Taylor Atkinson

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Independent investigation into
the death of Mr Taylor Atkinson,
a prisoner at HMP Eastwood Park,
on 9 July 2022
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Taylor Atkinson, who was a transgender man, died on 9 July 2022, after he cut his
neck in his cell at HMP Eastwood Park. He was 50 years old. I offer my condolences to
Mr Atkinson’s family and friends.
Mr Atkinson had lived as a male for several years. He had a significant history of
substance misuse and mental health difficulties and frequently harmed himself, particularly
when he felt emotionally overwhelmed. He also had number of physical health problems,
for which he received medication.
Staff managed Mr Atkinson under suicide and self-harm prevention procedures (known as
ACCT) on several occasions at Eastwood Park. While they showed concern and correctly
started and re-started ACCT procedures following incidents of self-harm and associated
thoughts, there were a number of failings in the management of ACCT.
Staff failed to develop an appropriate ACCT care plan, did not consider involving Mr
Atkinson’s next of kin in the ACCT process and did not always allocate a case co-ordinator
or hold multi-disciplinary case reviews. They also failed to complete properly the process
for closing and re-starting ACCT procedures. I am particularly concerned that staff did not
fully assess Mr Atkinson’s increased risk in the time leading up to his death and monitor
him under constant supervision.
It is disappointing and concerning that we identified similar failings in the management of
ACCT procedures in our investigation into the death of a prisoner who took their own life at
Eastwood Park two days before Mr Atkinson. The Director of Women will need to address
this.
The clinical reviewer considered that healthcare staff did not display adequate clinical
enquiry when they attended to Mr Atkinson on 9 July and found that they should have
started cardiopulmonary resuscitation (CPR). I am particularly concerned that prison
nurses did not start CPR, despite telling an ambulance call handler that they could not be
sure if Mr Atkinson had died.
The clinical reviewer also considered that the care Mr Atkinson received at HMP Eastwood
Park before the emergency response was equivalent to that which he could have expected
to receive in the community. However, she identified two areas for improvement, namely
that healthcare staff did not review Mr Atkinson’s blood thinning medication prescription
following an incident of self-harm five days before his death and they did not complete an
appropriate mental health care plan.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 6
Background Information ................................................................................................... 7
Key Events ....................................................................................................................... 9
Findings ......................................................................................................................... 22
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Summary
Events
1. On 5 March 2010, Mr Taylor Atkinson received an Imprisonment for Public
Protection (IPP) sentence for aggravated burglary, with a minimum term to serve of
three years and nine months.
2. Mr Taylor Atkinson was a transgender man, who had lived as a male for several
years. He had a history of substance misuse and was prescribed methadone to
treat opiate dependence. He had a diagnosis of emotionally unstable personality
disorder and a significant history of self-harm and suicidal ideation. He also had
several physical health problems, including deep vein thrombosis (DVT).
3. On 17 September 2019, Mr Atkinson was transferred to HMP Eastwood Park. A
prison GP liaised with the mental health team and prescribed several medications
including methadone, quetiapine (an antipsychotic) and rivaroxaban (a blood-
thinning medication to treat DVT). A mental health nurse conducted an initial
assessment and noted that Mr Atkinson would be managed under the Care
Programme Approach (CPA).
4. Over the next two and a half years, healthcare staff reviewed Mr Atkinson frequently
and discussed his care at multi-disciplinary meetings. Although Mr Atkinson’s
ability to manage his emotions improved, staff monitored him under suicide and
self-harm monitoring procedures (known as ACCT) on several occasions. The
Parole Board held a review and concluded that the best way to manage Mr
Atkinson’s risk was to transfer him to open conditions. Prison staff subsequently
moved him to Residential Unit Seven (Res 7), which is set up to reflect open
conditions. He left the prison three times subject to an assisted Release on
Temporary Licence (ROTL).
5. On 20 May 2022, Mr Atkinson left the prison on ROTL and failed to comply with the
instructions of the accompanying officer. When he returned to prison, he became
angry when staff told him that he had broken the rules of ROTL and would not
return to Res 7. Prison staff started ACCT procedures. They stopped monitoring
him under ACCT procedures on 24 May.
6. On 8 June, prison staff re-started ACCT procedures after Mr Atkinson made a cut to
his neck. There is, however, no record that they considered an assessment or
added any actions to his care plan. Staff stopped ACCT monitoring on 21 June.
7. On 4 July, a prisoner found Mr Atkinson in his cell with self-inflicted wounds to his
neck and one of his arms. Prison staff re-started ACCT procedures and set his
observation requirement at four an hour. However, there is, again, no record that
they considered an assessment or added any information or actions to his care
plan.
8. At 11.45am on 8 July, an officer noted in the ACCT record that Mr Atkinson had
asked about ending ACCT monitoring, obtained books on human anatomy from the
library and said that that he had struggled with the recent death of a prisoner. The
officer recorded that Mr Atkinson had discussed his recent self-harm with another
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prisoner and said that the next time he harmed himself, no one would find him. At
3.45pm, a supervising officer (SO) chaired an ACCT review without Mr Atkinson.
The SO recorded that Mr Atkinson was not taking his medication and a nurse, who
was present, noted that Mr Atkinson wanted his observation requirement reduced
but also reported suicidal thoughts. Attendees kept his observation requirement the
same but there is no record that they considered constant supervision or removing
razors.
9. At 9.50pm on 9 July, an officer conducted his sixth ACCT check of the evening on
Mr Atkinson. He told us that during his checks, he observed Mr Atkinson in various
positions, including behind a makeshift curtain covering the toilet area at the back of
his cell.
10. At 10.04pm, an operational support grade (OSG) looked through Mr Atkinson’s cell
observation panel and saw him sitting in the toilet area, which was shielded by a
privacy screen and a curtain, with his head visible and blood on the floor. She
notified a nearby officer and radioed an emergency code red. The officer entered
the cell, found Mr Atkinson was unresponsive and with a significant cut to his neck.
He did not move him or start CPR.
