Stephen Sleaford

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Stephen
Sleaford, a prisoner at HMP
Gartree, on 27 October 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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 focussed, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Sleaford died from hanging on 27 October 2022 at HMP Gartree. He was 49 years old.
I offer my condolences to Mr Sleaford’s family and friends.
Mr Sleaford had been in prison since 2011, and had been in Gartree on several separate
occasions over a number of years. It is clear that Mr Sleaford was unsettled in the weeks
before his death, but Gartree had begun efforts to transfer him to a different prison and
there were no obvious indications that he might take his life.
We have not made any recommendations but have identified areas of learning that the
Governor will want to consider.
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 November 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
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Summary
Events
1. Mr Stephen Sleaford had been in prison since 2011 and was serving a 23 year
sentence for murder. From May to August 2022, Mr Sleaford moved temporarily to
HMP Lincoln for accumulated visits with family and friends, before returning to HMP
Gartree on 11 August.
2. On 25 October, Mr Sleaford was thought to be under the influence of drugs and
during a cell search, was found in possession of illicit alcohol and was also seen to
throw an improvised smoking pipe out of his cell window. At a review the following
day of his incentives and earned privileges (IEP) level, his entitlement was reduced
to basic, the lowest level. He was noted to be angry at the outcome.
3. At 5.46am on 27 October, at the early morning routine check, the night officer found
Mr Sleaford’s observation panel covered. The officer gained an oral response from
Mr Sleaford and continued with her checks. She did not ask Mr Sleaford to remove
the obstruction or otherwise check on his welfare.
4. At 7.07am, a day officer found that Mr Sleaford’s observation panel was still
covered. The officer tried to get a response from Mr Sleaford, without success. The
officer requested support to enter the cell and when staff opened the door, they saw
Mr Sleaford on his knees hanging from a ligature tied to the window frame. Staff
radioed a medical emergency code and cut the ligature. Staff also radioed for a
response from anyone who could do cardiopulmonary resuscitation (CPR), but they
did not start CPR until told to do so by a nurse who arrived four minutes later.
5. Paramedics arrived at 7.42am, and took charge of Mr Sleaford’s treatment. At
8.01am, they confirmed that Mr Sleaford had died.
Findings
6. While Mr Sleaford was unsettled in the weeks before his death, there were no clear
indications that he was at risk of suicide, and he was not subject to additional
monitoring when he died.
7. The night officer should have asked Mr Sleaford to remove the obstruction from his
observation panel at 5.46am.
8. The officers who found Mr Sleaford hanging should have started CPR without delay.
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The Investigation Process
9. HMPPS notified us of Mr Sleaford’s death on 27 October 2022. The investigator
issued notices to staff and prisoners at HMP Gartree informing them of the
investigation and asking anyone with relevant information to contact him. One
prisoner responded.
10. The investigator visited Gartree on 15 November 2022 and obtained copies of
relevant extracts from Mr Sleaford’s prison and medical records.
11. The investigator interviewed eight members of staff and one prisoner at Gartree
from 16 to 20 January 2023. He interviewed one other member of staff on 28
February by video link.
12. NHS England commissioned a clinical reviewer to review Mr Sleaford’s clinical care
at the prison. The investigator and clinical reviewer conducted joint interviews with
the clinical staff.
13. We informed HM Coroner for Rutland and North Leicestershire of the investigation.
The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
14. The Ombudsman’s family liaison officer contacted Mr Sleaford’s brother to explain
the investigation process and to ask if he had any matters he wanted us to consider.
Mr Sleaford’s brother asked about his brother’s medication. Mr Sleaford’s brother
also raised some other issues that we have dealt with in separate correspondence.
15. We shared our initial report with Mr Sleaford’s brother and with HMPPS. Mr
Sleaford’s brother pointed out that the clinical review stated that his brother was
seen alive at approximately 5.46am on 27 October, but the evidence was that his
brother’s observation panel was covered so he was not in fact seen. We have
amended the clinical review accordingly, and also clarified that the check at 5.46am
was the first check on Mr Sleaford since the check at 8.09pm the previous evening.
