Steven Mullen

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Independent investigation into
the death of Mr Steven Mullen,
a prisoner at HMP Leeds,
on 30 November 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2026
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Steven Mullen died in hospital in the late evening of 30 November having been found
hanging in his cell at HMP Leeds two hours earlier. He was 48 years old. I offer my
condolences to Mr Mullen’s family and friends.
Mr Mullen was the 14th prisoner to take his life at Leeds since November 2021.
Mr Mullen was in Leeds for little more than 24 hours by the time he was found hanging. I
am satisfied that he received appropriate care in his brief time there and that staff had no
reason to consider him at raised risk of suicide or self-harm. 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 July 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On 29 November 2024, Mr Steven Mullen was remanded to HMP Leeds charged
with criminal damage, actual bodily harm and assault. His alleged victim was his
wife.
2. During reception screening, Mr Mullen provided a positive urine test for methadone
and opiates and he was prescribed a low dose of methadone starting that evening.
He told reception staff that he had no thoughts of suicide or self-harm. He then
moved to a shared cell on the induction unit.
3. CCTV shows that Mr Mullen came out of his cell during 30 November to receive his
medication and to collect his meals.
4. Mr Mullen and his cellmate returned to their cell with their evening meals at 4.22pm
and were locked in for the remainder of the day. Mr Mullen’s cellmate said that he
gave part of his meal to Mr Mullen as he was still hungry.
5. At around 9.25pm, Mr Mullen’s cellmate woke from a brief sleep and saw Mr Mullen
hanging by his belt from the window frame. He unbuckled the belt and Mr Mullen fell
to the floor. The cellmate rang the cell bell and officers responded promptly. The
officers believed that Mr Mullen was breathing and they placed him in the recovery
position. Nurses arrived around a minute later. They found that Mr Mullen was not
breathing and they began cardiopulmonary resuscitation (CPR). Ambulance
paramedics arrived at 9.44pm and after they established a pulse they took Mr
Mullen to hospital, where he died at 11.30pm.
6. Staff found a letter in the cell that Mr Mullen had written to his wife. He wrote that
being in prison was the best place for him to be at that time and he asked her to
send him some money. He gave no indication in the letter that he was thinking of
taking his own life.
Findings
7. We are satisfied that staff at Leeds appropriately assessed Mr Mullen’s risk of
suicide and self-harm and that they could not reasonably have predicted or
prevented his death.
8. The clinical reviewer concluded that Mr Mullen’s healthcare at Leeds was
equivalent to that which he could have expected to receive in the community.
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The Investigation Process
9. HMPPS notified us of Mr Mullen’s death on 1 December. The investigator issued
notices to staff and prisoners at HMP Leeds informing them of the investigation and
asking anyone with relevant information to contact him. No one responded.
10. The investigator visited Leeds on 11 December and spoke to three prisoners. He
met the prison Governor and obtained copies of relevant extracts from Mr Mullen’s
prison and medical records.
11. The investigator interviewed five members of staff and two prisoners at Leeds on 18
February 2025.
12. NHS England commissioned a clinical reviewer to review Mr Mullen’s clinical care
at the prison. She and the investigator jointly interviewed five clinical staff by MS
Teams on 20 February.
13. The investigator interviewed a further member of staff via Ms Teams on 3 March.
14. We informed HM Coroner for West Yorkshire Eastern District of the investigation.
The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
15. We contacted Mr Mullen’s wife to explain the investigation and to ask if she had any
matters she wanted us to consider. She said she had reported her concerns about
her husband’s risk to himself to the police the day before he went to court. She said
that her friend also told police that if Mr Mullen could not contact her or she ended
the relationship, he would take his own life. Mr Mullen’s wife also said that on 31
October 2024 he had threatened to take his own life by jumping from a bridge. The
police and community mental health team were aware of this. She believed that
there would have been warning signs on the paperwork sent from court that the
prison had either lost or ignored.
