Stephen Bird

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Independent investigation into
the death of Mr Stephen Bird,
a prisoner at HMP Altcourse,
on 8 September 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, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Stephen Bird was found hanging in his cell at HMP Altcourse on 8 September 2023.
Prison staff and paramedics tried to resuscitate him but were unsuccessful. He was 53
years old. I offer my condolences to Mr Bird’s family and friends.
Mr Bird’s death was the sixth self-inflicted death at Altcourse in three years.
Mr Bird had been in prison for only four days when he was found hanging. Staff correctly
started suicide and self-harm monitoring procedures (known as ACCT) on the evening of 8
September, when he indicated that he might be considering taking his own life. He was
found hanging a few hours later.
We are satisfied that prior to 8 September, Mr Bird gave no indication to staff that he was
at risk of suicide. Once staff started ACCT procedures on 8 September, they managed
them appropriately.
I make no recommendations.
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 June 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 4 September 2023, Mr Stephen Bird was remanded to HMP Altcourse, charged
with drug offences. He told a nurse that he had problems with alcohol and drugs,
and had a mental illness but did not remember what it was. The nurse recorded that
Mr Bird struggled to understand what was happening and that he showed signs of
alcohol withdrawal. A GP prescribed relevant medication and staff monitored him
for signs of withdrawal.
2. On 6 September, Mr Bird said that he had twice fallen from the top bunk bed. A
nurse noted a small cut on his head, but he was otherwise well. The same day, a
nurse carried out a mental health screening. She assessed that Mr Bird showed no
signs of mental illness and that his mood was stable, but he was slow to answer
questions. She referred him for a cognitive ability test which he had the same day.
He had some issues with information recall.
3. On 7 September, Mr Bird said he had fallen from his bed again and a nurse
assessed him. That evening he once again said that he had fallen from his bed and
a nurse referred him to see the doctor about some pain in his heel.
4. On the evening of 8 September, wing staff contacted healthcare staff as they were
concerned about Mr Bird’s presentation. A nurse went to see him, and Mr Bird was
lethargic and had difficulty answering questions. The nurse arranged for him to
move to the healthcare unit. While they were making arrangements, Mr Bird said “I
don’t want to be here”. Staff asked him what he meant but he would not expand.
Staff started suicide and self-harm prevention procedures (known as ACCT) and set
observations at two an hour. They took Mr Bird to the healthcare unit. A healthcare
assistant (HCA) checked him twice an hour in line with the ACCT plan.
5. During an ACCT check at 10.56pm, the HCA looked through the observation panel
in the cell door and saw Mr Bird’s legs pointing away from the door, which
suggested that he was sitting with his back against the door. When the HCA spoke
to Mr Bird he did not reply. The HCA telephoned the duty manager to report this
and then returned to the cell. He managed to open the observation hatch in the cell
door and realised that Mr Bird had been attached to the hatch by a ligature, which
broke when he opened it. He used his radio to call a medical emergency code and
the control room called an ambulance.
6. An officer responded to the code but waited outside the cell until two more prison
officers arrived. The officers and the HCA then entered the cell and started CPR,
which ambulance paramedics continued when they arrived. However, resuscitation
attempts were unsuccessful and at 11.25pm, paramedics recorded that Mr Bird had
died.
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Findings
7. We are satisfied that Mr Bird did not show any indication that he was at risk of
suicide or self-harm up to the evening of 8 September. We consider that staff
correctly started ACCT procedures on 8 September and managed them
appropriately.
8. Mr Bird used a damaged cell door to secure the ligature. Following Mr Bird’s death,
other cells were found to contain similar damage, which had not been identified
during standard cell checks. These have since been repaired. We make no
recommendation, but the Director will need to monitor that cell checks are
identifying damage.
9. Staff delayed going into Mr Bird’s cell as they were under the incorrect impression
that three officers needed to be present to open a cell at night. We understand that
national training is being updated to make it clear that staff can enter cells in
emergencies for preservation of life.