Mr Sleaford’s brother also questioned the evidence about his brother’s mental
health and expressed the view that there were indications that his brother was at
risk. In addition, Mr Sleaford’s brother asked for a number of comments to be
placed on record about Gartree and about the Ombudsman’s investigation.
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Background Information
HMP Gartree
16. HMP Gartree is near Market Harborough in Leicestershire. It holds up to 700 men
mainly sentenced to life imprisonment and other indeterminate sentences.
Nottinghamshire NHS Trust provides healthcare. Nursing staff are available 24
hours a day.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Gartree was in January 2023. In his
introduction, the Chief Inspector said that Gartree was a well-led institution that
continued to provide generally good outcomes for those detained. Inspectors found
good leadership from the prison’s Governor and Deputy Governor as well as good
first-line leadership. Inspectors noted that one search dog had been trained to
recognise illegally brewed alcohol and staff estimated that 200 litres were
discovered each month.
18. Inspectors noted that the recorded rates of self-harm had reduced by 21% since the
previous inspection in 2017. Inspectors noted that many in-cell toilets lacked privacy
screening (so were situated in full view of the observation panel). Inspectors found
that staff-prisoner relationships were generally good, with 85% of prisoners saying
that staff treated them with respect (compared to 64% in similar prisons). Prisoners
were also generally positive about the key worker scheme and their assigned key
worker.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to November 2022, the IMB noted
that it believed that relationships between prisoners and staff were generally
positive, with many supportive and constructive interactions observed. The IMB
reported a ten percent increase in the number of self-harm incidents compared to
the previous year with 27 of the 242 incidents being classed as serious ‘near-miss’
incidents. The IMB noted that there continued to be an influx of drugs into the
prison, although targeted searches allowed detection of various illicit items including
drugs and illicitly brewed alcohol.
Previous deaths at HMP Gartree
20. Mr Sleaford was the 16th prisoner to die at Gartree since January 2020. Of the
previous deaths, three were self-inflicted and 12 were from natural causes. There
was a further self-inflicted death at Gartree on 1 November 2022, but there were no
similarities with Mr Sleaford’s death.
21. In our previous investigation into the death of a prisoner at Gartree in February
2020, we found that staff failed to take action when a prisoner had blocked his
observation panel. In response to our recommendation, the Governor reissued a
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notice to staff on the action they should take in such circumstances. We again found
an issue with a blocked observation panel in a death in September 2021 (we have
not yet released this report).
Incentives and Earned Privileges Scheme
22. The Incentives and Earned Privileges (IEP) Scheme is a Prison Service system
used to encourage good behaviour. There are three levels on the scheme: basic,
standard and enhanced. Prisoners on the basic level have limited privileges, while
prisoners on the enhanced level have greater privileges and are able to apply for
the more trusted and more desirable prison jobs, such as wing cleaner. Poor
behaviour will usually result in the prisoner moving to a lower level on the scheme
and the prisoner will need to display good consistent behaviour to move back to a
higher level.
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Key Events
23. On 26 September 2011, Mr Stephen Sleaford was remanded to HMP Lincoln
charged with murder. This was not his first time in prison. Mr Sleaford was
convicted of murder on 24 January 2013 and sentenced to life imprisonment with a
minimum term of 23 years.
24. On 23 July 2013, Mr Sleaford was transferred to HMP Gartree before later moving
to HMP Lowdham Grange and then to HMP Full Sutton. From June 2018, Mr
Sleaford began to receive temporary moves to HMP Lincoln for accumulated visits
with his family. (Accumulated visits are where a prisoner saves visits over a period
of time to take them all during a brief period of time at a prison close to their family.)
Mr Sleaford would not have been able to transfer permanently to Lincoln as it is a
local prison, primarily for remand and newly convicted prisoners.
25. On 15 April 2020, Mr Sleaford was transferred back to Gartree.
26. On 6 March 2021, Mr Sleaford rang his cell bell and said that he had tried to hang
himself. Staff started Prison Service suicide and self-harm monitoring procedures
(known as ACCT). At his first ACCT review later that day, Mr Sleaford said that he
had tied a lace around his neck but the lace had snapped and he had fallen to the
floor. He said that he had a number of issues, primarily his father’s poor health as
well as pain he was experiencing from an old leg injury. Mr Sleaford said that he
was embarrassed at his actions.