16. We shared our initial report with HMPPS and with Mr Mullen’s wife via her solicitor.
Mr Mullen’s wife’s solicitor identified an incorrect name in one of the report dossier
documents, which we have amended.
17. We have also amended several paragraphs in this report to reflect the information
contained in the Person Escort Record which accompanied Mr Mullen from the
police station to court. Despite several requests while the investigation was
ongoing, we only received this information during the initial report consultation
period.
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Background Information
HMP Leeds
18. HMP Leeds is a local prison holding men who are on remand, convicted or
sentenced. The prison serves the courts of West Yorkshire. Practice Plus Group
provides healthcare services, including mental health and substance misuse
services. Nurses are available 24 hours a day.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Leeds was in June 2022. Inspectors noted that
the prison received into custody around 388 new prisoners every month. Inspectors
found that Leeds was a well-led prison and managers were visible on the wings.
However, inspectors also noted that the prison needed improvement in safety
outcomes with at least eight self-inflicted deaths since the previous inspection in
2019. Inspectors found that the prison was working to address this major issue
including developing positive early days in custody processes.
20. In July 2023, inspectors returned to Leeds to review progress since the previous
inspection. Inspectors noted that there had been seven self-inflicted deaths in the
previous 13 months and that Leeds had the second highest rate of self-inflicted
deaths of any prison in England and Wales. Inspectors noted that unemployment
and long periods locked-up at weekends were common factors in many of the
deaths. Inspectors found that Leeds was capable of making progress, but there
needed to be clearer, sharper and more sustained focus on what was needed to
improve the well-being of prisoners.
Independent Monitoring Board
21. 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 2023, the IMB
expressed its concern about the continuing high number of deaths at the prison,
including high numbers of self-inflicted deaths. The IMB noted that Leeds had
introduced new strategies for peer support for potentially vulnerable prisoners to
boost the support already provided by Listeners (prisoners trained by the
Samaritans to provide support to other prisoners). The IMB noted that staff and
prisoner relationships were generally positive. However, they also found that many
officers were newly qualified and often lacked experience in dealing with sometimes
difficult and demanding prisoners. The IMB commented on the level of
overcrowding at Leeds with prisoners having to share cramped cells.
Previous deaths at HMP Leeds
22. Mr Mullen was the 22nd prisoner to die at Leeds since November 2021. Of the
previous deaths, 13 were self-inflicted, seven were due to natural causes and one
was drug related. There were no similarities between Mr Mullen’s death and the
previous deaths.
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23. Since Mr Mullen’s death, there have been five further deaths at Leeds up to the end
of April 2025. Three of these deaths were self-inflicted and two were due to natural
causes.
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Key Events
29 November 2024
24. In the late afternoon of Saturday 29 November 2024, Mr Steven Mullen was
remanded to HMP Leeds charged with offences of criminal damage, actual bodily
harm, controlling behaviour and assault committed between 1 June and 28
November. The alleged victim was Mr Mullen’s wife. It was his first time in prison for
around 15 years.
25. The paperwork that accompanied Mr Mullen to Leeds included a digital Person
Escort Record (PER), a document that accompanies prisoners between police
custody, courts and prisons and which sets out any risks. Mr Mullen’s PER covered
the period of his detention at court up to his handover to Leeds staff. It noted that he
was not deemed at risk of suicide or self-harm. (The PER that earlier accompanied
Mr Mullen from police custody to court noted that he suffered with depression, but
also noted that he was not deemed to be at risk of suicide or self-harm. This PER
was not seen by Leeds and we were only provided with a copy following issue of
our initial report.)
26. Another prisoner told the investigator that he and Mr Mullen arrived in Leeds at the
same time, and they spoke in the reception holding cell while waiting to be seen by
staff. He said that he and Mr Mullen had similar problems with drug dependency
and he asked staff if they could share a cell.