11. At 10.07pm, a mental health nurse entered the cell. He checked Mr Atkinson for a
pulse but found no evidence of life. A minute later, another mental health nurse
arrived and noted that it was hard to assess Mr Atkinson due to his position. They
did not move him, apply a defibrillator or start CPR. One of the nurses then spoke
to an ambulance call handler and told them that they could not be sure if Mr
Atkinson had died. At 10.27pm, ambulance paramedics arrived at Mr Atkinson’s
cell and moved him onto the floor. At 10.33pm, a critical care doctor pronounced
that Mr Atkinson had died.
Findings
Risk management
12. Mr Atkinson had a significant history of self-harm, particularly when he felt
emotionally overwhelmed. We are satisfied that staff showed concern and
appropriately opened and re-started ACCT procedures following incidents of self-
harm and associated thoughts. However, we found a number of failings in the
management of ACCT procedures.
13. Staff did not develop an appropriate ACCT care plan. They did not always allocate
a case co-ordinator or hold multidisciplinary case reviews and failed to invite Mr
Atkinson to a case review the day before he died.
14. Prison staff did not conduct the ACCT post-closure process in line with national
policy and did not record whether they considered the ACCT assessment and care
plan when re-starting ACCT procedures.
15. Prison staff did not consider Mr Atkinson’s access to razors after he cut his neck on
4 July. We are particularly concerned that staff misinterpreted Mr Atkinson’s risk
the day before he died and, despite several indicators of increased risk, did not
monitor him under constant supervision.
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16. Staff did not fully consider the positive impact an enhanced regime had on Mr
Atkinson’s level of risk. While his behaviour did not meet the criteria, staff should
have at least explored the possibility of reinstating his enhanced prisoner status to
manage his risk.
17. Prison staff did not always provide a detailed record of conversations and failed to
consider the risk of Mr Atkinson having a curtain that covered the toilet area of his
cell despite a recent episode of serious self-harm.
18. We identified similar failings in the management of ACCT procedures in our
investigation into the death of a prisoner who took their own life two days before Mr
Atkinson. We therefore consider that urgent action is now required to ensure that
ACCT procedures at Eastwood Park improve.
Emergency response
19. Prison and healthcare staff checked Mr Atkinson’s vital signs but did not move him
onto the floor or start CPR. The clinical reviewer considered that taking his pulse
and blood pressure was not enough to verify that Mr Atkinson was dead. While we
cannot say whether this affected the outcome for Mr Atkinson, we are concerned
that staff did not start CPR despite telling an ambulance call handler that they could
not be sure if Mr Atkinson had died.
20. The clinical reviewer also considered that healthcare staff did not sufficiently justify
their reasoning for not starting CPR in Mr Atkinson’s medical record. She found
that the level of life support training held by the emergency response nurses on 9
July was not adequate.
Clinical care
21. The clinical reviewer considered that the care Mr Atkinson received at HMP
Eastwood Park before the emergency response was equivalent to that which he
could have expected in the community. However, she identified areas for
improvement.
22. The clinical reviewer found that although Mr Atkinson was managed under the CPA
framework and had regular CPA reviews, he did not have a formal care plan in
place.
23. The clinical reviewer considered that although Mr Atkinson presented an increased
risk of excessive bleeding due to taking rivaroxaban, healthcare staff did not always
take his clinical observations following his self-harm. She concluded that while it
was not within her expertise to determine if rivaroxaban contributed to excess
bleeding, staff should have considered a medication review after he cut his neck on
4 July.
Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide and self-harm in line with national instructions, including that:
• a case co-ordinator is appointed at the first ACCT case review;
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• ACCT support actions are specific and meaningful, consider all of the issues
identified at assessments and case reviews, and are updated at each review.
• ACCT case reviews are multidisciplinary and include healthcare staff where
relevant, and that prisoners are invited to contribute to all case reviews;
• case reviews consider and document all relevant information that affects risk,
including the removal of razor blades, items that might impact staff’s vision of a
prisoner, and other items when relevant;
• staff review the risk of suicide and self-harm whenever an event occurs which
indicates an increase in risk, including starting constant supervision when
necessary;
• observations and comprehensive conversations are carried out as directed and
documented in the ACCT record;
• staff review the previous ACCT document when re-starting ACCT procedures
and include all important information relevant to the assessment of risk; and
• staff complete the seven-day post closure monitoring form and ensure that post-
closure reviews take place at the proper time and consider events following the
closure of the ACCT.
• The Director of Women for HMPPS should write to the Ombudsman to set out what
action she has taken to satisfy herself that meaningful improvements have been
made to the assessment and management of the risk of suicide and self-harm at
HMP Eastwood Park.
• The Governor and Head of Healthcare should ensure that staff are aware of their
responsibilities in medical emergencies, including that;
• staff apply a defibrillator and start CPR when appropriate if there are not clear
signs of irreversible death; and
• when healthcare staff decide not to start CPR, they evidence their decision-
making in the medical record.
• The Head of Healthcare should undertake a review of the concerns raised by the
clinical reviewer of Nurse A and Nurse B to ensure that appropriate actions are
taken, including consideration of a referral to the NMC.
• The Head of Healthcare should ensure that:
• all prisoners managed under the CPA framework have a formal mental health
care plan; and
• when a prisoner is prescribed anticoagulant medication and bleeds, staff take
their clinical observations, record a National Early Warning Score and arrange a
medication review.
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• The Governor and Head of Healthcare should ensure that a copy of this report is
shared with the staff named in this report and that a senior manager discusses the
Ombudsman’s findings with them.
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The Investigation Process
24. The investigator issued notices to staff and prisoners at HMP Eastwood Park
informing them of the investigation and asking anyone with relevant information to
contact him. One prisoner responded.
25. The investigator obtained copies of relevant extracts from Mr Atkinson’s prison and
medical records.
26. The investigator interviewed eight members of staff and three prisoners at
Eastwood Park between 20 and 22 September. He also interviewed six members of
staff by telephone and video conference between 3 and 17 October.
27. NHS England commissioned a clinical reviewer to review Mr Atkinson’s clinical care
at the prison. She and the investigator jointly interviewed healthcare staff.
