff that he had urinated himself, but it was later established that he had
not. The mental health nurse told staff that they might see a change in Mr Follos’
behaviour after he had received his depot injection. (Mr Follos was given his depot
injection on 28 June.)
52. Later that morning, Mr Follos told the mental health nurse that he was struggling,
that officers were picking on him and he had been told that everything he did was a
behavioural concern. The nurse noted that Mr Follos appeared calm and apologised
for his behaviour.
53. That afternoon, an officer used minimal force to restrain Mr Follos after he was
verbally aggressive and threatening. The following day, Mr Follos apologised for his
behaviour which he said was because he had heard voices. The officer said staff
did not know “which version” of Mr Follos they would get when they opened his cell
door.
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54. On 27 June, the SO carried out an incentives review for Mr Follos due to his poor
behaviour. He remained on the basic regime. The following day, Mr Follos
continued to misuse his cell bell but settled over the following days.
55. On 30 June, Mr Follos applied to speak to someone from safer custody as he said
he had been attacked three times and nothing had been done.
56. On 3 July, Mr Follos was told that a member of staff would complete a welfare
check and he would be asked to give a statement so the matter (the alleged
attacks) could be investigated. An officer, who completed the check, noted that Mr
Follos had said he felt fine and wanted to know when he would get his television
back. The officer told him that he would be allowed a television when his behaviour
improved.
57. That day, a prisoner offender manager (POM) met Mr Follos to discuss his post-
release accommodation plans as he was due for release on 25 August.
58. On 4 July, Mr Follos told the mental health nurse that his depot injection was
working. The nurse noted that although Mr Follos presented with some delusion, it
was minimal compared to previous weeks.
59. On 6 July, a worker from OMU noted that Mr Follos had ordered a copy of his birth
certificate which he would need when released.
60. On 10 July, Mr Follos’ incentives level was raised to standard following a period of
good behaviour.
61. That day, Mr Follos made an application to a SO for a transfer to another prison as
he said he did not feel safe at Stoke Heath. Mr Follos also told chaplaincy and safer
custody staff that he did not feel safe at the prison after telling other prisoners that
he was a paedophile.
62. On 11 July, during a welfare check, Mr Follos told an officer that he felt “unsteady”
on the wing after he had told prisoners that he was a paedophile. Mr Follos declined
to have a separate regime from other prisoners. (The chaplaincy staff also told Mr
Follos to contact OMU. The SO responded and told Mr Follos to write his concerns
on a witness statement.)
63. On 12 July, Mr Follos was given his post-sentence supervision order and licence
conditions in preparation for his release.
64. On 13 July, Mr Follos made a further application for a prison transfer and asked if
his community support worker had been contacted.
65. On 15 July, during a welfare check, Mr Follos told an officer that he was okay on the
wing, wanted to stay out of trouble and keep to himself. The officer noted Mr Follos’
positive attitude.
66. On 18 July, Mr Follos told the mental health nurse that he was struggling, he was
increasingly confused and paranoid that prisoners on the wing were talking about
him and calling him a paedophile. The nurse reminded Mr Follos that this was likely
because he had told them that. He planned to see Mr Follos again when he
returned from leave.
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67. On 19 July, Mr Follos made an application to healthcare. He said he had swallowed
a razor the previous week. He asked for and was prescribed sleeping tablets.
68. On 20 July, an officer completed a key work session. He noted that Mr Follos had
said he was okay but wanted to keep to himself and not mix with other prisoners. Mr
Follos declined the officer’s offer to help prepare for his release.
69. That day, Mr Follos made an application to the safer custody team to say he had
been attacked in his cell and did not feel safe on the wing. On 24 July, the safer
custody team responded that they were looking into his concerns and a welfare
check would be completed. (There is nothing in Mr Follos’ prison record, or other
wing records about him being attacked.)
70. That afternoon, an officer held another key work session with Mr Follos. Mr Follos
said he did not need anything in preparation for his release and wanted to keep his
head down until then. The officer noted that he ended the session as Mr Follos
appeared bored and wanted to return to his cell.
71. The officer told the investigator that he was concerned about Mr Follos’ hygiene and
had to tell him to shower and clean his cell.