27. A nurse saw Mr Mullen for a reception health screen. Mr Mullen said that he had no
issues with alcohol but had a history of crack cocaine misuse and was prescribed
methadone. Mr Mullen said that he had no mental health problems and had no
thoughts of suicide or self-harm. Mr Mullen provided a urine sample that tested
positive for methadone and opiates. Mr Mullen’s community healthcare records
were not available to the nurse at the time of her assessment. These would have
been requested the following Monday after obtaining Mr Mullen’s consent.
28. A reception officer noted that he had a lengthy conversation with Mr Mullen. Mr
Mullen said that he had been in prison before, knew what was expected of him as a
prisoner and knew about support available through the Samaritans and Listeners.
He said that he had no issues with being in prison and had no thoughts of suicide or
self-harm.
29. A trainee advanced nurse practitioner noted that Mr Mullen was alert and orientated
and prescribed him 10ml of methadone starting that evening. The doses were to
increase over the following days in line with standard methadone prescribing
procedures. Mr Mullen again said that he had no thoughts of suicide or self-harm.
30. From reception, Mr Mullen moved to cell D4-37, a cell on the fourth landing of D
wing, the induction unit. He moved in with the prisoner he met in the reception
holding cell. This prisoner told the investigator that he took the bottom bunk, and Mr
Mullen took the top bunk.
31. As Mr Mullen was new in prison, staff made four welfare checks on him through the
night and noted no concerns about him.
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30 November 2024
32. The investigator watched CCTV footage and body worn video camera footage
(BWVC). He also obtained information from Yorkshire Ambulance Service. The
following account is based on these sources as well as statements and interviews
with staff and the cellmate.
33. At just before 9.00am on 30 November, an officer unlocked Mr Mullen, and he came
out of his cell and spoke to other prisoners. Mr Mullen had a further 10ml dose of
methadone at 9.32am. (The cellmate said that he and Mr Mullen should have had
their doses earlier that morning, but they had both lost their identity cards, so these
needed to be replaced before they could have further doses.)
34. At just after 10.00am, an officer went to cell D4-37 to give Mr Mullen and his
cellmate some general information about prison life. She gave them prison
induction booklets and asked if they had any questions about being in prison. She
asked Mr Mullen if he wanted her to inform his family that he was in prison and he
asked her to contact his wife. She telephoned Mr Mullen’s wife to tell her that Mr
Mullen was in Leeds and that he was okay. She noted that Mr Mullen’s wife raised
no concerns. (As Mr Mullen’s wife was the victim of his alleged offence, he was not
allowed to contact her directly.)
35. A substance recovery worker reviewed Mr Mullen that morning. She noted that Mr
Mullen engaged well and said that he had no thoughts of suicide or self-harm. She
noted that Mr Mullen said that he had a history of depression and had been
prescribed an antidepressant in the past but he had not taken the medication for a
long time. She told Mr Mullen about the process for booking a GP appointment.
36. At just before midday, Mr Mullen and his cellmate collected their lunches and
returned to their cell which staff locked.
37. At 2.18pm, Mr Mullen received a further 10ml dose of methadone and he then
returned to his cell, and an officer locked it at 2.23pm.
38. CCTV shows that two prisoners separately went to Mr Mullen’s cell several times
that afternoon. One prisoner said that he went to the cell to speak to the cellmate,
as they had served sentences together at HMP Wealstun. He said that when he
went to the cell Mr Mullen was lying in bed and he did not speak to him. The other
prisoner said that he knew the cellmate from the community and had gone to the
cell to ask him for some sugar as he had none. He said that he did not see Mr
Mullen.
39. At 4.18pm, an officer unlocked cell D4-37 and Mr Mullen and his cellmate walked
downstairs to collect their evening meals. They returned to their cell with their meals
at 4.22pm and another officer locked the door. All prisoners were locked in at
around this time and they remained locked in for the rest of the day. The officer told
the investigator that he had seen Mr Mullen engage with the regime during the day
and he had appeared positive and well. When he locked the cell that afternoon, he
asked Mr Mullen and his cellmate if they had everything they needed for the night,
and they said that they did.