28. We informed HM Coroner for Avon of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
29. A senior investigator contacted Mr Atkinson’s friend, his nominated next of kin, on
behalf of the Ombudsman’s family liaison officer, to explain the investigation and to
ask if they had any matters they wanted us to consider. Mr Atkinson’s friend did not
ask any specific questions but shared concerns about the ACCT and emergency
response processes. She also said that she felt that the care Mr Atkinson received
Eastwood Park was not appropriate.
30. Mr Atkinson’s next of kin received a copy of the initial report. The solicitor
representing his next of kin wrote to us pointing out some factual inaccuracies
and/or omissions. The report has been amended accordingly. They also raised a
number of questions that do not impact on the factual accuracy of the report. We
have provided clarification by way of separate correspondence to the solicitor.
31. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Eastwood Park
32. HMP Eastwood Park is a closed prison in Gloucestershire which holds up to 442
women. It has 10 residential wings, two of which provide specialist substance
misuse services. At the time of Mr Atkinson’s death, integrated healthcare services
at Eastwood Park were provided by Inspire Better Health (part of Avon and
Wiltshire Mental Health Partnership NHS Trust). Practice Plus Group took over the
contract on 1 October 2022 but have partnered with Avon and Wiltshire Mental
Health Partnership NHS Trust, who continue to provide psychosocial and mental
health services.
HM Inspectorate of Prisons
33. An inspection report of HMP Eastwood Park followed an inspection in May 2019.
(Inspectors subsequently completed an inspection in October 2022. This report had
not yet been published when we issued our investigation report.) Inspectors found
that relationships between staff and prisoners remained a strength, and prisoners
reported that staff were supportive. Inspectors noted that prisoners in crisis
received good care, including excellent peer support, but the quality of recording in
case management documents for prisoners at risk of suicide and self-harm was not
sufficiently good. Inspectors reported that healthcare staff responded to all
emergencies, had received life support training, officers were familiar with the
emergency codes protocol and emergency ambulances were called promptly.
34. In the inspection report following the October 2022 inspection, published in
February 2023, inspectors found that safety had declined considerably and gave it
their lowest judgment ‘poor’.
35. Inspectors carried out a review in September 2023. They found that the prison had
the highest rates of self-harm in the women’s estate, but incidents were slowly
reducing. There was some improvement in how ACCTs were carried out (such as
more consistent case management), but some women remained frustrated at how
difficult it was to get basic requests dealt with. Staffing levels on residential units
had improved giving women more time out of their cells with staff able to deliver
more regime.
Independent Monitoring Board
36. 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 October 2021, the IMB reported
that while the management of suicide and self-harm prevention procedures had
improved, the care planning aspect continued to be a weakness. They also
reported that there continued to be an inward flow of illicit items, including lighters,
mobile phones and drug paraphernalia.
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Previous deaths at HMP Eastwood Park
37. Mr Atkinson was the third prisoner to die at Eastwood Park since July 2020. Of the
previous deaths, one was self-inflicted, and one was due to natural causes. We
have previously made recommendations about suicide and self-harm monitoring
procedures.
Assessment, Care in Custody and Teamwork (ACCT)
38. ACCT is the care planning system the Prison Service uses to support prisoners at
risk of suicide or self-harm. The purpose of the ACCT is to try to determine the
level of risk posed, the steps that staff might take to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Checks should be made at
irregular intervals to prevent the prisoner anticipating when they will occur.
39. Part of the ACCT process involves assessing immediate needs and drawing up a
support plan to identify the prisoner’s most urgent issues and how they will be met.
Staff should hold regular multidisciplinary reviews and should not close the ACCT
plan until all the actions of the caremap are completed. Guidance on ACCT
procedures is set out in Prison Service Instruction (PSI) 64/2011 on safer custody.
Parole Board
40. The Parole Board for England and Wales is an independent public body. Its role is
to make risk assessments about prisoners to assess their suitability for transfer to
open conditions and to decide whether they can safely be released into the
community once they have served the minimum sentence imposed by the courts.
Release on temporary licence (ROTL)
41. Release on temporary licence (ROTL) facilitates the rehabilitation of offenders by
helping to prepare them for resettlement in the community once they are released.
This includes, among other examples, finding work and rebuilding family ties.
ROTL is mostly used in open prisons, but closed prisons can release eligible
prisoners if they have suitable resourcing and infrastructure in place.
Imprisonment for Public protection (IPP)
42. Sentences of Imprisonment for Public Protection (IPP) were first used in April 2005
and allow the court to set a minimum term of imprisonment, after which the offender
will be released once they can satisfy the Parole Board that their risk of reoffending
has sufficiently reduced.
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Key Events
43. Mr Taylor Atkinson was a transgender man, who had identified as male for several
years. He had not had gender reassignment surgery or hormone therapy and did
not have a gender recognition certificate (which is necessary to obtain a new birth
certificate recognising the acquired gender).
2010 to 2020
44. On 5 March 2010, Mr Atkinson received an Imprisonment for Public Protection (IPP)
sentence for aggravated burglary, with a minimum term to serve of three years and
nine months. He was sent to HMP Bronzefield.
45. Mr Atkinson had a history of substance misuse problems and was prescribed
methadone to treat opiate dependence. He had a diagnosis of emotionally unstable
personality disorder and had a significant history of self-harm and suicidal ideation,
which increased in frequency when he felt stressed and/or overwhelmed. Mr
Atkinson often made cuts to his neck and on one occasion, in 2018, following a
refusal from the Parole Board, he made a cut that required surgery. He also had
several physical health problems, including epilepsy and deep vein thrombosis
(DVT).
46. On 5 June 2019, due to repeated episodes of self-harm at HMP Peterborough, Mr
Atkinson was admitted to Littlemore Mental Health Centre, Oxford, under Section
47 of the Mental Health Act 1983, which allows health professionals to transfer
prisoners to hospital for treatment.
HMP Eastwood Park
47. On 17 September 2019, Mr Atkinson was discharged from Littlemore and
transferred to HMP Eastwood Park. A nurse conducted an initial health
assessment and made mental health and substance misuse referrals. A prison GP
liaised with the mental health team and prescribed several medications, including
methadone, quetiapine (an antipsychotic), trazadone (an antidepressant), zopiclone
(to assist sleep), pregabalin (to treat epilepsy and nerve pain) and rivaroxaban (an
anticoagulant to treat DVT).
