Stephen Hodgson

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Stephen
Hodgson, a prisoner at HMP
Full Sutton, on 3 February 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 HM 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 Hodgson was found hanged in his cell on 3 February 2023 at HMP Full
Sutton. He was 26 years old. I offer my condolences to Mr Hodgson’s family and friends.
Mr Hodgson was a challenging prisoner for staff to manage. He was located in the
segregation unit during his time at Full Sutton. His behaviour was poor and despite the
best efforts of staff, he refused to return to a standard wing. Mr Hodgson’s frequent
incidents of self-harm meant that staff monitored him under Prison Service suicide and
self-harm prevention measures (known as ACCT) for the majority of his time at Full Sutton.
My investigation found that staff provided good support to Mr Hodgson.
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 March 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
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Summary
Events
1. In May 2020, Mr Stephen Hodgson was convicted of attempted rape and sentenced
to eight years in prison. In August 2021, he was sentenced to life in prison for
wounding another prisoner at HMP Wymott.
2. Mr Hodgson was difficult to manage in prison and he was moved from the
segregation unit at HMP Wakefield to the segregation unit at HMP Full Sutton on 23
September 2022. He was managed under Prison Service suicide and self-harm
prevention measures (known as ACCT) on 28 occasions before he arrived at Full
Sutton.
3. Mr Hodgson had a history of poor mental health and personality disorders. Mental
health nurses saw him daily in the segregation unit and a GP at the prison
prescribed Mr Hodgson anti-psychotic and antidepressant medication.
4. Mr Hodgson refused to move to a standard wing for vulnerable prisoners and on 11
October, staff made a referral to the STEP unit (which aims to break the cycle of
long-term segregation and prepare prisoners to re-enter mainstream location). Staff
held fortnightly segregation review boards and created a care plan to support Mr
Hodgson’s progression out of the segregation unit.
5. Staff managed Mr Hodgson under ACCT procedures for most of his time at Full
Sutton. Mr Hodgson said that he would continue to self-harm until he was moved to
a prison outside of the long-term high security estate (LTHSE). Mr Hodgson used
threatening and abusive language and behaviour towards staff regularly.
6. On 23 December, staff from the STEP unit decided that Mr Hodgson’s poor
behaviour meant that he was unsuitable for the unit and would need to demonstrate
a period of stability.
7. Mr Hodgson’s behaviour continued to decline and on 2 February 2023, he
assaulted an officer. Staff decided that a minimum of four officers in personal
protective equipment (PPE) should be present when staff unlocked Mr Hodgson’s
cell.
8. At 3.45pm on 3 February, a Supervising Officer (SO) went to Mr Hodgson’s cell, but
could not see him because he had covered his observation panel. The SO removed
the inundation point (a fire safety measure to allow a hose into a cell) and saw Mr
Hodgson hanging from a light fitting. He immediately radioed a medical emergency
code and authorised staff to enter the cell without PPE in an attempt to preserve Mr
Hodgson’s life. Staff started cardio-pulmonary resuscitation (CPR). Paramedics
arrived at 4.11pm, and at 4.51pm they confirmed that Mr Hodgson had died.
Findings
9. Mr Hodgson was considered to be at risk of self-harm but there were no particular
indications that his risk of suicide had increased in the days before his death. The
ACCT procedures provided good support to Mr Hodgson. Case reviews were multi-
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disciplinary and care map actions reflected his concerns about his pathway out of
the LTHSE, his medication and mental health needs.
10. Segregation is known to negatively impact a prisoner’s mental state and can
increase the risk of suicide or self-harm. Mr Hodgson was located in the
segregation unit at Full Sutton because his poor custodial behaviour meant he was
unsuitable for the STEP unit and he refused to move to a wing for vulnerable
prisoners. His behaviour meant that he could not easily be transferred to another
prison, and certainly not one outside the LTHSE.
11. The investigation found that Mr Hodgson being held in segregation did not appear
to negatively impact on his mental state or level of risk. On the evidence available,
we consider that it was appropriate to locate Mr Hodgson in the segregation unit.