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40. At 4.47pm, another officer looked into cell D4-37 and checked that the door was
locked (she checked all the cells on the landing). She told the investigator that due
to the number of prisoners on D wing, they were unlocked at different times during
the day for the various aspects of the regime. She said Mr Mullen stuck in her mind
as he had a distinct mark under his right eye. She said that she recalled interacting
with Mr Mullen and his cellmate throughout the day. She said that Mr Mullen
engaged appropriately with the regime and nothing arose to cause her any concern.
41. At 8.44pm, an officer made a routine check on all the cells. She told the investigator
that she could not recall what Mr Mullen and his cellmate were doing at the time of
her check, but said that she would have taken action had she noticed anything of
concern.
42. The cellmate said that he ate some of his evening meal but gave one of his
sandwiches to Mr Mullen as he was still hungry. Mr Mullen had said nothing at any
time in the day to suggest that he was thinking of harming himself. He said that he
and Mr Mullen watched television in the evening, and he believed that he fell asleep
at around 9.00pm. He said that he woke up a short time later and got out of bed to
make a cup of tea. As he got up, he saw Mr Mullen hanging from the window frame.
He lifted Mr Mullen’s body, unbuckled the belt he had used as a ligature, and Mr
Mullen fell to the ground. He then pressed the emergency cell bell and checked to
see if Mr Mullen had a pulse, but he could not find one.
43. CCTV shows that the cell bell light for the cell illuminated at 9.27pm. Officer A
reached the cell at 9.28pm. He told the investigator that when he reached the fourth
landing he heard knocking from cell D4-37 which suggested an emergency. He said
that when he opened the observation panel Mr Lawson was standing at the door
and he pointed to the back of the cell where Mr Mullen was lying on the floor partly
obscured by the toilet privacy screen. He radioed a medical emergency code blue
(to indicate a prisoner is unconscious or having breathing difficulties). As there were
two prisoners in the cell and the circumstances were unclear, he waited for other
staff to arrive before going into the cell. Officer B reached the cell 22 seconds after
Officer A. CCTV then shows Officer A looking over the bannisters to check where
other staff were and, with two more officers climbing the stairs, he unlocked the cell
at 9.29pm. As he went into the cell, the cellmate told him that Mr Mullen had
hanged himself with a belt.
44. Officers moved Mr Mullen away from the corner of the cell and, after checking him,
they believed he had a pulse and was breathing so they moved him onto his side
(the recovery position). A nurse arrived at 9.31pm and was followed by a colleague.
After checking Mr Mullen, the nurse said that Mr Mullen was not breathing, and her
colleague started CPR. Officers took turns in giving CPR while the nurses gave
oxygen and periodically checked Mr Mullen with a defibrillator.
45. Control room staff called an ambulance when the code blue call was made, and
paramedics arrived at 9.44pm. They took charge of the efforts to resuscitate Mr
Mullen. The paramedics established a pulse and at 10.59pm they took Mr Mullen to
hospital. Mr Mullen died in hospital at 11.30pm.
46. Mr Mullen had left a letter in his cell in which he told his wife that being in prison
was the best place for him to be at that time for both their sakes, He wrote that he
would do anything to get back what he had lost but, if he did not hear back from her,
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he would understand. He asked her to send him some money from his savings. He
gave no indication in the letter that he was thinking of taking his own life.
Contact with Mr Mullen’s family
47. The Duty Governor telephoned Mr Mullen’s wife at 10.59pm to tell her that Mr
Mullen had been taken to hospital and was in a serious condition. Mr Mullen’s wife
went to the hospital to see him. One of Leeds’ family liaison officers telephoned Mr
Mullen’s wife on 2 December. Leeds contributed to the cost of Mr Mullen’s funeral in
line with national instructions.