10. The clinical reviewer concluded that the care Mr Bird received for his substance
misuse and mental health was of a good standard and equivalent to that which he
could have expected to receive in the community.
11. We make no recommendations.
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The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Altcourse informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
13. The investigator visited Altcourse on 21 September 2023. He obtained copies of
relevant extracts from Mr Bird’s prison and medical records.
14. The investigator interviewed eight members of staff at Altcourse in November and
December 2023.
15. NHS England commissioned an independent clinical reviewer to review Mr Bird’s
clinical care at the prison. The investigator and the clinical reviewer conducted joint
interviews of healthcare staff.
16. We informed HM Coroner for Liverpool and The Wirral of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
17. The Ombudsman’s family liaison officer contacted Mr Bird’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked why Mr Bird was taken to the healthcare unit in a wheelchair, why he had the
items he used to hang himself, and why he had been unable to get through to her
on the telephone. We have addressed these issues in the report.
18. We shared our initial report with HMPPS. They found no factual inaccuracies.
19. We sent a copy of our initial report to Mr Bird’s mother. Her legal representatives
responded on her behalf and highlighted several factual inaccuracies in the clinical
review. This has been amended and the updated version is attached as an annex to
this report.
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Background Information
HMP Altcourse
20. HMP Altcourse is a local prison in Liverpool, which takes prisoners from courts in
Merseyside and Cheshire. It holds up to 1,164 remanded and sentenced adults and
young men. G4S managed the prison and provided primary healthcare services
until NHS England took over healthcare services in April 2023, and in June 2023
Sodexo took over management of the prison. GP services are managed by Practice
Plus Group.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Altcourse was in November 2021. Inspectors
noted that prisoners’ safety was not sufficiently good and had deteriorated since the
last inspection in 2017. Eight prisoners had taken their own lives; four in the
previous 12 months.
22. Levels of self-harm remained high and Early Learning Reviews had not been
transferred into longer term safety plans. There were issues with some aspects of
ACCT management, including weaknesses with risk assessment. Staffing numbers
had a detrimental impact on the development of primary and mental health care.
Independent Monitoring Board
23. 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 June 2023, the IMB reported that
staff shortages had impacted on the prison. Incidents of self-harm had risen.
Prisoners in the healthcare centre were well cared for.
Previous deaths at HMP Altcourse
24. Mr Bird was the 22nd prisoner to die at Altcourse since September 2020. Of the
previous deaths, 15 were from natural causes, five were self-inflicted, and one was
drug related.
Assessment, Care in Custody and Teamwork (ACCT)
25. 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.
26. 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 multi-disciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
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ACCT plan should not be closed until all the actions of the caremap have been
completed.
27. All decisions made as part of the ACCT process and any relevant observations
about the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction (PSI) 64/2011.
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Key Events
28. On 2 September 2023, Mr Stephen Bird was arrested and charged with intent to
supply class A drugs. On 4 September, he was remanded in custody and taken to
HMP Altcourse. It was not his first time in prison, but he had not been in prison
since 2017.
29. Mr Bird’s Person Escort Record (PER, a document that accompanies prisoners
between police custody, court and prisons, which sets out the risks they pose)
noted that Mr Bird had historical markers for suicide and self-harm (from 2015).
30. A nurse carried out the initial health screen when Mr Bird arrived at Altcourse. Mr
Bird said that he had problems with alcohol and drugs, including heroin,
methadone, cannabis, benzodiazepines and cocaine. He had most recently used
cocaine three days before (this was the only drug to show up in a drug test). He
also had sight and hearing loss and said he had a mental illness but could not
remember what. He said he had no history or thoughts of self-harm. The nurse
noted that Mr Bird struggled to engage with the process and had clear difficulties
understanding what was happening. She noted that he showed signs of alcohol
withdrawal. A GP prescribed diazepam to help with alcohol withdrawal symptoms.
Mr Bird was allocated a double cell on Furlong Wing, the detoxification wing, and
monitored for alcohol withdrawal.