27. Prison staff stopped ACCT procedures on 17 March, when Mr Sleaford was no
longer deemed to be at risk.
28. In July, an officer became Mr Sleaford’s new key worker. The key worker said that
Mr Sleaford could be “fiery”, but he believed they established a good working
relationship. He said that Mr Sleaford would often complain about Gartree, but
would also complain about other prisons, saying that they were worse than Gartree.
29. On 9 March 2022, prison staff searched Mr Sleaford’s cell and he was found in
possession of fermenting liquid (home-made alcohol, known as hooch). He was
also found in possession of some tablets that were not prescribed to him. There is
no recorded evidence that staff took any further action.
30. On 25 May, Mr Sleaford moved to Lincoln for a further period of accumulated visits.
He returned to Gartree on 11 August.
31. On 23 August, a GP at the prison saw Mr Sleaford about constant dull, throbbing
pain in his ankle: Mr Sleaford had been reporting chronic pain in his leg since 2020
and reported an increase in pain from twisting his ankle in June 2021. The GP
prescribed a 28 day course of co-codamol to start from 26 August and she stopped
his existing prescription of paracetamol. The GP also noted that a physiotherapist
needed to review Mr Sleaford.
32. Mr Sleaford’s co-codamol prescription ended on 22 September, but after he
complained of ongoing pain, an appointment was made for him to attend a clinic on
12 October. For reasons that remain unclear, Mr Sleaford was not seen at the clinic
that day.
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33. On 26 September, Mr Sleaford asked his key worker about moving to a new prison.
He said that he still felt the “presence” of a friend who had died at Gartree the
previous year and that he had had a silly argument with some of his friends on his
wing. He said that a move to another prison would help him stabilise. Following
further conversations with Mr Sleaford, the key worker emailed Mr Sleaford’s
prisoner offender manager (POM), listing Mr Sleaford’s six preferred choices for a
prison move, including Lincoln.
34. On 7 October, a Supervising Officer (SO) made a welfare check on Mr Sleaford
after he made comments about being frustrated with his leg pain as well as
concerns for his father’s health and the death of his friend. She noted the various
issues that were causing him concern. Among other things, he said that he would
turn 50 in February 2023, and he wanted a quieter environment and not one around
youngsters. She noted that Mr Sleaford was due to see his POM the following
Monday and that while he had “a lot going on”, he had no thoughts of suicide or
self-harm.
35. On 10 October, the POM met Mr Sleaford about his request to transfer to another
prison. Mr Sleaford spoke about the issues that were affecting him, including that
his father was in a care home and his health was deteriorating. He also said that his
long-term on and off relationship with his partner had ended since his return to
Gartree.
36. In an email exchange on 12 October between various staff at Gartree, the POM
noted that she understood that Mr Sleaford had completed an application form for a
prison transfer, but she had not yet received the form. She added that Mr Sleaford
should submit a general transfer application as well as an application to move to
Lincoln on compassionate grounds.
37. On the morning of 25 October, a GP at Gartree saw Mr Sleaford after he
complained about the pain in his ankle. He said that he had not been able to sleep
properly since his prescription for co-codamol had ended. The GP prescribed a five
day course of promethazine and noted that Mr Sleaford understood that this was an
acute prescription for him to get his sleep “back on track”. The GP referred Mr
Sleaford for a physiotherapy review.
38. In the afternoon of 25 October, an officer thought that Mr Sleaford appeared to be
under the influence of drugs or alcohol. He locked Mr Sleaford in his cell and called
for a nurse to come to check him. He recorded various actions in the daily briefing
sheet, including placing Mr Sleaford’s name on the substance misuse log, so that
the substance misuse team would see him. He estimated that it was at least an
hour before a nurse came to the wing and, on looking at Mr Sleaford, she said that
she did not think he was under the influence of any substances. (Mandatory drug
testing was suspended at this time because a restricted regime was implemented at
the prison as a result of the COVID-19 pandemic and Mr Sleaford did not meet the
prison’s current criteria for testing.) Mr Sleaford was let back out of his cell.