12. The clinical reviewer concluded that Mr Hodgson’s mental health care was
equivalent to what he could have expected to receive in the community. Mental
health nurses attended ACCT reviews and implemented a mental health care plan
to support Mr Hodgson’s move from the segregation unit.
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The Investigation Process
13. On 3 February 2023, HMPPS informed us of Mr Hodgson’s death. The investigator
issued notices to staff and prisoners at HMP Full Sutton informing them of the
investigation and asking anyone with relevant information to contact her. No one
responded.
14. The investigator obtained copies of relevant extracts from Mr Hodgson’s prison and
medical records.
15. NHS England commissioned a clinical reviewer to review Mr Hodgson’s clinical care
at the prison.
16. The investigator interviewed eleven members of staff at Full Sutton between April
and June 2023. She and the clinical reviewer jointly interviewed healthcare staff.
17. We informed HM Coroner for Hull and the East Riding of Yorkshire of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
18. We wrote to Mr Hodgson’s uncle to explain the investigation and to ask if he had
any matters he wanted the investigation to consider. Mr Hodgson’s uncle did not
have any questions but asked for a copy of the report.
19. Mr Hodgson’s uncle received a copy of the initial report. He did not raise any further
issues, or comment on the factual accuracy of the report.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Full Sutton
21. HMP Full Sutton is a high security prison that holds up to 626 adult men. Spectrum
Community Health CIC provides health services, and healthcare staff are on duty
24 hours a day.
HM Inspectorate of Prisons
22. The most recent inspection of HMP Full Sutton was in February and March 2020.
Inspectors reported that the number of self-harm incidents had increased over
recent years, but was now declining. Prisoners subject to ACCT procedures for
those at risk of suicide or self-harm received good support, including oversight from
the weekly safety intervention meeting.
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 December 2022, the IMB
reported that staff maintained safety in the prison and there was no increased risk
of men self-harming during the year.
Previous deaths at HMP Full Sutton
Mr was the seventh prisoner to die at Full Sutton since February 2020. Of the
previous deaths, five were from natural causes and one was self-inflicted. There are
no significant similarities with our findings in the investigation into Mr Hodgson’s
death and the findings of the previous deaths at Full Sutton.
Assessment, Care in Custody and Teamwork
24. ACCT is the Prison Service care-planning system used to support prisoners at risk of
suicide or self-harm. The purpose of ACCT is to try to determine the level of risk, how
to reduce the risk and how best to monitor and supervise the prisoner. After an initial
assessment of the prisoner’s main concerns, levels of supervision and interactions
are set according to the perceived risk of harm. Checks should be carried out at
irregular intervals to prevent the prisoner anticipating when they will occur. Regular
multidisciplinary review meetings involving the prisoner should be held.
The STEP unit
25. The STEP unit is a small unit at Full Sutton with a capacity of ten prisoners, opened
in 2019, as part of the long-term and high security estate’s (LTHSE) pathways to
progression programme. It aims to break the cycle of long-term segregation and
prepare prisoners to re-enter mainstream location through a high level of purposeful
activity and other psychology-informed services. The STEP unit offers a mixed
regime for both general and vulnerable prisoners.
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Care Programme Approach
26. The Care Programme Approach (CPA) is an NHS system of delivering community
mental health services to individuals diagnosed with a severe mental illness or other
vulnerabilities such as a history of violence or self-harm. Someone who needs CPA
support should have a formal written plan that outlines any risks and a CPA care
coordinator to organise and review the plan.
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Key Events
27. On 19 May 2020, Mr Stephen Hodgson was convicted of attempted rape and
sentenced to eight years in prison. On 25 August 2021, he was sentenced to life in
prison for wounding another prisoner at HMP Wymott. Mr Hodgson had been in
prison before.
28. Mr Hodgson had a poor custodial history and assaulted both staff and prisoners. He
spent a brief period in The Westgate Unit (for prisoners with complex psychological
needs) at HMP Frankland but was removed after he had flooded his cell and
threatened staff.