31. On 5 September, a clinical support worker carried out Mr Bird’s secondary health
screen. Mr Bird said that he was on a prescription of methadone (though his drug
test did not show any in his system). He could not remember the pharmacy who
managed his prescription. He was displaying mild symptoms of substance
withdrawal. The clinical support worker referred him for a psychosocial substance
misuse assessment.
32. On 6 September, Mr Bird said that he had twice fallen from the top bunk bed. A
nurse noted a small cut on his head but that he was otherwise physically well.
33. When collecting his prescription of diazepam on the morning of 6 September, Mr
Bird tried to conceal it and take it away. The nurse saw him do so and challenged
him, whereupon Mr Bird swallowed the medicine. He was warned that if this
happened again his prescription would be cancelled.
34. The same day, a nurse saw Mr Bird for a mental health screening (all new arrivals
at Altcourse are screened for mental health issues). She noted that Mr Bird was
tired and left long pauses before answering questions, though he was aware of
where he was. He said he had no thoughts of harming himself and his mood was
stable. He said that he had a history of mental health problems but showed no signs
of psychosis. The nurse recorded that Mr Bird would benefit from further
assessment of his cognitive abilities and added him to the list for a further test. A
clinical support worker gave Mr Bird a cognitive impairment test the same day. He
had problems with recalling information.
35. That afternoon, a nurse monitored Mr Bird’s detoxification. He reported a stomach
ache, but no further symptoms.
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36. During the early hours of 7 September, a nurse was called to see Mr Bird. He was
lying on his cell floor and said that he had fallen from the top bunk bed and hurt his
heel. The nurse noted a small graze but no other problems. She recommended to
prison officers that he ought to be on the lower bunk bed.
37. On the evening of 7 September, a nurse was asked to see Mr Bird. He said that he
had fallen from the top bunk bed again and reported pain in his heel. She arranged
for him to move to the lower bunk bed and referred him to see the doctor about the
pain and his medication.
Events of 8 September
38. On the morning of 8 September, a nurse assessed Mr Bird, who mentioned bruising
to his foot. His detoxification programme was going well, and the nurse had no
medical concerns. The nurse, who knew Mr Bird from previous sentences, thought
that he was not acting like his usual self, so she sent a message to the mental
health team asking them to bring his cognition test forward. At interview, the nurse
said that she had no concerns about him presenting any risk to himself.
39. That evening, wing staff contacted the healthcare department because they were
concerned about Mr Bird. A nurse went to the wing. Mr Bird had just woken up, and
was lethargic and had difficulty answering questions. The nurse was also
concerned at his presentation and arranged for him to move to the healthcare unit.
While they were making arrangements, Mr Bird said “I don’t want to be here”. Staff
asked him where he did not want to be, but he would not elaborate. As it was not
clear what Mr Bird meant, an officer started suicide and self-harm prevention
procedures (known as ACCT) at 6.30pm. She set observations at two an hour.
40. The nurse saw that Mr Bird was unsteady on his feet, so arranged for a wheelchair
to take him from the bottom of the stairs on the wing to the healthcare centre. Once
there, they went into cell 6. The nurse was concerned, however, at the height of the
bed in relation to Mr Bird’s unsteadiness, so they relocated him to cell 5. The nurse
took Mr Bird’s physical observations, which were all within normal range.
41. The officer told the Operational Middle Manager (OMM) that she had started ACCT
procedures for Mr Bird. The OMM went to the healthcare unit to complete the
management actions of the ACCT process. He spoke to the nurse, completed the
Immediate Action Plan, and then spoke to Mr Bird. He explained the ACCT process
and the support that was available. Mr Bird signed the ACCT document. The OMM
said in interview that he had no concerns at that stage about Mr Bird’s risk to
himself and considered there was no reason to remove any personal possessions
given there needed to be strong justification to remove personal items. He kept
observations at two an hour.