Support for prisoners and staff
48. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death. Key elements of postvention care include a hot debrief for staff
involved in the emergency response and engaging Listeners to identify prisoners
most affected by the death.
49. A Custodial Manager (CM) 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.
50. The prison posted notices informing other prisoners of Mr Mullen’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 Mullen’s death. Listeners
were deployed to speak to other prisoners and staff started prison suicide and self-
harm support procedures for Mr Lawson.
Post-mortem report
51. The pathologist gave Mr Mullen’s cause of death as pressure on the neck
consistent with hanging.
52. Mr Mullen’s toxicology report found the presence of methadone at a level consistent
with therapeutic use.
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Findings
Assessment of risk of suicide and self-harm
53. Assessment, Care in Custody and Teamwork (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. There should be regular multidisciplinary review
meetings involving the prisoner. In determining whether to start ACCT procedures,
staff are expected to consider any potential risk factors in addition to any overt
actions or words suggesting risk.
54. Mr Mullen had a number of potential risk factors. His alleged offences were against
his wife, whom he would not have been allowed to contact, and he appeared to
have no other external support in the community. He had problems with drug use
and had not been in prison for a number of years. Despite these potential risk
factors, nothing occurred in Mr Mullen’s very brief time at Leeds to indicate that he
was thinking about taking his own life. He consistently told staff that he had no
thoughts of suicide or self-harm, and he had quickly formed a level of friendship and
support with his cellmate. In addition, Mr Mullen’s unsent letter to his wife
suggested that he was thinking of the future with hopes of rekindling their
relationship.
55. Mr Mullen’s wife told us that both the police and the community mental health team
were aware of recent events that might have suggested that he was at risk.
Following issue of our initial report we obtained a copy of the PER that
accompanied Mr Mullen from police custody to court. The PER noted that Mr Mullen
suffered with depression but also noted that he was not considered to be at risk of
suicide or self-harm. (Leeds did not receive a copy of this PER.)
56. We have found no reason for staff at Leeds to have believed that Mr Mullen was at
risk and in need of any additional support through ACCT procedures.
Emergency response
57. Leeds’ staff information notice on entering cells titled ‘Entering a cell – Dynamic
Risk Assessment’, explains that staff have a duty of care to prisoners, to
themselves and to other staff. The notice states that preservation of life must take
precedence over security concerns although staff should not take action that they
feel would put themselves and others in danger. The notice makes clear that there
are many different incidents that can occur in prison so it is difficult to be
prescriptive about the actions to be taken in any particular set of circumstances.
58. When Officer A responded to the cell bell from cell D4-37, he found the cellmate
standing at the door, and he indicated there was a problem with Mr Mullen, who
was lying at the back of the cell partly obscured by the toilet privacy screen. He
radioed a code blue but, as there were two prisoners in the cell and the situation
was unclear, he made the decision to wait for further support before entering the
cell. Officer B arrived 22 seconds after Officer A, and when Officer A saw further
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officers approaching, he and Officer B went into the cell. They went in 46 seconds
after Officer B first attended the cell. Officer A told the investigator that he
understood the need for a dynamic risk assessment and in other circumstances he
might have gone into the cell at an earlier point.
59. We consider that Officer A made a reasonable decision in line with the staff
information notice and the information before him at the time.
Clinical care
60. The clinical reviewer found that Mr Mullen’s care at Leeds was of the required
standard and was equivalent to that he could have expected to receive in the
community. The clinical reviewer made one recommendation that was not directly
delated to Mr Mullen’s death.
Inquest
61. An inquest into Mr Mullen’s death held between 22 and 26 June 2026, concluded
that his cause of his death was suicide by hanging. The inquest jury found that the
outcome might have been different if information known to the police about Mr
Mullen’s mental health had been known to the prison.
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