29. On 25 November 2021, Mr Hodgson transferred to HMP Wakefield. After an initial
period on the reverse cohort unit (a process for the temporary separation of newly
received prisoners for 14 days to confirm that there is no risk of COVID-19 infection)
Mr Hodgson refused to move to a standard wing. Prison staff moved him to the
segregation unit on 8 December after he had damaged his cell and threatened
violence towards staff. Mr Hodgson’s poor custodial behaviour meant that he was
unsuitable for a move to the STEP unit at Wakefield. After he assaulted staff and
concealed a weapon in his cell, prison managers authorised Mr Hodgson’s transfer
to the segregation unit at HMP Full Sutton.
30. Before he moved to Full Sutton, Mr Hodgson was managed under Prison Service
suicide and self-harm prevention measures (known as ACCT) on 28 occasions after
making cuts (sometimes recorded as superficial and sometimes requiring hospital
treatment), expressing suicidal thoughts and reporting suicide attempts.
HMP Full Sutton
31. On 23 September, Mr Hodgson arrived at Full Sutton. Staff took him straight to the
segregation unit and he did not go through the normal reception procedures. An
officer completed Mr Hodgson’s first night interview and noted his history of suicide
attempts, self-harm and mental health issues. The officer assessed Mr Hodgson as
a high risk to staff and other prisoners due to his custodial history. They also
referred him to the Safety Intervention Meeting. (SIM - a weekly multi-disciplinary
meeting to discuss prisoners who are at risk). Staff allocated Mr Hodgson a
keyworker who saw him regularly in the segregation unit.
32. A nurse completed Mr Hodgson’s initial health screen and noted that he was calm,
in a good mood and communicated well with staff. He raised no medical concerns
and denied any thoughts of suicide and self-harm. The nurse noted that Mr
Hodgson had a dissocial personality disorder (a mental health condition where a
person shows no regard for right and wrong and ignores the rights and feelings of
others), an emotionally unstable personality disorder (a mental health condition that
affects how a person thinks, feels and interacts with others) and depression. No
diagnosis dates were recorded in Mr Hodgson’s clinical record. His current
medication was recorded as quetiapine, used to treat symptoms of a personality
disorder and sertraline, an antidepressant.
33. The Head of Residence and Catering held an initial segregation review board and
authorised Mr Hodgson’s segregation under Prison Rule 45, in order to maintain
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good order and discipline. A mental health nurse completed the segregation safety
algorithm and indicated that there were no medical reasons why Mr Hodgson could
not be segregated. (Segregation can increase the risk of suicide or self-harm
because it isolates the prisoner and reduces their access to the normal regime and
can have a negative impact on their mental health. As a result, a nurse must
complete a safety algorithm to indicate if there are any medical reasons why an
individual should not be segregated, a supervising manager will then countersign it.)
34. Prison staff notified the Independent Monitoring Board (IMB) that Mr Hodgson was
being held in segregation and records show that an IMB member attended the
segregation review boards.
35. On 27 September, the Head of Reducing Reoffending held a segregation review
board. He told Mr Hodgson that he would remain segregated for a period of
assessment to determine his suitability for the STEP unit. Mr Hodgson was
compliant with the segregation regime and did not have any concerns. He told staff
that he would refuse to be located on a standard wing. Staff gave Mr Hodgson a
diary to help him express his feelings. The Head reviewed Mr Hodgson’s custodial
history and security information report and noted that he was suitable to move to a
standard wing for vulnerable prisoners (due to the nature of his original offence). He
set Mr Hodgson six segregation care plan targets to enable him to demonstrate a
willingness and ability to change his behaviour and to support his progression from
the segregation unit.
36. That day, the mental health team meeting referred Mr Hodgson to the psychiatrist
and added him to a mental health nurse’s caseload. The mental health team
managed Mr Hodgson under the NHS Care Programme Approach (CPA - used to
coordinate the care of patients with complex mental health disorders).