42. Mr Bird asked for some food, so staff took him some toast. They then locked the
cell door. A healthcare assistant (HCA) was on duty in the healthcare centre and he
checked on Mr Bird in line with the ACCT plan. At the 9.30pm check, Mr Bird asked
for some sleeping tablets, but the HCA told him that only a doctor could prescribe
these. The HCA made further checks at 9.42pm, 10.04pm and 10.12pm and had no
concerns.
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43. At 10.56pm, the HCA went to the cell and looked through the observation panel (a
viewing window in the cell door). He could see Mr Bird’s legs pointing away from the
cell door, which suggested that he was sitting on the floor leaning back against the
door. Mr Bird did not respond to the HCA’s attempts to talk to him. The HCA said in
interview that he was not concerned for Mr Bird’s safety at this point. He returned to
the office and telephoned the duty manager to report that he had a prisoner he
could not see properly who was not answering him.
44. The HCA then returned to the cell. It was now 10.59pm. He tried to open the cell
door observation hatch (a larger opening in the door to allow healthcare staff
access to give medication and/or treatment) and encountered some resistance. He
used more force and the panel released. He realised that Mr Bird had been
suspended by a ligature attached to the panel. He reached into the cell and found
that the ligature had broken. He used his radio to call a code blue emergency (a
medical emergency code used when a prisoner is unconscious or having difficulty
breathing).
45. An officer responded to the code blue call. CCTV footage showed that he arrived at
the cell at 11.01pm. He asked the HCA what the issue was, and he said that he
thought Mr Bird was hanging behind the door. The officer said in interview that
when the prison is in night state (when there are fewer staff on duty and different
security arrangements apply than during the day) staff should not open cell doors
unless three members of staff were present. At 11.03pm, two more prison officers
arrived, and they opened the cell door and went in. Mr Bird had made a ligature
from a belt attached to a shoelace. The shoelace had broken, so the officer used
his anti-ligature knife to remove the belt from around Mr Bird’s neck. The HCA
checked Mr Bird for a pulse but was unable to locate one. The prison officers
started cardiopulmonary resuscitation (CPR) while a nurse applied a defibrillator (a
machine that can apply an electric shock to restart the heart if electrical activity is
still present). The defibrillator found no electrical activity and advised to continue
with CPR. The code blue emergency had prompted the control room to call an
ambulance. Staff continued to provide medical aid to Mr Bird until ambulance
paramedics arrived and took over. However, resuscitation attempts were
unsuccessful and at 11.25pm, paramedics declared that Mr Bird had died.
Information received after Mr Bird’s death
46. After Mr Bird’s death, on 9 September, an intelligence report was submitted which
said that Mr Bird had confessed to murdering somebody. The investigator tried to
find out the source of this information, but the prison was unable to identify the
source. It is possible that this was a factor in Mr Bird taking the actions he did. The
police provided no further information to the investigator about whether they were
investigating the claim.
Contact with Mr Bird’s family
47. The prison appointed a family liaison officer. Mr Bird had not nominated a next of
kin so the family liaison officer contacted the police to see if they could provide
family details. The police were unable to help so prison staff examined historical
telephone records to try to identify numbers for Mr Bird’s parents. They found a
number for Mr Bird’s mother and on the afternoon of 9 September, the family liaison
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officer and the Deputy Director went to Mr Bird’s mother’s home to inform her of her
son’s death. In line with HMPPS policy, Altcourse offered a contribution to the cost
of Mr Bird’s funeral.
Support for prisoners and staff
48. After Mr Bird’s death the duty director debriefed the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team also offered support.
49. The prison posted notices informing other prisoners of Mr Bird’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 Bird’s death.
Post-mortem report
50. Post-mortem examinations showed that Mr Bird died as a result of hanging.
Toxicology examinations found no evidence of recent substance misuse.
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Findings
Assessment of risk
51. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others, sets out the procedures (known as ACCT) that
staff should follow when they identify that a prisoner is at risk of suicide or self-
harm.
52. Staff correctly started ACCT procedures for Mr Bird on 8 September, when he gave
an indication that he might be at risk of suicide. We are satisfied that he had given
no indication before then that he might be at risk. We consider that the frequency of
checks was appropriate and that the checks were carried out at the required
frequency. Mr Bird died before the assessment interview and first case review were
due to take place, so staff had not had an opportunity to put a care plan in place.