72. On 26 July, the psychiatrist reviewed and renewed Mr Follos’ depot prescription.
73. On 28 July, Mr Follos made an application to the mental health team to say he
could not sleep for more than two hours a night and felt depressed.
74. On 31 July, Mr Follos told staff he felt low, and he was given time to talk to a
Listener (a prisoner trained by the Samaritans to provide a listening service). He
said talking to the Listener helped and he denied thoughts of self-harm.
75. On 3 August, a SO downgraded Mr Follos’ incentives status to basic after he
misused his cell bell. She noted that Mr Follos had asked for vapes which was not
considered an emergency.
76. On 5 August, Mr Follos told staff that voices had told him to kill himself, that he had
wanted to die and had recently drunk the contents of a vape capsule. Staff started
suicide and self-harm prevention procedures, monitoring him hourly. A mental
health nurse saw Mr Follos and referred him to the mental health team. He declined
to speak to a Listener or the Samaritans. He told staff he wanted to stay on A wing
and would probably “snap out of it”.
77. On 6 August, an officer completed an ACCT assessment. He noted Mr Follos
struggled with his mental health and had been given vapes to calm down.
78. A SO chaired an ACCT review. A nurse from the mental health team attended. The
SO noted that Mr Follos appeared positive and spoke about his future but said he
had not slept, felt stressed and struggled with hearing voices. Mr Follos denied
thoughts of self-harm. Staff considered that Mr Follos’ risk of self-harm was low,
and his observations were lowered to five a day. The nurse referred Mr Follos to the
mental health team to discuss his medication. It was noted that Mr Follos was
grateful for the referral as he wanted to stabilise his mental health before release.
That afternoon, Mr Follos spoke to a Listener, appeared in a better mood, and
socialised with other prisoners.
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79. On 7 August, an officer completed a keywork session. Mr Follos told the officer that
he did not need any support in preparation for his release.
80. That day, Mr Follos made an application to the chaplaincy team. He asked to be
baptised a Catholic and wanted an exorcism, as he was possessed by an evil spirit.
81. On 8 August, Mr Follos told an officer at a keywork session that he was going to join
a prisoner-led support group for prisoners with mental health issues. The officer
noted that Mr Follos did not appear to take care of himself and gave him cleaning
products. Mr Follos told the officer he still heard voices but denied thoughts of
suicide or self-harm.
82. That day, a SO chaired an ACCT review. The officer attended. A nurse gave the SO
a healthcare update beforehand. She told the SO that the mental health team was
due to see Mr Follos the next day. The SO noted that Mr Follos engaged well, said
he was doing “alright” and found talking to Listeners and the Samaritans useful. The
SO reminded Mr Follos about his meeting with the mental health team and noted
that Mr Follos had said that there was nothing further staff could do to support him,
but he found it helpful to talk. The SO considered Mr Follos posed a low risk of
suicide and self-harm, and as there were no further caremap actions to be
completed, she closed the ACCT. That afternoon, it was noted that Mr Follos
collected his meal and appeared “in excellent spirits”.
83. On 9 August, Mr Follos told a nurse that he had harmed himself the previous
weekend because he had felt low. He said he just wanted to get on with things
before his release and denied thoughts of suicide and self-harm. The nurse noted
that arrangements for a community mental health team referral would be made
pending his release.
84. On 9 August, a SO noted, following an incentives review, that Mr Follos would
remain on the basic regime for continually misusing his cell bell. He later noted that
Mr Follos had engaged positively with other prisoners who had helped him
complete pre-release forms.
85. During the evening routine roll check on 11 August, Mr Follos told an Operational
Support Grade (OSG) that he had swallowed a pen as he felt fed up. Staff restarted
ACCT monitoring and agreed to observe him hourly.
86. A Custodial Manager (CM) completed an ACCT review. He noted that Mr Follos
displayed no symptoms after allegedly swallowing a pen and had no difficulty
breathing. Mr Follos said he was bored and was due for release in thirteen days.
The CM told him that he would be monitored overnight and would be referred to the
healthcare team. Other items that Mr Follos might swallow were removed from his
cell.
87. On 12 August, Mr Follos had a prison X-ray body scan (in response to having
swallowed a pen). Nothing was detected and a CM noted that Mr Follos could not
explain why. Healthcare staff assessed Mr Follos, took observations but noted no
further concerns.