37. On 30 September, the Deputy Director of Custody (DDC) for the LTHSE reviewed
Mr Hodgson’s continuing segregation. The DDC recommended that the mental
health team implement an appropriate care plan and prison staff identify a
progressive pathway to support Mr Hodgson’s move to an alternative location, and
segregation review boards should continue to set Mr Hodgson behavioural targets.
The DDC continued to authorise Mr Hodgson’s segregation every 42 days at Full
Sutton. Staff provided Mr Hodgson with a copy of his care plan and behavioural
targets.
38. Staff completed a One Page Plan with Mr Hodgson to identify why he was in the
segregation unit, his risks and problem behaviours and to support his progression.
Staff provided Mr Hodgson with distraction material to help him occupy his time.
39. A mental health nurse assessed Mr Hodgson on 2 and 5 October. Mr Hodgson was
compliant with his prescribed medication and had no thoughts of suicide and self-
harm. He had no concerns with the segregation unit regime.
40. On 4 October, an officer from the STEP unit spoke to Mr Hodgson about a referral.
He explained that the unit would provide him with the opportunity to progress in a
supportive environment. Mr Hodgson said he was unsure if the unit was his best
option, but he would not relocate to a standard wing. A further discussion took place
on 10 October. Mr Hodgson said that he was easily triggered by a change in his
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circumstances and he was worried about coping in the unit. Staff reassured Mr
Hodgson that he would receive support.
41. On 7 October, a nurse saw Mr Hodgson. Mr Hodgson agreed to engage with the
mental health team and said that he found keeping a mood diary helpful. He
struggled to cope most in the evening and during the night. The pharmacist agreed
to change the time of Mr Hodgson’s medication to the evening.
42. The duty prison manager saw Mr Hodgson daily in the segregation unit. The Head
of Segregation held a segregation review board on 11 October and noted that Mr
Hodgson was now willing to give the STEP unit a chance, but he would not move to
a standard wing. Staff made a referral to the STEP unit.
43. On 12 October, prison staff started ACCT monitoring after Mr Hodgson smashed
his cell observation panel and made cuts to his right arm and bicep. Mr Hodgson
told a multidisciplinary ACCT case review that he was frustrated about being in a
prison that was part of the long-term high security estate (LTHSE). He was also
having difficulty sleeping. He denied any further thoughts of suicide and self-harm.
Prison staff added two actions to Mr Hodgson’s caremap (designed to identify the
main areas of concern and the actions required to reduce risk), which included that
he should see the GP to discuss his medication and speak to his prison offender
manager (POM) about his sentence plan targets. Prison staff assessed Mr
Hodgson’s risk of suicide and self-harm as low and decided he should be monitored
once an hour. A prison manager completed the defensible decision document which
said that Mr Hodgson should remain segregated during ACCT monitoring. Records
show that this was completed again on each occasion Mr Hodgson was subject to
ACCT monitoring in the segregation unit.
44. During an ACCT case review on 13 October, Mr Hodgson said that he wanted to
make a fresh start at Full Sutton and had no thoughts of suicide and self-harm. A
GP at the prison had amended his anti-psychotic medication to help him sleep, and
staff had sent an email to his POM to arrange a meeting. Mr Hodgson declined the
opportunity to attend a psychology drop-in session. Staff agreed to stop ACCT
monitoring. Mr Hodgson’s risk was assessed as low and the actions on his caremap
were complete. The post-closure phase would end on 20 October.
45. On 15 October, prison staff started ACCT monitoring again after Mr Hodgson made
superficial cuts to his arm with a plastic knife that he was issued with to eat his
meals. Mr Hodgson said that he was frustrated about his lack of progression in the
prison and felt that his anti-psychotic medication had impacted negatively on his
sleep. Prison staff decided that Mr Hodgson should be monitored once every hour
and added one additional action to his caremap which said that he should engage
with the psychiatrist.