48. A mental health nurse conducted an initial assessment. He noted that Mr Atkinson
had agreed to return to prison as he did not want to engage in therapy at Littlemore.
He also noted that Mr Atkinson had a history of self-harm and needed to be
allocated to the Care Programme Approach (CPA, a package of care for people
with mental health problems).
49. On 10 November, an officer met with Mr Atkinson to complete a Transgender Case
Board – Advanced Disclosure document. He recorded that Mr Atkinson’s legally
recognised gender was female and that Mr Atkinson saw himself as “gender fluid”.
On 15 November, an officer and a nurse visited Mr Atkinson to find out why he had
decided not to attend a Transgender Board meeting, but he refused to engage. The
nurse noted that Mr Atkinson had told wing staff that he did not want to go as he
had been “screwed over by mental health” in the past. There is no evidence that Mr
Atkinson was invited to, or attended, another Transgender Board before his death.
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50. Over the next 15 months, healthcare staff reviewed Mr Atkinson frequently and
discussed his care at regular multidisciplinary team meetings. Prison records show
that although Mr Atkinson’s ability to manage his emotions improved, he continued
to harm himself when under increased stress and staff monitored him under suicide
and self-harm monitoring procedures (known as ACCT) on several occasions.
2021
51. On 22 February 2021, the Parole Board wrote to Mr Atkinson advising him of the
result of a parole hearing that took place on 5 January. While they acknowledged
that he had worked hard and that his emotional management had improved, they
noted that he continued to have periods of emotional instability. The Parole Board
concluded that the best way to manage Mr Atkinson’s risk was for him to transfer to
open conditions. At interview, the Head of Offender Management Delivery told the
investigator that the initial plan was for Mr Atkinson to transfer to one of the two
female open prisons. However, neither prison assessed him as suitable due to
concerns about his medication and the provision of appropriate mental health care.
52. On 20 May, as a response to Mr Atkinson’s recommended progression to open
conditions, staff moved him to Residential Unit Seven (Res 7) which aims to
resemble an open environment within a closed setting. Over the following six
months, prison records show that Mr Atkinson found it difficult to adjust to the
regime on Res 7 and received several entries for negative behaviour as a result of
forming a relationship with another prisoner. However, he remained stable on his
medication and incidents of self-harm decreased substantially.
53. Between 5 November and 15 December, Mr Atkinson twice left the prison on
assisted Release on Temporary Licence (ROTL). Mr Atkinson’s licence stipulated
that he had to comply with the instructions of the accompanying officer, which
included staying within their proximity. The Head of Offender Management Delivery
told the investigator that although the ROTLs went well, it later transpired that the
officer accompanying Mr Atkinson on the second ROTL let him go off on his own,
unsupervised. She said that she told Mr Atkinson that it should not have happened,
but that as the ROTL had gone well, he could continue to apply for ROTL.
2022
54. On 17 March 2022, Mr Atkinson went on assisted ROTL to Bristol City Centre. The
Head of Offender Management Delivery told the investigator that, again, she was
subsequently made aware that the accompanying officer had allowed Mr Atkinson
to spend time unsupervised. She said that she raised her concern with the prison
and that it became apparent that the escorting officer may have been instructed to
allow Mr Atkinson to leave their supervision. She added that as the ROTL had, in
principle, gone well, she agreed for Mr Atkinson’s ROTLs to continue as he
managed himself well in a city that he did not know and returned at the agreed time.
55. On 21 March, Mr Atkinson’s allocated Prison Offender Manager (POM) met Mr
Atkinson for an additional engagement session to review his recent ROTL. She
recorded that Mr Atkinson seemed pleased that it had gone well. (Due to his
complex needs, she met Mr Atkinson on a mostly weekly basis for an additional
engagement session instead of him having a keywork session with an officer, as
outlined in the Prison Services Custodial Policy Framework 2018.)
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56. On 9 May, the Head of Offender Management Delivery contacted the prison’s
mental health staff advising them that there was intelligence to suggest Mr Atkinson
was selling pregabalin. On 13 May, a consultant psychiatrist re-prescribed
pregabalin but noted that her intention was to start reducing Mr Atkinson’s dose as
soon as possible.
57. On 16 May, Mr Atkinson’s allocated mental health keyworker reviewed him on the
wing. She noted that Mr Atkinson said that the Parole Board had moved the time
period for his next review and that it would now take place between September
2022 and March 2023. Mr Atkinson said that he felt the process was “setting him
up to fail”, but that he was looking forward to an overnight ROTL at a Probation
Approved Premises (AP) in Birmingham, which had been scheduled for 24 May.
Events of 20 May
58. At around 10.00am, Mr Atkinson left the prison on ROTL to Bristol City Centre
accompanied by an officer. The Head of Offender Management Delivery told us
that the officer contacted her beforehand to check the requirements of the escort
and that she confirmed that Mr Atkinson should remain in her sight at all times. She
also said that prison staff gave the same message to Mr Atkinson. However, prison
records show that Mr Atkinson failed to comply with the instruction and went
missing for several hours. He later re-established contact with the officer by going
to a shopping complex contact point and asking them to put a message out over the
public announcement system.
59. At around 3.50pm, Mr Atkinson returned to the prison. An officer recorded that Mr
Atkinson became angry and refused to leave Reception after staff told him that they
would need to put the items he had bought on his property card before he could
have them. Staff placed Mr Atkinson in a holding cell, and he became angry again
when staff told him that he had broken the rules of ROTL and would not return to
Res 7. Prison records state that Mr Atkinson stormed out of the holding cell and
tried to grab a plant pot, which resulted in staff using force to escort him to Res 8 (a
standard residential unit). They also charged him with breaching prison rules
because of his actions.
60. At 5.00pm, an officer completed a concern form and recorded that, due to Mr
Atkinson’s history of self-harm, staff had decided to start ACCT procedures. At
5.15pm, a Supervising Officer (SO) completed an immediate action plan and set Mr
Atkinson’s observation requirement at four an hour.