88. That afternoon, a CM chaired an ACCT case review. Healthcare staff gave an
update beforehand. He noted that healthcare staff had found no evidence that Mr
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Follos had swallowed a pen. Mr Follos told the CM he was stressed about his
impending release but had no thoughts of suicide or self-harm. The CM discussed
with Mr Follos his accommodation on release and assured him that it would be
arranged. He noted that the mental health nurse would see Mr Follos on 15 August,
and this boosted Mr Follos’ mood. He concluded that Mr Follos was upbeat, not in
crisis and denied thoughts of suicide and self-harm. He concluded that the ACCT
could be closed.
89. On 15 August, Mr Follos told the mental health nurse that he only managed to sleep
for two to three hours a night. The nurse noted that Mr Follos appeared unkempt
but did not look tired. Mr Follos asked him if the psychiatrist could give him sleep
medication. The nurse told Mr Follos that the psychiatrist was not at the prison for
two weeks and could therefore not review his medication before his release. He
noted that Mr Follos accepted this, was looking forward to his release and was
determined not to return to prison. Mr Follos provided his release address, which
was in supported housing. The nurse told him that he would refer him to the
community mental health team who would take over his mental healthcare.
90. That day, Mr Follos contacted a SO and told him his release address had been
approved. Mr Follos was moved to C wing. There is nothing to explain why he was
moved.
91. On 16 August, a worker from the prison’s substance misuse team tried to speak to
Mr Follos but was unable to due to an incident on the wing.
92. A member of staff from OMU sent details of Mr Follos’ licence and release address
to his COM. The following day, healthcare staff sent a summary of Mr Follos’
healthcare needs to his local GP surgery. Mr Follos’ incentives level was raised to
standard due to an improvement in his behaviour.
93. On 18 August, a CM completed Mr Follos’ post-closure ACCT review. Mr Follos told
him that he enjoyed being on C wing as people left him alone. Mr Follos said that
when he felt low, he felt “not worthy” and a “piece of shit”, but he was trying to have
a positive mindset and would speak to staff if he felt low. The CM decided the
ACCT could remain closed as Mr Follos’ mindset had been positive.
Events of Sunday 20 August
94. At 7.30pm on 20 August, Mr Follos told an officer that he had swallowed a key. Staff
restarted ACCT procedures. A CM, who was temporarily undertaking the role,
chaired an ACCT case review. Mr Follos said he was fed up of hearing voices, felt
low and did not know what to do. Mr Follos asked the CM to move him to the
segregation unit. (The CM said Mr Follos was fixated on this.) The CM told him that
the segregation unit was not the safest or most appropriate place for him and there
was more support on the wing. Mr Follos asked staff to remove his television, laptop
and other items from his cell to prevent self-harm. The CM told Mr Follos that he
could speak to the mental health team the next day. He noted that Mr Follos was
concerned about his release the following week. He explained to Mr Follos that staff
would be available to help him the following morning. He noted this in the ACCT so
that staff could pick it up the next day. He said that Mr Follos reassured him that he
would not do anything overnight, and he concluded that Mr Follos should be
observed hourly until his next review the following morning.
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95. At around 8.21pm, an officer spoke to Mr Follos at his cell door. Mr Follos told the
officer he had swallowed stuffing from his pillow and did not want to live anymore.
Staff removed the pillow from Mr Follos. At 8.57pm, the officer carried out a check
and noted that Mr Follos was lying on his bed, fully clothed.
Events of 21 August
96. Mr Follos told an officer that he had wet his bed during the night. The officer said he
took the comment at face value but on closer inspection, it looked as if Mr Follos
had poured a cup of water on himself. At around 8.40am, the officer noted that Mr
Follos had been given clean clothing, bedding and cleaning products for his cell.
That morning, Mr Follos mixed with other prisoners.
97. At 10.00am, a CM chaired an ACCT review which the mental health nurse
attended. Prior to the review, Mr Follos had been cleaning his cell. The CM said he
read a CM’s review from the previous evening. Mr Follos told the CM that he
struggled with voices in his head which did not stop, and he wanted to be left in
peace. In response to the CM’s questions, Mr Follos said he did not know what had
changed since the ACCT had been closed on 18 August, but he wished he did not
have mental health issues.