46. On 20 October, a community consultant forensic psychiatrist saw Mr Hodgson. Also
present was a trainee psychiatrist and a nurse. Mr Hodgson said he coped with the
rapid fluctuations in his thoughts through violence and deliberate self-harm. The
psychiatrist noted that Mr Hodgson demonstrated a level of insight into his
personality dysfunction and wanted to address his response to traumatic events. He
amended Mr Hodgson’s anti-psychotic medication to once a day in the early
evening and said this should improve his sleep.
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47. On 25 October, staff held a multi-disciplinary ACCT case review. Mr Hodgson said
that his medication issues were resolved and that he felt better. As his behaviour
had improved, staff agreed that he could meet with his POM in person. Staff agreed
to stop ACCT monitoring and noted that the post-closure phase would end on 1
November. Later, staff held a segregation review board and approved Mr
Hodgson’s segregation for a further fourteen days.
48. Mr Hodgson met with his POM on 27 October. She noted that Mr Hodgson
presented a very serious risk of harm to prisoners due to his violent offending.
Prison records indicated that he would struggle to cope on a standard wing and his
behaviour was often aggressive and disruptive. Mr Hodgson said he wanted a
transfer to HMP Dovegate. Mr Hodgson’s POM explained that he would need to
demonstrate a reduction in his risk before he would be considered for a move
outside of the LTHSE and she encouraged him to engage with prison staff on the
STEP unit. His POM did not recommend a transfer to a prison out of the LTHSE
and noted that Mr Hodgson’s current location in the segregation unit meant he did
not meet HMP Dovegate’s eligibility criteria.
49. On 31 October, Mr Hodgson became verbally and physically abusive towards staff
and self-harmed by making a superficial cut to his arm. Staff started ACCT
monitoring again. During an ACCT case review, staff told Mr Hodgson that a place
was available for him on a standard wing for vulnerable prisoners. Mr Hodgson
refused to leave the segregation unit and said he would only move to Dovegate.
Staff noted that Mr Hodgson’s ACCT reviews would take place on the same day as
the segregation review boards to ensure prison staff considered the impact of
segregation on Mr Hodgson’s risk of suicide and self-harm.
50. On 4 November, the Head of Healthcare saw Mr Hodgson to discuss his referral to
the STEP unit. She explained that Mr Hodgson would need to demonstrate a
reduction in his self-harm and an improvement in his behaviour before he could be
eligible.
51. On 8 November, Mr Hodgson attended an ACCT case review before his
segregation review board. Staff noted that Mr Hodgson’s behaviour had improved.
He told staff that he had changed his mind about going to the STEP unit and
wanted a move to a prison outside of the LTHSE. As Mr Hodgson did not have any
thoughts of suicide and self-harm, staff agreed to stop ACCT monitoring. At his
segregation review board, Mr Hodgson said there was no reason for him to be at
Full Sutton and he would continue to refuse to leave the segregation unit.
52. That day, Mr Hodgson met with his POM. She noted that Mr Hodgson used violent
and reckless behaviour as an attempt to manipulate staff.
53. On 12 November during the post-closure review period, Mr Hodgson self-harmed
again and staff restarted ACCT monitoring. He told staff that he would continue to
self-harm unless they transferred him to another prison.
54. On 17 November, a Supervising Officer (SO) told Mr Hodgson that STEP unit staff
would discuss his referral at a multi-disciplinary team meeting (MDT) and if
successful, he would be allocated a place when one became available. That day,
Mr Hodgson told the trainee psychiatrist that he had superficially self-harmed but
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had no intention to attempt suicide. Mr Hodgson appeared settled and did not
display any symptoms of psychosis.
55. During an ACCT case review on 28 November, staff agreed to stop ACCT
monitoring. Mr Hodgson was settled and did not express any thoughts of suicide
and self-harm. The post-closure period would end on 6 December. Records show
that Mr Hodgson self-harmed during the post-closure period. Staff decided that due
to his pattern of self-harm, they would monitor him under ACCT procedures for the
remainder of his time at Full Sutton for extra support.
56. Mental health nurses saw Mr Hodgson every day and attended ACCT case reviews
and segregation review boards. Staff noted that Mr Hodgson attempted to
manipulate staff regularly by threatening to self-harm.