39. At around 6.15pm, officers began locking prisoners in their cells for the night. A
friend of Mr Sleaford, who lived in the opposite cell, said that he had something to
give to Mr Sleaford. An officer unlocked Mr Sleaford’s cell and, as he did so, Mr
Sleaford threw something out of his window that looked like an improvised smoking
pipe. The officer checked outside the cell and found a rolled up piece of foil. He then
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searched Mr Sleaford’s cell and found two two-litre bottles of fermenting liquid. He
placed Mr Sleaford on report.
Events of 26 October
40. On 26 October, a substance misuse practitioner saw Mr Sleaford as a result of the
cell search discoveries. Mr Sleaford said that the hooch was for Christmas and he
said that he had used Spice (a psychoactive substance) the day before due to the
pain in his leg and because he was stressed about his father’s health. Mr Sleaford
said that he was disappointed that he had let himself down. He said that he needed
to “sort himself out”, but he declined the offer of support from the substance misuse
team.
41. Later that day, a Custodial Manager (CM) saw Mr Sleaford for an IEP review
following the discovery of illicit items in his cell the previous day. The CM recorded
that in line with policy, possession of fermenting liquid meant that Mr Sleaford would
be automatically downgraded from enhanced level to basic level on the IEP
scheme. He noted that Mr Sleaford did not react well as he was not expecting to be
moved straight to basic level. As he walked from the office Mr Sleaford said “if you
want to put me on basic, I will show you basic behaviour”.
42. The CM told the investigator that he had known Mr Sleaford for many years. He
said that Mr Sleaford was generally a settled prisoner who wanted to get on with his
sentence, but that he would flare-up if something irritated him. He said that Mr
Sleaford was never physically violent but would vent his anger with words. He said
that he thought Mr Sleaford might react by smashing his television or smashing a
window.
43. At 8.09pm, Officer A carried out the last routine check of the day. She noted that
when she reached Mr Sleaford’s cell, they exchanged a joke and they both laughed.
She asked him how he was that evening and he said he was all right. She noted
that he seemed as cheerful as usual and was getting ready for the night.
Events of 27 October
44. At 5.46am, Officer A carried out an early morning routine check (Mr Sleaford’s first
check since his check at 8.09pm the previous evening). She said that Mr Sleaford’s
observation panel was covered, but she tapped the door and Mr Sleaford called out
“yo” in acknowledgement. She said that it was common practice for prisoners to
cover their observation panels, and in that case, officers were expected to gain an
oral response from them.
45. At 7.07am, Officer B went to Mr Sleaford’s cell to carry out another routine check
and found that the observation panel was obscured. He knocked on Mr Sleaford’s
door a number of times, but without response. He said that it was common practice
at Gartree for prisoners to cover their observation panels although the prison was
trying to deal with this problem.
46. At Gartree, the protocol required three officers to be present when unlocking cells
during the night patrol state, which was still in place at this time of the morning. (The
exception to this would be if the prisoner can be seen, in which case officers are
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expected to make a dynamic risk assessment on entering the cell with fewer
officers.) As Officer B could not see Mr Sleaford, he went to the wing office around
30 metres away for support. Officer C was in the office and Officer B called the
centre office for further support. At 7.13am, staff reached Mr Sleaford’s cell. An
officer unlocked the door, which Officer B then had to kick open because Mr
Sleaford had made a barricade behind the door.
47. Once the door was open, the officers could see Mr Sleaford on his knees hanging
from a ligature tied to the window frame. Officer B and Officer D went into the cell,
while another two officers radioed a medical emergency code blue (to indicate a
prisoner is unconscious or having breathing difficulties). Officer C said that he was
unsure if his colleague’s call had been acknowledged by the communication room,
so he made a follow-up call to be safe. Officer D cut the ligature, and Mr Sleaford
fell to the floor. Mr Sleaford was in the corner of the cell against the radiator and
Officer C went into the cell to help Officer D move him to where there was more
room and they placed him on his back. Officer D said that she could not find a pulse
and her only thought was to move Mr Sleaford to his side in the recovery position.
She said that she was not first aid trained and she was worried that she could do
more harm than good in attempting CPR. She said that she radioed to ask for
anyone who knew how to do CPR to come to the cell. (Both Officer B and Officer C
were trained in CPR: Officer B acknowledged at interview that he should have
started CPR before the nurse arrived. Officer C said that he was about to start CPR
when the nurse arrived.)