98. The mental health nurse said that Mr Follos looked tired, anxious and low, but Mr
Follos denied this and said he was looking forward to his release. Mr Follos told the
nurse that he did not think his medication worked and he wanted to see the
psychiatrist again. The nurse told Mr Follos to raise any concerns with the
community mental health team on release.
99. Mr Follos was concerned that he might be sectioned on release. He was reassured
that this would not happen. Mr Follos then said he wanted to be sectioned as he
had committed an offence so that he could be taken into custody to get help. The
mental health nurse told Mr Follos that on release, he could voluntarily section
himself, but the community mental health team would ultimately decide. The nurse
told Mr Follos that his community mental health referral had been completed.
100. Mr Follos told the CM that he had no thoughts of suicide or self-harm and wanted to
continue cleaning his cell. The CM and the mental health nurse concluded that Mr
Follos should remain on ACCT monitoring until his release, but they agreed to
reduce his observations to five times a day. A further review was scheduled for 23
August, two days before Mr Follos’ planned release.
101. At 10.52am, OMU sent Mr Follos a message to confirm that post-release
accommodation had been found and he should attend his probation appointment on
release. At 2.41pm, Mr Follos responded, “okay thanks”.
102. That morning, a worker from the substance misuse team went to see Mr Follos to
discuss the risks of substance misuse in preparation for his release. He later noted
that he had not been able to do so as Mr Follos had appeared angry or upset and
was in an “animated conversation” with an officer. He said Mr Follos was “talking
forcefully”. (We have not been able to identify this officer or any further details about
the nature of the exchange.) He considered that there was no point trying to speak
to Mr Follos afterwards and planned to see him again after his depot injection.
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103. The worker told the investigator that he spoke to the mental health nurse about Mr
Follos’ presentation. He said that the nurse told him that Mr Follos was due his
depot injection and his mental health deteriorated in the period leading to it. (Mr
Follos received his depot injections at the end of each month.)
104. At 3.45pm, a nurse noted that Mr Follos had attended the medication hatch and told
healthcare staff that he had swallowed a vape and burnt his left hand which was
noted as red but with no blistering. She noted in the ACCT record that she would
hand over to the evening duty nurse and wing staff. (There is no entry in Mr Follos’
medical records or in other prison records to confirm if this happened.)
105. Staff completed Mr Follos’ ACCT checks that evening and an officer noted that Mr
Follos raised no concerns.
Events of 22 August
106. On the night of 21 to 22 August, staff checked on Mr Follos in line with his ACCT
observations but noted no concerns.
107. At 7.45am on 22 August, Mr Follos’ cell was unlocked, and he left to exercise
outside before Officer A locked him back in his cell. At 8.24am, Officer B spoke to
Mr Follos at his cell door. He could not recall their conversation, but said it was
most likely that Mr Follos had asked for vapes.
108. At 9.13am, Officer B unlocked Mr Follos. He left his cell and on several occasions
over the following few hours, left and returned to his cell and interacted briefly with
other prisoners. During some of this time, Mr Follos squatted on the floor outside his
cell, vaping, and watched another prisoner have a haircut. At 10.50am, Mr Follos
was locked in his cell.
109. At 11.29am, Officer B unlocked Mr Follos to collect his lunch. The officer locked him
back in his cell at 11.34am.
110. At 11.49am, Officer A answered Mr Follos’ cell bell. He said that when he opened
the cell door, Mr Follos told him he felt like smashing his laptop and asked him to
take it away. He said that when he took the laptop, Mr Follos told him to take his
trainers too. He said he did not recall asking Mr Follos why he wanted to damage
the laptop or why he wanted the items removed because it was not the first time he
had asked staff to remove items from his cell.
111. Officer A said that Mr Follos had said he felt tired. The officer suggested he should
sleep. He said that Mr Follos had not appeared distressed.
112. At 11.53am, Officer A completed the roll check. He said that Mr Follos was lying on
his bed. At 11.55am, Officer B completed an ACCT check on Mr Follos. This was
the last time Mr Follos was seen alive.