57. Staff reported incidents where Mr Hodgson’s behaviour had been threatening and
abusive towards staff. On 7 December, he had threatened to rape a female officer,
damaged the smoke detector in his cell and attempted the throw pieces of toilet
paper he had set on fire through his observation panel.
58. On 14 December, the STEP unit declined Mr Hodgson’s referral due to concerns
about his behaviour. An MDT decided that Mr Hodgson’s behaviour could not be
managed safely on the STEP unit and he would have a negative impact on the
other prisoners and their progression. The MDT said that following a period of
stability, a potential onward pathway for Mr Hodgson could include an assessment
for a personality disorder service or an assessment for a therapeutic community.
The MDT noted that Mr Hodgson had not completed any work to explore his
offending behaviour.
59. On 21 December, a pharmacy technician noted that Mr Hodgson was concealing
his anti-psychotic medication in his mouth. Mr Hodgson said that he did not want to
take his medication and became verbally abusive toward staff. As a result, the
psychiatrist discontinued Mr Hodgson’s anti-psychotic medication for one week.
60. On 24 December, a SO told Mr Hodgson that his referral for the STEP unit was
unsuccessful. He advised Mr Hodgson that the unit would accept another referral
after a period of three months if his behaviour improved.
61. The psychiatrist saw Mr Hodgson on 29 December. He noted that Mr Hodgson’s
mood had deteriorated since he had stopped taking the anti-psychotic medication.
Mr Hodgson agreed to restart his anti-psychotic medication and the psychiatrist
prescribed a single daily dose to be given at 4.00pm, with a further review in six
weeks.
62. Mr Hodgson’s behaviour continued to decline and staff reported that he was
uncooperative and had made threatening and sexually abusive comments. Mr
Hodgson continued to refuse to move to a standard wing and told staff that he
intended to remain in the segregation unit until staff transferred him to a prison
outside of the LTHSE.
63. Staff continued with ACCT monitoring and held multidisciplinary ACCT case
reviews and segregation review boards. Mental health staff saw Mr Hodgson every
day and he saw a GP in the prison once a week.
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64. On 18 January, Mr Hodgson asked to speak to a prison listener (prisoner volunteers
trained by Samaritans to listen to prisoners who are in distress). Staff arranged for a
listener to speak to Mr Hodgson in the segregation unit. The next day, Mr Hodgson
told a SO that he wanted a move to C wing (a standard wing for vulnerable
prisoners). Due to his long period of segregation, staff arranged for Mr Hodgson to
spend a period of association on C wing to help him adjust to a new environment.
Staff arranged for a peer mentor and a listener to meet Mr Hodgson on the wing. Mr
Hodgson spent the evening association period on C wing and staff noted that he
had interacted well with other prisoners and he did not have any concerns.
65. On 20 January, the Head of Segregation spoke to Mr Hodgson about his move to C
wing. Mr Hodgson would spend association periods on the wing and would move
there permanently on 23 January. Mr Hodgson told him that he would not move to
C wing and intended to remain in the segregation unit.
66. Over the next few days, staff reported that Mr Hodgson was misusing his cell bell
and was verbally abusive towards staff and other prisoners. During a keyworker
session with an officer on 26 January, Mr Hodgson said that he was keen to focus
on a pathway out of segregation but wanted to move to a prison out of the LTHSE.
The officer encouraged Mr Hodson to move to a standard wing because it would
help with a transfer application to a prison outside of the LTHSE.
Events of 2 and 3 February
67. At approximately 3.18pm on 2 February, an officer unlocked Mr Hodgson’s cell for
dinner and Mr Hodgson headbutted the officer in the face. Mr Hodgson was
threatening and abusive towards staff. Staff removed him under restraint to a high
control cell (a designated cell for prisoners who pose a high risk of harm to others).
The Head of Segregation told segregation staff that they should only unlock Mr
Hodgson when four officers in personal protective equipment (PPE) were present. A
review would take place on 7 February.