Events from 21 to 31 May
61. At 12.05pm on 21 May, a prison offender manager (POM) conducted an ACCT
assessment and noted that although Mr Atkinson said he continued to feel angry
about what happened on ROTL, he did not intend to harm himself. She noted that
although the regularity of Mr Atkinson’s self-harm had reduced over the last 12
months, he had a significant history of throat cutting and said that he did it because
he loathed himself. She also completed the risk, triggers and protective factors of
the ACCT care plan and noted that Mr Atkinson’s main risks were his continuing
sentence, history of substance misuse, self-harm, adverse childhood experiences
and paranoia that prison and probation staff were “setting him up to fail”.
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62. At 2.20pm, a SO chaired a first ACCT case review, which a mental health crisis
support worker, attended. He recorded that Mr Atkinson said “a bomb went off in
his head” when reception staff said that they would conduct a search and planned
on charging him with a disciplinary offence. He also noted that Mr Atkinson said he
was not happy about being on Res 8 and wanted to return to Res 7. Attendees
decided that, in light of Mr Atkinson’s past behaviour, he presented a risk of suicide
and self-harm. They kept his observation requirement at four an hour. Two support
actions were added to the care plan: for Mr Atkinson to see mental health staff and
for him to speak to the Offender Management Unit (OMU) about his ROTL issues.
63. At 6.35pm, the mental health crisis support worker completed a mental health risk
assessment and recorded that Mr Atkinson’s risk of suicide and self-harm had
increased in light of what happened while on ROTL. She identified that the move to
Res 8 had reduced Mr Atkinson’s support network and that he viewed it as a huge
step backwards. She added that Mr Atkinson had been known to harm himself
when experiencing emotional distress and that he would no longer have his
medication in his cell with him.
64. On 23 May, a POM visited Mr Atkinson on Res 8, with the Head of Offender
Management Delivery, to find out more about the ROTL incident. At interview, she
told the investigator that Mr Atkinson said the “system had let him down” and that
he felt it was the escorting officer’s job to follow him, not the other way around. She
also added that Mr Atkinson was strongly of the view that he had not done anything
wrong, and that staff were punishing him for doing the right thing.
65. At 11.47am, the POM contacted the allocated mental health keyworker and
informed her that Mr Atkinson’s planned overnight ROTL for 24 May would not go
ahead. She added that Mr Atkinson was due to have a disciplinary hearing later
that day and that he was fully aware of the significance this was likely to have in
terms of his application for release on parole later in the year.
66. The Acting Head of Safety chaired the disciplinary hearing following the ROTL
incident. She noted that while the charge of failing to comply with a condition of
temporary release could not be heard as it was not laid in the relevant timescales,
the other charges of unauthorised items, insulting behaviour and damage were
heard. As a consequence, Mr Atkinson was prevented from making canteen
(prison shop) orders and using his private cash for seven days.
67. On 24 May, a Custodial Manager (CM) and a SO held an Incentives and Earned
Privileges (IEP) review. (The IEP scheme aims to encourage and reward
responsible behaviour, improve engagement in positive activity and create a safer
environment. There are three levels: basic, standard and enhanced.) The SO
noted that Mr Atkinson showed some remorse for the events on 20 May and did
accept all of the facts as true. He added that they felt that Mr Atkinson should have
been moved to basic IEP on the day of the incident but as this did not happen, they
decided it was more appropriate to move him to standard IEP instead. (Mr Atkinson
had previously been on the enhanced IEP level.)
68. At 3.00pm, a CM chaired an ACCT case review and recorded that Mr Atkinson did
not appear to accept responsibility for what happened on 20 May. She added that
Mr Atkinson felt like he had lost everything and had nothing to work for. Mr
Atkinson also said that he had not harmed himself for over a year and that ACCT
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procedures did not help him. Attendees decided to stop ACCT monitoring and
noted that Mr Atkinson was receiving support from the mental health team and
OMU. There is, however, no record that staff conducted the required seven-day
post-monitoring review process.
69. Later that afternoon, prison staff moved Mr Atkinson to Res 5, a standard residential
unit. (The reason for the move is not recorded.)
70. On 30 May, an administrator noted that she had received a voicemail message from
Mr Atkinson’s next of kin stating that she had heard that there had been a death at
Eastwood Park and that she was worried as she had not heard from Mr Atkinson in
a while. She liaised with prison staff before contacting his next of kin to say that
there had not been a death and that Mr Atkinson was doing OK.
Events from 1 June to 3 July
71. On 1 June, a nurse and a substance misuse recovery worker saw Mr Atkinson for a
substance misuse clinical management plan review. She recorded that although Mr
Atkinson said he remained frustrated by his situation, he presented as positive
about working towards returning to Res 7 and having ROTLs.
72. Later that day, a CM saw Mr Atkinson for an ACCT post-closure review and noted
that he remained unhappy about what happened on ROTL but had started to settle
on Res 5. She added that Mr Atkinson had friends on the wing, did not report any
thoughts of suicide and self-harm and continued to engage with OMU.
73. Later, the allocated mental health keyworker saw Mr Atkinson for an assessment of
needs as there had been issues with his compliance with quetiapine. Mr Atkinson
said that he did not always attend to collect his medication because he did not like
to take a morning dose if he felt he did not need it. Mr Atkinson did not report any
thoughts of suicide or self-harm and said that he had met the Head of Offender
Management Delivery and a prison manager, who said that he could apply for Res
7 and ROTLs after 42 days.
74. On 8 June, a nurse reviewed Mr Atkinson after officers found him with a cut to his
neck. She noted that she stemmed the bleeding and tried to close the wound, but
Mr Atkinson presented as agitated and declined treatment. He did, however, agree
to tend to the wound himself and was given dressings.
75. In the meantime, a SO re-started the previous ACCT and recorded that Mr Atkinson
had harmed himself with a razor due to an issue with his canteen order. He set Mr
Atkinson’s observation requirement at three an hour with three conversations daily
(am, pm, and evening). He also noted that Mr Atkinson was asked to hand over
any razors that he had. There is, however, no record that staff considered
completing another assessment or added any support actions to the care plan.