113. At 4.30pm, Officer B unlocked Mr Follos’ cell so he could collect his evening meal.
He turned to walk away from the cell but returned within seconds as he felt
something was not right and went into the cell. He found Mr Follos at the back of
the cell, in a seated position below the window, with a ligature made out of a sheet
around his neck and tied to the window. (He said the ligature did not need to be cut.
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He described it as like a loop of fabric which Mr Follos had sunk into.) He radioed a
general alarm and a prisoner passing by on the landing also pressed the alarm.
Seconds later, he radioed a medical emergency code blue (indicating a prisoner is
unconscious or having trouble breathing) and an ambulance was called at 4.31pm.
114. Two prisoners helped Officer B lift Mr Follos from the ligature as Officer C arrived.
Officer B checked for signs of life but found none. He started CPR. Officer C and
other officers who attended took over resuscitation efforts. Healthcare staff arrived
at 4.34pm with their emergency response bags. Mr Follos was moved onto the
landing and healthcare staff took the lead in resuscitation attempts. A defibrillator
was attached but advised no shock. At 4.55pm, paramedics arrived, assessed Mr
Follos and continued CPR. At 5.03pm, an air ambulance doctor declared that Mr
Follos had died.
Contact with Mr Follos’ family
115. Despite the significant efforts of the prison, police and other services to contact Mr
Follos’ next of kin, it was not until the evening of 29 August – a week after Mr Follos’
death - that West Midlands Police broke the news of his death to his sister. The
following day, the family liaison officer contacted Mr Follos’ sister and later visited
her. Mr Follos’ sister told her that she had received a letter from Mr Follos a few
days before his death. She said he had asked her to send him her telephone
number and some money, he had said he did not feel very well, and his medication
did not suit him. But he also said he was looking forward to his release, planned to
go to Alcoholics Anonymous meetings and to look for charity work.
116. Stoke Heath contributed more than the recommended amount outlined in national
instructions towards funeral expenses. The prison’s chaplaincy helped Mr Follos’
sister organise his funeral and provided additional support.
Support for prisoners and staff
117. Stoke Heath initiated postvention procedures. After Mr Follos’ death, the Governor
debriefed the staff involved in the incident to ensure they had the opportunity to
discuss any issues arising, and to offer support. The care team also offered
support.
118. The prison posted notices informing other prisoners of Mr Follos’ death and offered
support. The prison also used Listeners to offer support on the wing. Staff reviewed
all prisoners assessed as at risk of suicide or self-harm in case they had been
adversely affected by Mr Follos’ death.
Information provided to IMB and PPO after Mr Follos’ death
119. After Mr Follos’ death, prisoners made allegations to the IMB and PPO about staff
and prisoners mistreating Mr Follos, and engaging in unprofessional behaviour, at
Stoke Heath. The PPO interviewed three prisoners about these allegations.
120. One of the prisoners who made some of the allegations had transferred to another
prison. That prisoner had shared his concerns with prison staff who then submitted
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intelligence reports. Stoke Heath told us that they did not take any action or conduct
an investigation, as the intelligence reports did not contain dates or staff names.
Post-mortem report
121. A post-mortem examination found that Mr Follos died from hanging. The post-
mortem report highlighted that Mr Follos had a number of objects in his stomach
and rectum, including a Chubb key, two scrunched up plastic bags and thin pieces
of plastic/metal which may have been vape cartridges.
122. Toxicology tests confirmed no evidence of recent synthetic cannabinoid use.
However, a number of other substances, including promethazine (which was
prescribed) and citalopram, diazepam and amphetamine (which were not
prescribed) were identified at low levels. The pathologist concluded that these were
unlikely to have contributed to Mr Follos’ death.
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Findings
Management of risk of suicide and self-harm
123. In line with Prison Service Instruction (PSI) 64/2011 on safer custody, which was in
place at the time of Mr Follos’ death, staff appropriately started ACCT monitoring on
5 August 2023, after Mr Follos told them he had drunk the contents of a vape
capsule and had heard voices telling him to kill himself. Mr Follos’ ACCT monitoring
was closed on 8 August but reopened for a day on 11 August, after Mr Follos told
staff he had swallowed a pen. Staff restarted ACCT monitoring on 20 August, after
Mr Follos said he had swallowed a key and was fed up with hearing voices.