68. At 5.15pm, the Head of Operations saw Mr Hodgson in the segregation unit. Mr
Hodgson was confrontational and continued to make derogatory comments towards
staff. The Head noted that segregation was the appropriate location for Mr Hodgson
and completed the defensible decision document.
69. Staff observed Mr Hodgson every hour during the night and did not report any
concerns.
70. At 8.15am, a SO went to Mr Hodgson’s cell and saw that he had made superficial
cuts to his arms. Mr Hodgson refused to be assessed by a mental health nurse and
was shouting abuse.
71. At 9.35am, the SO and three officers went to Mr Hodgson’s cell to complete a fabric
check in his cell. As Mr Hodgson left his cell, he attempted to assault staff and was
threatening and abusive. Staff completed their checks, and a nurse gave Mr
Hodgson his medication through the observation panel.
72. At 10.05am on 3 February, a SO held an ACCT case review with another SO and a
nurse. Mr Hodgson refused to contribute from his cell. The SO noted that Mr
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Hodgson had made superficial cuts to his arms. She decided that staff should
continue to observe him once every hour.
73. At 10.30am, the Head of Segregation spoke to Mr Hodgson. Mr Hodgson said that
he did not know why he was violent the previous day and wanted a fresh start. He
encouraged Mr Hodgson to think about his behaviour. Mr Hodgson accepted his
lunch at 1.00pm. Staff observed him in his cell at 1.45pm, 2.18pm, 2.28pm and
3.22pm. Mr Hodgson did not raise any concerns.
74. At 3.45pm, a SO went to Mr Hodgson’s cell to ask if he wanted his medication. Mr
Hodgson had covered his observation panel and was unresponsive. He removed
the inundation point in the cell door and saw Mr Hodgson sitting on the floor with his
back to the cell door. He saw that Mr Hodgson had a ligature around his neck. He
radioed an emergency code blue (indicating a prisoner is unconscious or is having
breathing difficulties). The control room staff called an ambulance immediately.
75. Staff arrived at the cell and agreed with the SO that they should enter Mr Hodgson’s
cell with caution but without PPE. An officer used her anti-ligature knife to remove
the ligature from Mr Hodgson’s neck and started CPR. Staff attached a defibrillator
to Mr Hodgson and it did not detect a shockable rhythm.
76. A nurse arrived very shortly after and assisted with emergency lifesaving support.
Paramedics arrived at 4.11pm. At 4.51pm, the paramedics confirmed that Mr
Hodgson had died.
Contact with Mr Hodgson’s family
77. The prison appointed the safer custody manager as family liaison officer. Due to the
location of Mr Hodgson’s mother’s address, the prison asked family liaison officers
(FLOs) from HMP Haverigg to break the news of his death.
78. At 11.00am, the FLOs from Haverigg visited the address recorded on Mr Hodgson’s
prison record and they were informed that Mr Hodgson’s mother had moved. The
police provided an alternative address and at 2.15pm, the FLOs told Mr Hodgson’s
mother that he had died.
79. The prison contributed towards the cost of Mr Hodgson’s funeral in line with national
policy.
Support for prisoners and staff
80. After Mr Hodgson’s death, the Head of Offender Management 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.
81. The prison posted notices informing other prisoners of Mr Hodgson’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 Hodgson’s death.
82. The Samaritans attended the prison and met with the listeners who had provided
support to Mr Hodgson. They also attended the segregation unit and spoke with
both prisoners and staff.
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Post-mortem report
83. The pathologist gave Mr Hodgson’s cause of death as hanging. The toxicology
report did not detect any illicit substances in Mr Hodgson’s blood.
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Findings
Assessment of Mr Hodgson’s risk of suicide and self-harm
84. Mr Hodgson was a challenging prisoner who had assaulted both staff and
prisoners. He used threatening and abusive language, particularly towards female
officers regularly. Mr Hodgson was frequently managed under ACCT suicide and
self-harm prevention procedures before he was transferred to Full Sutton, and his
pattern of self-harm continued despite his new location.