76. In the evening, a nurse reviewed Mr Atkinson following a request from prison staff
and recorded that that his wound had increased in size and was gaping. She
transferred Mr Atkinson to hospital to have his wound sutured. He returned to the
prison at around midnight.
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77. On 9 June, the Acting Head of Safety chaired a safety intervention meeting. In the
minutes, it is noted that Mr Atkinson was experiencing a period of instability and that
there was intelligence about him trading medication.
78. An administrator took a call from Mr Atkinson’s next of kin. She recorded that his
next of kin was aware that Mr Atkinson had harmed himself and said that playing on
his games console really helped during times of emotional instability. Mr Atkinson’s
next of kin said that he could not currently use the console as his games were in
Reception. She subsequently contacted a CM and told her about Mr Atkinson’s
games.
79. A prison GP chaired a multidisciplinary team meeting and noted that staff discussed
the risk of Mr Atkinson taking opiates in addition to his prescribed sedating
medications, with particular focus on pregabalin. She noted that in light of the
ROTL incident, a change of wing and recent self-harm, they did not want to add to
the risk of self-harm by reducing Mr Atkinson’s pregabalin. She recorded that
attendees agreed to hold a joint meeting with the substance misuse team in a
month to formulate a plan for reducing pregabalin slowly.
80. In the evening, the allocated mental health keyworker reviewed Mr Atkinson who
gave several reasons for his self-harm. He said that he was concerned about his
ROTLs being suspended, not having any computer games in his cell, a friend
leaving prison on 10 June and his canteen not arriving. He added that although he
continued to feel angry, he did not currently have any thoughts of suicide and self-
harm.
81. On 11 June, the allocated mental health keyworker visited Mr Atkinson on the wing
for a follow-up review. She recorded that he was mixing with his peers on the wing
and declined a review. Mr Atkinson said that he felt better now that he had access
to computer games and had obtained work as a wing cleaner.
82. On 12 June, a pharmacy assistant recorded that Mr Atkinson presented to collect
his medication with slurred speech and pin-point pupils. She spoke to a nurse, who
noted that Mr Atkinson presented “dazed” and that he did not think it was safe to
issue his evening medication. On 13 June, an officer recorded that Mr Atkinson had
received a negative IEP warning for being under the influence of illicit substances.
83. On 15 June, a CM chaired an ACCT case review without input from healthcare staff
as she was unable to book in a multidisciplinary review. She noted that Mr Atkinson
said that he was in a much better place and had not harmed himself since staff re-
started ACCT procedures. Attendees agreed that ACCT monitoring should remain
in place but reduced Mr Atkinson’s observation requirement to three observations
during the day and two at night.
84. That day, a nurse and a substance misuse recovery worker saw Mr Atkinson for a
substance misuse clinical management plan review. The nurse recorded that Mr
Atkinson was struggling with the move from Res 7, losing ROTL and his relationship
with another prisoner being “in limbo”. She noted that when asked about illicit
substance misuse, Mr Atkinson said, “I would use heroin if there was some, but
there ain’t any, so no”. She added that she and the recovery worker would continue
to review Mr Atkinson frequently.
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85. The allocated mental health keyworker visited Mr Atkinson for keyworker risk
assessment review. She recorded that he looked drowsy, described his mood as
“not too bad” and said that he did not always take his quetiapine as he felt stable
and used his computer games as a distraction. She added that she was not sure
about Mr Atkinson’s reasoning and tried to explore this further, but he said that he
could not explain it. She also noted that she tried to engage Mr Atkinson in a care
planning discussion, but he said that he had a headache and returned to his cell.
86. On 16 June, Mr Atkinson phoned a friend who had recently been released from
custody and with whom he had been in a relationship in prison. Mr Atkinson
wanted to know whether his friend wanted to “call it quits”. His said that she did not
know how it was going to work over the phone. Mr Atkinson said that nothing bad
was going to happen, but he wanted to know ‘yes’ or ‘no’ so that she could try to
move on. (All prisoners telephone calls are recorded. Prison staff listen to some at
random and others are listened to if security staff have intelligence that information
about the safety of individuals or the prison might have been discussed. Mr
Atkinson’s telephone calls were not listened to before his death.)
87. On 21 June, a CM chaired an ACCT case review which a POM also attended.
There is no record that healthcare staff attended. The CM recorded that Mr
Atkinson presented as very positive and said he was ready to move on from where
he was a few weeks ago. Mr Atkinson said that his goal was going to work and
getting back to Res 7. Attendees decided that as Mr Atkinson appeared positive
and had not harmed himself, they would stop ACCT monitoring. There is no record
that staff completed the seven-day post-closure monitoring and final review
process.
88. On 23 June, the Acting Head of Safety chaired a safety intervention meeting. Staff
noted that Mr Atkinson’s ACCT monitoring had stopped, that a parole review had
not been set and that there was a lot of intelligence that Mr Atkinson used drugs.
They removed Mr Atkinson from the list of prisoners discussed at the safety
intervention meeting. At interview, the Head told the investigator that they decided
to remove Mr Atkinson because there was no immediate concern about his risk.
89. On 25 June, Mr Atkinson phoned his friend, whom he had named as his next of kin.
He told them that he had packed up his belongings and was waiting to move to a
cell on Res 3. He appeared positive about the move and said that would put him in
a good position for a move to Res 7. He also said that the Head of Offender
Management Delivery had provided him with ROTL paperwork and said he could
re-apply from 3 July. (Mr Atkinson moved to Res 3 later that day.)
90. On 2 July, an officer recorded that Mr Atkinson had received a negative IEP
warning for being found lying on top of another prisoner, kissing her. Prison staff
charged Mr Atkinson with a breach of prison discipline.
Events of 4 July
91. At 10.20am, a prison manager chaired a disciplinary hearing which a SO and Mr
Atkinson attended. He noted that Mr Atkinson admitted to the charge and said that
he cuddled the prisoner as he felt low and wanted to get back to his former self. Mr
Atkinson lost seven days of canteen as a consequence.