We consider that the ACCT was managed appropriately.
Mr Bird’s healthcare
53. The clinical reviewer concluded that Mr Bird’s substance misuse and mental health
care was of a good standard and equivalent to that which he could have expected
to receive in the community.
54. Mr Bird reported falls from his bunk on four occasions. The clinical reviewer found
that proper procedures were not followed in falls management assessment, and for
this reason his physical healthcare was only partly equivalent. The clinical reviewer
makes a recommendation, which the Head of Healthcare will wish to address.
Emergency response
Accessing the cell
51. PSI 24/2011 on the management and security of nights states that staff have a duty
of care to prisoners, themselves and other staff, and that the preservation of life
must take precedence over usual arrangements for opening cells. It says that where
there is or appears to be immediate danger to life, a single member of staff can
enter the cell alone, after performing a rapid dynamic risk assessment.
52. Altcourse’s local instruction on opening cells at night says that where there is or
appears to be immediate danger to life cells may be unlocked without the authority
of the Night Duty Operations Manager and an individual member of staff may enter
a cell on their own. They must not take any action that puts themselves in
unnecessary danger.
53. At interview, the first officer to arrive at the incident said that it was his
understanding that staff could not open cell doors in night state unless there were
three members of staff present, whatever the circumstances. This is not in line with
policy and resulted in a short delay in staff entering Mr Bird’s cell. Staff uncertainty
about entering cells in an emergency has been a recurring issue in PPO
investigations. As a result of a recent national recommendation, HMPPS begun a
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programme to update national guidance for staff on entering cells in an emergency
to preserve life. We therefore make no recommendation.
Requesting an ambulance
55. The control room log shows that the HCA called a code blue emergency at
11.00pm, and an ambulance was not requested until 11.05pm. In interview, the
officer working in the control room said that despite recording those times he was
confident that he called the ambulance immediately after acknowledging the
emergency call and ensuring that the duty manager was aware. The Ambulance
Service logged the time of the call as 11.04pm. The prison was unable to provide
recordings of the radio traffic, so we have been unable to assess how long the
messages following the code blue call took. We do not therefore make a
recommendation but bring this to the Director’s attention.
Ligature point
56. Mr Bird used a damaged cell door as a ligature point. Cells are regularly checked,
but these did not pick up the damage to that cell door. The Deputy Head of
Facilities told the investigator that following Mr Bird’s death, Altcourse had checked
all doors in the healthcare unit. Four doors were identified with damage and had
been repaired. As appropriate action has been taken, we do not make a
recommendation, but the Director will need to keep cell checks under review to
ensure damage is identified and rectified promptly.
Liaison with Mr Bird’s family
57. PSI 64/2011 says that following a death in custody, prisons must promptly notify
next of kin. Mr Bird died at 11.32pm on 8 September. His mother was not informed
of his death until the following afternoon.
58. We acknowledge that Mr Bird had not nominated a next of kin and there were
difficulties in finding contact details for his next of kin which led to the delay in
notifying them. Nonetheless, a family liaison officer was not appointed, and staff did
not begin efforts to locate Mr Bird’s next of kin until the morning after he died. The
family liaison log was not opened until 1.30pm, which meant that the efforts to
contact next of kin were not documented. Mr Bird’s mother was not informed of his
death until 3.00pm, over 15 hours after he died. We bring this matter to the
Governor’s attention.
Telephone calls
59. Mr Bird tried to call his mother several times while he was at Altcourse but was
unable to connect on each occasion. The number he dialled differed from the
number that had been added to his prison phone account (only approved numbers
can be dialled). Altcourse was unable to locate the form submitted by Mr Bird
setting out the numbers he wanted to be added to his account. We are therefore
unable to say how the error came about.
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Inquest
60. The inquest, held from 24 February to 4 March 2025, concluded that Mr Bird died
by suicide.
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