124. However, we are concerned that the ACCT procedures were not always started
when they should have been, they were poorly managed, did little to support Mr
Follos or address his underlying issues and were closed prematurely.
Failure to start ACCT monitoring
125. On 15 June, when Mr Follos told the mental health nurse that voices had told him to
kill himself, the nurse should have opened an ACCT. The nurse said he did not do
so as he felt Mr Follos was saying it more than thinking it. He told us he had not
received ACCT training but if he had genuinely thought Mr Follos would harm
himself, he would have opened an ACCT. While this may be the case, the PSI was
clear that staff should begin ACCT procedures if a prisoner disclosed thoughts of
suicide or self-harm. This was a missed opportunity to identify any increasing risk
factors for Mr Follos and address them early through an ACCT assessment and
review.
126. Following a scheduled ACCT review on 21 August, Mr Follos told a nurse that he
had swallowed a vape pen and had burnt his hand. The nurse recorded details in
the ACCT, but it is not clear if she took any other steps to inform prison staff or
healthcare colleagues. Staff should have held an ad hoc case review in line with
PSI 64/2011 to re-assess his immediate risk. This was another missed opportunity
to assess Mr Follos’ risk and to consider introducing protective measures such as
increasing the frequency of his observations and arranging an urgent mental health
review.
Frequency of ACCT observations
127. At the ACCT review on 21 August, the day before he died, Mr Follos denied
thoughts of suicide and self-harm and said he was looking forward to his release.
However, he had also told them at that review and the ad hoc review the previous
day, that he continued to struggle with voices in his head, did not think his
medication was working and wanted to see a psychiatrist. The mental health nurse
also noted that he appeared tired, anxious and low - which he denied. At the ad hoc
review on 20 August, Mr Follos had also said that he was concerned about his
release and that day had said he had harmed himself by swallowing stuffing from
his pillow. Staff at the ACCT review concluded that the frequency of observations
could reduce from hourly to five observations during the day and night.
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128. We consider that the reduction in frequency of ACCT checks was premature given
the unpredictability of Mr Follos’ behaviour and demeanour. He was due a depot
injection and staff recognised that his behaviour was more difficult in the days
before his next dose of antipsychotic medication. The frequency of ACCT
observations on the day Mr Follos hanged himself did not adequately reflect his
level of risk, and we do not consider that the risks identified in the reviews on 20
and 21 August were sufficiently addressed before staff lowered the frequency of
observations.
129. We are also concerned that on 22 August, the day Mr Follos died, staff completed
all five of the required ACCT observations between 7.00am and 11.55am. They did
not check on him again until 4.30pm, when they unlocked his cell for his evening
meal and found him hanged. While we accept that the five ACCT checks were
completed, they were not evenly distributed throughout the day but were completed
within a five-hour window in the morning. A CM agreed that the expectation could
have been made clearer to staff that they should have spread the observations
more evenly through the day to keep Mr Follos safe.
Use of the ACCT care plan to inform decisions
130. On two occasions, staff closed ACCT procedures prematurely before all the care
plan actions had been completed. On 8 August, Mr Follos’ ACCT was closed
despite him telling an officer that day that he still heard voices and an action for the
mental health team to assess him remaining outstanding. In interview, a SO said
she stood by her decision to close the ACCT given that Mr Follos was already
under the care of the mental health team, was not new to prison and, from her
experience of working with him, was not at a point of crisis.
131. A nurse, who had referred Mr Follos to the mental health team on 6 August, said
she would have expected the ACCT to have remained open until the mental health
assessment had been completed. We agree.
132. On 12 August, a CM closed Mr Follos’ ACCT, even though he had told staff he had
swallowed a pen the previous evening and had said that he was stressed about his
accommodation on release. Although the CM noted that he had assured Mr Follos
that his accommodation would be arranged, the ACCT should not have been closed
but instead, his care plan should have been updated to reflect Mr Follos’ concerns
about his release so that his offender manager could address these.
133. On 20 August, Mr Follos told staff he had swallowed a key as he was fed up with
hearing voices and was concerned about his release. Staff restarted ACCT
monitoring and at an ACCT review, a CM told Mr Follos that he could speak to the
mental health team the following day and staff would address his concerns about
release. Again, neither action was noted on Mr Follos’ care plan, and staff therefore
did not address them the following day. The CM acknowledged that he should have
done this. We also note that the care plan did not include reference to Mr Follos
eating the stuffing from his pillow.