85. Prison Service Instruction (PSI) 64/2011 on safer custody, requires all staff who
have contact with prisoners to be aware of the triggers and risk factors that might
increase the risk of suicide and self-harm, and take appropriate action. Mr Hodgson
had several of these risks including previous self-harm, poor mental health including
the diagnosis of a serious mental illness and recent contact with psychiatric
services.
86. When Mr Hodgson self-harmed on 3 February, the day of his death, staff continued
to monitor him regularly. Mr Hodgson told a prison manager that he wanted a fresh
start and there was no indication that his risk of suicide had increased or that he
was in crisis.
87. We consider that the ACCT procedures provided good support to Mr Hodgson. Staff
held regular and supportive multi-disciplinary case reviews which appropriately
assessed his risk. They added actions to Mr Hodgson’s caremap which reflected his
concerns about his pathway out of the LTHSE, his medication and his mental health
needs.
Location in the Segregation Unit
88. PSO 1700 Segregation, acknowledges the specific risks of holding vulnerable
prisoners in segregation. It notes that rates of suicide among segregated prisoners
are high, and that segregation should only be used as a last resort. Prisoners
monitored under ACCT procedures can be segregated but only when they are such
a risk to others that no other suitable location is appropriate and where all other
options have been tried or are considered inappropriate. We have considered
whether, in the circumstances, it was appropriate to hold Mr Hodgson in the
segregation unit when he was on an ACCT.
89. Mr Hodgson had spent time in the segregation unit at Wakefield before he
transferred to the segregation unit at Full Sutton. Mr Hodgson remained in the
segregation unit at Full Sutton for just over four months. His behaviour was clearly
challenging for staff to manage and he assaulted an officer shortly before he died.
His poor behaviour meant he was unsuitable for the STEP unit and despite the best
efforts of staff, he refused to move to a standard wing for vulnerable prisoners. Staff
held regular segregation review boards and sought support from the DDC who
advised on the appropriate actions to assist with Mr Hodgson’s progression. Staff
reviewed the action plan at least every two weeks.
90. Mr Hodgson repeatedly told staff he should not be in a high security prison and that
he intended to remain in the segregation unit until he was moved to another prison.
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Staff regularly explained to Mr Hodgson that he would need to show an
improvement in his behaviour before he could move to a lower security prison.
91. We consider that staff continuously reviewed whether it was appropriate to keep Mr
Hodgson segregated, actively explored other reasonable options and persisted in
encouraging Mr Hodgson to consider realistic pathways out of segregation. On the
evidence available, it does not seem that being segregated, in itself, increased Mr
Hodgson’s risk of suicide. It is difficult to see how Full Sutton could have managed
this differently.
Mental health
92. The clinical reviewer concluded that Mr Hodgson’s mental healthcare was
equivalent to what he could have expected to receive in the community.
93. Healthcare staff referred Mr Hodgson to the mental health team when he arrived at
Full Sutton on 23 September and he received good mental health support from staff
using the Care Plan Approach. Mental health nurses attended ACCT case reviews
and a psychiatrist reviewed him regularly. Mental health nurses implemented an
appropriate mental health care plan to support Mr Hodgson’s move from the
segregation unit.
Good Practice
94. When the SO found that Mr Hodgson had blocked his observation panel and was
unresponsive, he quickly removed the inundation point to enable him to see inside
Mr Hodgson’s cell. He saw that Mr Hodgson had ligatured.
95. Mr Hodgson’s violent behaviour towards staff meant that they would not unlock his
cell without the presence of at least four staff who were wearing PPE. The SO
made a rapid dynamic risk assessment and concluded that the preservation of Mr
Hodgson’s life should take precedence over normal unlock procedures.
96. We consider that the decision of the SO to authorise the emergency response
officers to enter Mr Hodgson’s cell with caution but without PPE, to be good
practice. This ensured that staff were able to start CPR quickly.
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Inquest
97. At the inquest, which took concluded on 10 February 2025, the Coroner concluded
that Mr Hodgson died by suicide.
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