48. Officer C said that he believed that another officer had said that she thought Mr
Sleaford had a weak pulse and he also though he could feel a slight breath from Mr
Sleaford which, in retrospect, he thought might instead have been a draft of air
coming through the door.
49. A nurse said that she did not hear the code blue call, there was a lot of radio traffic
as day staff were registering onto the network. However, a colleague heard the
request for someone who could do CPR so they went to the wing and arrived at the
cell at 7.17am. A CM arrived at the same time. The nurse said that Mr Sleaford was
lying on his side in the recovery position with two officers waiting in the cell. The
nurse told the officers that Mr Sleaford needed to be brought out of the cell where
there was more room and they needed to start CPR. While the nurse was setting up
emergency equipment, Officer C and the CM took turns in giving CPR.
50. The nurse noted that Mr Sleaford had signs of cyanosis in his face (cyanosis is
when the skin turns blue through lack of oxygen). She checked Mr Sleaford with a
defibrillator a number of times, but each time it advised that no shock could be given
and that CPR should continue. Various staff took turns in giving CPR.
51. Ambulance paramedics were called when the code blue call was made and they
arrived at 7.42am. The paramedics assisted with efforts to resuscitate Mr Sleaford.
At 8.01am, the paramedics declared that further efforts should cease and they
confirmed Mr Sleaford had died.
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Contact with Mr Sleaford’s family
52. A family liaison officer (FLO) was appointed. The FLO and another family liaison
officer went to Mr Sleaford’s brother’s home, where they arrived at 1.30pm and
broke the news of Mr Sleaford’s death.
53. Gartree contributed to the cost of Mr Sleaford’s funeral in line with national
instructions.
Support for prisoners and staff
54. One of Gartree’s functional Heads 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.
55. The prison posted notices informing other prisoners of Mr Sleaford’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 Sleaford’s death.
Post-mortem report
56. Mr Sleaford’s post-mortem report gave his cause of death as hanging by ligature. A
toxicology report found a sub-therapeutic level of mirtazapine, an antidepressant
(sub-therapeutic means a level below that prescribed to treat an illness effectively).
Mr Sleaford was not prescribed mirtazapine.
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Findings
Assessment of Mr Sleaford’s risk
57. Mr Sleaford was clearly unsettled in the weeks leading up to his death. He was
troubled by his father’s ill health; he was seeking to move to a quieter environment
and a move to a new prison. He was also troubled by on-going pain in his ankle.
58. Mr Sleaford had not long returned from Lincoln following a temporary transfer there
for accumulated visits with his family and friends, and he would have been aware
that there would be a period of time before he would next be able to return to
Lincoln: he would also have been aware that Lincoln was a local prison so he would
not be able to move there permanently. However, staff at Gartree had asked Mr
Sleaford to identify his preferred prisons for a move and had started efforts to
arrange a move for him. He was also seen by a SO on 7 October for a welfare
check when he said that he had no thoughts of suicide or self-harm despite the
issues that were troubling him at that time.
59. Mr Sleaford had been in prison custody since 2011 and while there were several
issues that were causing him concern at the time of his death, we do not believe
that prison staff could reasonably have anticipated that he was at immediate risk of
either suicide or significant self-harm. Nor do we consider that there was any clear
reason for staff to have commenced suicide and self-harm monitoring procedures
(ACCT).
Observation panels
60. When Officer A checked Mr Sleaford at 5.46am, she found that his observation
panel was obscured. She said that she obtained an oral response from him and
indicated to the investigator that that was all that was required of her. The issue of
blocked observation panels has come up in two other death investigations at
Gartree, and in 2021 we made a recommendation to the Governor to remind staff of
the correct procedures.
61. The Governor at Gartree told the investigator that he had circulated the Governor’s
Notice to Staff setting out the actions they must take if they found a blocked
observation panel around five times since he took up the role in 2020, most recently
in November 2022. The notice states that if a panel has been blocked, staff should
ask the prisoner to remove the obstruction and if the prisoner fails to comply, staff
must take immediate action to check on the prisoner’s welfare. The notice explains
that the cell should be entered in a way that is consistent with local instructions for
entering cells and that particular care must be taken during the night state. The
notice states that at night, the duty manager must be informed immediately of any
blocked observation panel.