134. We are also concerned that a CM had not properly considered the importance of
the previous entries and reviews in Mr Follos’ ACCT on 21 August. He made no
further additions to the care plan.
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135. Guidance in the ACCT document notes that staff should not end ACCT procedures
if there are any outstanding issues. We consider that staff did not recognise that
actions on Mr Follos’ care plan had not been completed or that new actions should
have been added and addressed.
We identified similar deficiencies in ACCT procedures in our investigations into the
self-inflicted deaths of men at Stoke Heath in December 2021 and September 2022.
HMIP also identified that more work was needed to improve the quality of ACCT
case management. Although Stoke Heath agreed to implement our previous
recommendations, it is clear from the failings in this case that more needs to be
done to embed the necessary learning. We therefore make the following
recommendations:
The Governor should ensure that prison staff manage prisoners at risk of
suicide or self-harm in line with the Prison Safety Policy Framework,
including that stringent ACCT quality assurance procedures are in place for
senior managers to identify poor practice, learn lessons and, where
appropriate, provide staff with refresher training.
The Prison Group Director for West Midlands should outline in the action plan
for this report the steps she has taken to satisfy herself that effective action is
being taken to improve ACCT quality assurance at Stoke Heath.
Mr Follos’ concerns for his safety
136. PSI 64/2011 set out how violent prisoners should be managed. It said that victims
should be supported and protected. Being a victim of intimidation or violence are
recognised risk factors for suicide and self-harm. The PPO has published a range of
publications identifying the links between bullying and suicide and we identified the
need for staff to record and investigate all reports or suspicions that a prisoner is
being threatened or bullied and to consider the potential impact on the victim’s risk
of suicide.
137. On five occasions between 26 June and 20 July, Mr Follos told staff that he feared
for his safety and reported being attacked multiple times and having items stolen
from his cell. Staff recorded just three welfare checks during this period, and there
is no evidence that they took any specific action or investigated his concerns
appropriately.
138. Stoke Heath’s safer custody policy requires that the prison’s violence reduction or
safety team investigates allegations of bullying as soon as possible and that they
should produce a report outlining recommendations and next steps which may
include monitoring perpetrators, a referral to offending behaviour programmes and
the creation of a Challenge Support Intervention Plan (CSIP) for victims. (A CSIP is
a multidisciplinary approach which focuses on prisoners at raised risk of being
violent and works to change their behaviour.) There is no evidence that staff took
any meaningful action to investigate and address Mr Follos’ concerns and there is
little evidence that interventions were implemented to help him feel less scared.
139. It is not acceptable for any prisoner to feel unsafe. The Governor must ensure that
staff understand their responsibilities, and the policies and processes in place to
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challenge, investigate and escalate inappropriate behaviour by prisoners to one
another. We recognise the complexities in identifying and investigating alleged
inappropriate behaviour and the difficulties staff face in investigating unevidenced or
unspecified fears that a prisoner is under threat. However, it is possible that Mr
Follos’ experiences might have contributed to his feelings of hopelessness. We
make the following recommendation:
The Governor should ensure that staff:
• fully and promptly investigate information about bullying and
intimidation;
• challenge alleged perpetrators appropriately; and
• support victims effectively and properly consider and address the
possible impact on their risk of suicide and self-harm.
Allegations about staff behaviour towards Mr Follos
140. After Mr Follos’ death, several prisoners alleged to the PPO and IMB that staff and
prisoners had mistreated Mr Follos. The investigator interviewed fifteen members of
staff, including three whom allegations had been made against. The three officers
we interviewed about the allegations denied the behaviours alleged and they and
other officers told us that they felt confident reporting inappropriate behaviours
towards prisoners if they saw it.
141. In relation to some of the allegations, we have evidence to help us understand
whether they demonstrated that Mr Follos was being treated differently or unfairly
by staff (for example, losing his access to in-cell television through misuse of his
cell bell). However, we have not been able to establish whether other of the
allegations were true, and if they were, whether they contributed to Mr Follos’
decision to take his life.