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92. At around 4.00pm, a prisoner found Mr Atkinson in his cell with self-inflicted wounds
to his neck and one of his arms. They notified a SO, who radioed a medical
emergency code red (which indicates that a prisoner is bleeding or has severe burn
injuries). Two nurses responded, applied pressure to Mr Atkinson’s wounds and
took his clinical observations. Ambulance paramedics arrived and assessed Mr
Atkinson, but he declined to go to hospital.
93. At 4.30pm, a SO re-started ACCT procedures and set Mr Atkinson’s observation
requirement at four an hour. However, the first part of the ACCT document was not
completed, including the immediate action plan, assessment, care plan and key
information sections.
94. At 5.56pm, a prison GP recorded that Mr Atkinson was discussed at a
multidisciplinary team meeting. A nurse prescriber said that Mr Atkinson was not
taking his morning dose of quetiapine and that it might be best to stop it. The
allocated mental health keyworker said that it would probably be best to discuss this
with him first. The GP noted that it was a delicate time to change Mr Atkinson’s
medication and left it unchanged.
95. At 7.15pm, a SO chaired an ACCT first case review which several members of staff,
including the allocated mental health keyworker, attended. She recorded that Mr
Atkinson said he felt like he had “gone backwards” with his sentence and was
completely overwhelmed, which led to him harming himself. She added that Mr
Atkinson said that he continued to struggle with his current situation and that
attendees had decided to keep his observation requirement at four an hour. There
is, however, no record that staff considered adding any support actions to the ACCT
care plan.
Events from 5 to 7 July
96. At 10.35am on 5 July, a POM recorded in the ACCT ongoing record that she met
Mr Atkinson having been informed about his act of self-harm. She noted that Mr
Atkinson was low in mood and was preoccupied by what had happened to him
recently. She added that Mr Atkinson did not express any thoughts of self-harm,
but he had slurred speech and seemed tired.
97. At 12.09pm, Mr Atkinson phoned a friend and said, “I tried to kill myself yesterday”.
He said that he did it because he thought that he would have enough time, but
another prisoner entered his cell and alerted staff.
98. At 3.25pm, the allocated mental health keyworker saw Mr Atkinson for a mental
health review and recorded that he reported feeling drained [of energy] as a result
of recent events and blood loss. She added that he felt despondent about the
future and continued to dispute what happened on ROTL. She also made an entry
in Mr Atkinson’s ACCT record stating that he said he had intended to kill himself
when he harmed himself on 4 July, but he did not have any current thoughts of
suicide and self-harm.
99. On 6 July, a substance misuse recovery worker recorded that that Mr Atkinson
attended an alcoholics awareness meeting and shared with the group that he was
“in a dark place and that the only way out for him was in a body bag, where he
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could be reunited with his partner and parents”. She updated Mr Atkinson’s ACCT
record and noted that he said he found the meeting emotional but helpful.
100. At 11.13am on 7 July, a nurse and the substance misuse recovery worker met Mr
Atkinson to review his substance misuse clinical management plan. The nurse
noted that they spent time discussing the events of the previous week and that Mr
Atkinson remained low in mood. She added that they would both review Mr
Atkinson again in one week’s time.
101. At 5.00pm, a SO chaired an ACCT case review following the death of another
prisoner on the wing, which a mental health support worker attended. The SO
recorded that Mr Atkinson took the opportunity to talk about ROTL and blamed the
officer who accompanied him on 20 May for “ruining his hard work”. Mr Atkinson
said he wanted the ACCT stopped and the SO explained that the purpose of the
review was to offer support and to see whether he had been affected by the day’s
events. Mr Atkinson said that he only said “hello” to the prisoner once and was not
affected. Attendees kept his observation requirement at four an hour.
Events of 8 July
102. At 11.45am on 8 July, an officer noted in the ACCT record that Mr Atkinson had
asked about stopping ACCT monitoring. She also noted that he had obtained
books from the library on human anatomy. She noted that Mr Atkinson had told the
safer custody orderlies (trusted prisoners who work with the prison’s safer custody
department) that he had struggled with the recent death of a prisoner and how that
person was “in a better place”. Mr Atkinson also told the orderlies that the next time
he harmed himself, nobody would find him.
103. At 2.00pm, a SO chaired an ACCT case review which the officer attended. At
interview, the SO told the investigator that healthcare staff did not contribute as she
wanted to hold the review immediately. There is no record that Mr Atkinson
attended the review. She recorded that staff had informed her that Mr Atkinson was
trying to get his ACCT stopped. At interview, she said that she spoke to Mr
Atkinson but could not recall when this took place. Attendees kept his observation
requirement at four an hour.
104. At 3.07pm, a prison paramedic recorded that she reviewed Mr Atkinson through his
cell door observation panel and that his wounds were swollen and red. She
conducted a National Early Warning Score assessment (NEWS, a scoring system
to assess clinical deterioration in patients). Based on Mr Atkinson’s observations,
she scored him ‘0’ (low clinical risk). However, she could not take his blood
pressure due to the prisoners being locked in their cells. At 3.19pm, she sent an
electronic task to a GP, requesting antibiotics and a blood test.
105. At 3.45pm, the SO chaired a further ACCT case review which the Acting Head of
Safety, a mental health nurse and the prison paramedic attended. As with the
earlier ACCT review, Mr Atkinson did not attend. It is noted that he made a verbal
contribution. The SO recorded that Mr Atkinson continued to present as angry
about his ROTL and was not taking his medication. The nurse noted that Mr
Atkinson wanted his observation requirement reduced but also reported suicidal
thoughts. Attendees decided to keep Mr Atkinson’s observation requirement
unchanged. There is no record that staff considered removing razors from Mr
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Atkinson’s cell. Both the Acting Head of Safety and the SO told us that they
discussed constant supervision but did not consider it appropriate for Mr Atkinson’s
needs as he was a private person who found the ACCT process intrusive. (There is
no record of this discussion in the ACCT document.)