62. The notice acknowledges that prisoners might obscure their observation panel to
use the toilet or to undress, but they might also do so in order to use drugs or to use
an illicit telephone. The notice states that staff must make clear to prisoners the
need to keep their observation panel clear and that if a prisoner repeatedly covers
his observation panel, he should be managed using the IEP scheme or adjudication
process.
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63. The notice also states that staff should not accept an oral response alone and staff
should always be able to clearly observe prisoners in case they are unwell or there
is an emergency situation. The notice stresses that “A clear observation panel can
help to save lives”.
64. The Governor was certain that staff do know the correct actions to take, and that
Officer A was wrong to say that she was unaware. He acknowledged that prisoners
at Gartree continue to block their observation panels (mainly because the toilets in
their cells directly face the observation panel and are not fitted with privacy
screens). However, he said that the prison’s daily briefing sheet showed that most
staff do contact the duty manager when a prisoner fails to remove the obstruction
and obstructions are then removed, and action taken to sanction the prisoner. He
said that if staff fail to take the appropriate action, they are spoken to by their line
manager.
Governor to Note
65. The issue of blocked observation panels is a persistent one at Gartree and there is
historic evidence of systemic failure to address the problem. It is worthy of note that
the resident population is predominantly made up of prisoners serving very long
sentences and with the obvious challenges that presents in trying to ensure
conformity with prison rules. It is also relevant that there are no privacy screens for
residents using their toilets. That being said, the observation panels are there for a
reason and they should remain unobstructed and staff finding them covered should
comply with local policy to mitigate the risk. Systemic failure is exactly the area that
the Ombudsman should be making recommendations in. In this case we have noted
that the Governor is aware of the issue, has taken several actions to try and change
the culture amongst residents and officers and is currently engaged with delivering
a re-training program to all of his staff that includes a section on the reasons why
complying with the observation panel policy is important. 65% of staff have
completed this program and as it is an ongoing effort to solve the problem we will,
on this occasion, not make a further recommendation.
66. The actions of Officer A fall below the standard required. It is disappointing that she
stated that she was unaware of the correct procedure as she only went through
initial training in July 2021, 14 months before this incident. The correct procedure for
obtaining a response from the prisoner during roll checks forms part of the syllabus
of that training and it is also in the workbooks and forms part of the final exam. The
Governor has issued more than one Notice to Staff on the issue and on the balance
of probabilities it seems unlikely she was unaware of her responsibilities. Under
normal circumstances we would be making a recommendation that discipline
procedures were initiated. However, we have noted that she has been spoken to by
senior staff and reminded of the correct procedures and that she is due to attend
the above mentioned retraining program in July 2023 and, in those circumstances,
we will resist making such a recommendation.
Clinical care
67. The clinical reviewer concluded that Mr Sleaford’s overall care at Gartree was of a
standard equivalent to that which he could have expected to receive in the
community.
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68. She did, however, identify a number of areas for improvement. In particular, she
noted that Mr Sleaford had been reporting chronic pain in his right leg since 2020
and had received medication for this. However, when a four week prescription of co-
codamol ended on 22 September 2022, there was no review or alternative plan
made to support Mr Sleaford with his chronic pain.
69. The clinical reviewer has made a number of recommendations which we do not
repeat in this report, but which the Head of Healthcare will wish to address.
Other learning
70. None of the officers present in Mr Sleaford’s cell after he was found hanging began
CPR before the nurse arrived. One officer had not received CPR training but both
Officer B and Officer C were trained. Discovering someone in these circumstances
is clearly shocking for staff and we understand that their ability to make appropriate
decisions at speed will sometimes be affected by this. The Governor will wish to
consider whether there is anything that can be done to support dynamic decision
making (including beginning CPR where the circumstances indicate) in high stress
situations.
Inquest
71. An inquest into Mr Sleaford’s death concluded on 26 September 2024 that he
committed suicide and his cause of death was hanging by ligature.
12 Prisons and Probation Ombudsman
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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