142. They were of sufficient gravity that we raised them with the Governor. The
investigator and an Assistant Ombudsman at the PPO met the Governor remotely
on Teams twice between January and April 2024 to discuss in detail the allegations
made, concerns about staff conduct and the action he had taken and planned to
take.
143. HMPPS’ Tackling Unacceptable Behaviours Unit completed a climate assessment
report about Stoke Heath in April 2023. The Governor told the PPO that this had
been commissioned before he had arrived at Stoke Heath. The Governor reported
that most of the feedback from the assessment was about the prison’s senior
leadership team, equity of opportunities and staff culture. The Governor told us that
five new senior managers had taken up roles, including a new Head of Security and
Head of Residence.
144. The Governor told the PPO that Stoke Heath was safe and that a safety report from
the Operational and System Assurance Group, published in December 2023, had
given the prison an amber/green rating (indicating a generally positive assessment).
The Governor said that the HMIP report of 2023 had also given the prison a rating
of four out of five for safety and three out of five for respect. He said that the data on
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assaults and self-harm were significantly below the level for comparator prisons.
However, the Governor acknowledged that there may be pockets of staff who acted
illegitimately. He said he continued to make changes at Stoke Heath and, for
example, had changed incentives guidance to make the system fairer.
145. The Governor confirmed that one of the officers whom prisoners alleged had acted
inappropriately was dismissed for failing his probation. He told us that another
officer against whom allegations were made had also been dismissed on matters
unrelated to these allegations. The Governor told us that he had considered the
allegations we passed to him but considered that there was no other evidence to
warrant investigations into the other five officers identified. He said that he tackles
staff issues robustly when he has sufficient evidence to do so.
146. The Governor said that since his arrival at Stoke Heath in summer 2023, he had
dismissed eight members of staff for conduct-related issues and admitted that
Stoke Heath had challenges. He said he was committed to Stoke Heath being
progressive and rehabilitative and to rooting out bad behaviours.
147. On 5 August 2024, the PPO wrote to the Governor seeking further assurances that
the allegations about staff’s behaviour towards Mr Follos did not indicate a systemic
issue at Stoke Heath.
148. The Governor shared with us a summary of the climate assessment report which
had previously been shared with prison staff, and complaints data for the quarter
leading to Mr Follos’ death and the most recent completed quarter (which was to
August 2024).
149. The climate assessment summary reported that 24% of staff who had completed
the survey had been subject to bullying, harassment or discrimination, and a further
40% had witnessed such behaviours. The summary highlighted the perception that
the senior leadership team were most actively involved in behaviours considered to
be unacceptable. It also indicated concerns about attitudes, unacceptable
behaviours and comments about protected characteristics.
150. The complaints data provided indicated a similar number of complaints about staff
in 2023 and 2024. It did not provide sufficient detail for us to establish whether there
are systemic issues about staff misconduct at Stoke Heath, as raised in the
allegations made by prisoners – and in any case, we know that prisoners are often
reluctant to make complaints about staff behaviour for fear of repercussions.
151. The Governor assured us that he had implemented changes to keep Stoke Heath
safe and that he takes staff conduct and prisoner safety seriously. Given the
number of allegations about staff behaviour made after Mr Follos’ death, and his
own concerns for his safety, we consider this to be an issue requiring continued
focus at Stoke Heath. We expect Governor Greenhaf to continue his efforts to
prioritise safety and respect at the prison, and tackle staff misconduct.
Clinical care
152. The clinical reviewer concluded that the healthcare that Mr Follos received in
custody was of a good standard and was at least equivalent to that which he could
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have expected to receive in the community. The clinical reviewer concluded that Mr
Follos received care and support from mental health services at Stoke Heath.
153. However, Shropshire Community Health NHS Trust’s Serious Incidents
Investigation Report identified learning and made several recommendations about
the delivery of mental health services which the Head of Healthcare at Stoke Heath
will want to address.
Good practice
154. The appointed family liaison officer and the chaplaincy team at Stoke Heath
demonstrated compassion and provided comprehensive support to Mr Follos’ sister
after his death.
Inquest
155. The inquest into Mr Follos’ death was held on 10 to 14 November 2025. The jury
concluded that Mr Follos died with unknown intent having self-ligatured by means of
a bedsheet attached to a window in his cell. It was not possible to determine what
his intention was at the time that he did this.
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