106. In the record of the evening conversation, the officer noted that Mr Atkinson had
asked for some Velcro for his privacy curtain. (At interview, prison staff told us that
prisoners often install their own curtains to increase the privacy of the toilet area as
the wooden privacy screens provide minimal coverage.) The officer noted that she
could not find any Velcro, so she gave Mr Atkinson a curtain pole instead.
Events of 9 July
107. At 11.30am, Mr Atkinson phoned a friend. He said that he was “pissed off” and
wanted prison staff to “let him go” (implying that he wanted them to let him end his
life). Mr Atkinson talked about getting an IEP warning for kissing another prisoner
and said that once IEPs started, they kept coming. He said that 15-minute ACCT
observations were “doing his head in” and that he spoke to a SO about it the
previous day. He said that the SO said she would call him into a big meeting, but it
never happened. He added that later that evening he spoke to the SO, who said
she would not reduce his observations as his act of self-harm was serious.
108. Mr Atkinson then spoke about how bad it was in the jail and said that he was
“banged up” (locked in his cell) all the time. He then said that he asked staff to go
to the library and get him a book on human anatomy which they did. Mr Atkinson
said, “are they for real” and added that he had gone through it, “looking up
everything [he] needed to know”. He then spoke about having spiralled out of
control and going back to “square one”. He said that the reason things had become
so bad was because the officer on ROTL was a “barefaced liar” and he “cannot get
his head around it”. Mr Atkinson added that he felt he should have his enhanced
IEP status back and be allowed to start again, but that when he spoke to anyone
about what happened on the ROTL, they did not want to know.
109. An officer recorded in the ACCT document that Mr Atkinson said he felt he would
never get enhanced IEP status again and needed to be around positive people who
felt that progression was possible.
110. At 2.30pm, a prison GP prescribed Mr Atkinson antibiotics for a suspected wound
infection. At around 3.00pm, the allocated mental health keyworker reviewed Mr
Atkinson on the wing and recorded that she spent much of the session exploring his
feelings about not having his medication in his cell with him. She noted that Mr
Atkinson denied any thoughts of suicide and self-harm and said that he was
frustrated that prison staff had not reduced his ACCT observation requirement.
However, she added that she had to conclude the review after 20 minutes because
Mr Atkinson had a social visit.
111. At interview, a prisoner and friend of Mr Atkinson’s, who worked in the visits area
cafe, told the investigator that she saw him during his visit from a friend... She said
that she gave him a hug and he said, “I can’t do this”, “I’m tired” and “I have no way
out this time”. She said that Mr Atkinson said that he was getting lots of IEPs and
that there was no way staff would let him go back to Res 7 and have ROTLs again.
She added that when it was time to say goodbye, Mr Atkinson made a “big thing of
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it” and kept saying “I’m sorry”. She said that the “light in his eyes had gone” and
that she told him to keep going but he replied, “there’s no point”.
112. At 8.40pm, following an ACCT check, Officer A noted in the part of the ACCT record
on the evening summary of conversation that Mr Atkinson was resting on his bed,
and he said he was “okay”.
113. At 9.17pm, Nurse A, a mental health nurse, went to Mr Atkinson’s cell to issue his
antibiotic medication. At interview, she said that Mr Atkinson was behind a curtain
that he had put up in his cell and told her to come back later as he was using the
toilet. Around two minutes later, CCTV footage shows she returned to his cell. She
said Mr Atkinson remained behind his curtain and declined the medication, stating
that he had taken one earlier in the day and it had made him sick.
114. At 9.50pm, Officer A conducted his sixth ACCT observation of the evening. At
interview, he told us that during his checks, he observed Mr Atkinson laying on his
bed, standing up holding his in-cell phone, and in the toilet area. He said that he
could not remember having a conversation with Mr Atkinson but that he thought he
would have spoken to him.
115. At 10.04pm, an Operational Support Grade (OSG) looked through Mr Atkinson’s
cell door observation panel and saw him sitting on the toilet, which was shielded by
a privacy screen and a curtain, with only his head visible and a pool of blood on the
floor. CCTV footage shows that she ran to the wing office, located several metres
away and returned with Officer A ten seconds later. In the meantime, she radioed a
medical emergency code red and asked permission from a CM to enter the cell.
116. Officer A looked through the cell observation panel, broke the seal on his key pouch
and went into the cell before the CM gave permission. He saw Mr Atkinson
slumped on the floor, just inside the toilet area of the cell and with a pool of blood in
front of him. He radioed a medical emergency code blue (which indicates that a
prison is unconscious or has breathing difficulties). At interview, he told us that he
moved Mr Atkinson into an upright position by placing his hands on his left arm and
right shoulder. He said that Mr Atkinson had a substantial cut to his neck, was cold
to touch and had fixed eyes. He then left the cell and made his way to the entrance
of Res 3 to meet responding staff.
117. In the meantime, an OSG, who was working in the control room, phoned for an
ambulance. In his prison statement, he said that an automated system put him on
hold due to a high number of calls in the area.
118. At 10.07pm, Nurse B, a mental health nurse, went into the cell and saw Mr Atkinson
sitting in an upright position, with a mirror in his hand and his head bent forward. At
interview, he told us that he checked for a pulse but there was no evidence of life.
He said that Mr Atkinson was not breathing and that it looked like he had “bled out”.
A minute later, Nurse A arrived at the cell. She told us that although there was no
sign of life, it was hard to assess the extent of Mr Atkinson’s injuries as he was in a
confined space, and it was difficult to move him. She said that she checked his
pulse and blood pressure but could not get a reading. There is no evidence that
staff applied a defibrillator or started cardiopulmonary resuscitation (CPR).
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119. At 10.09pm, the Ambulance Service log shows that the call from the prison was
answered. The Ambulance Service’s recording of the call states that when asked if
the patient was breathing, the control room OSG said, “no, I think she’s dead”.
When asked why he thought this, he said, “the throats slit open, there’s a lot of
blood and she is not breathing”. The OSG transferred the operator to the wing and
Nurse A spoke to her. When asked why they thought Mr Atkinson was dead, she
said, “we’re not sure if she is dead, but we can’t check her pulse … we can’t take
her blood pressure and she is blue in the extremities”.
120. At 10.14pm, an ambulance was dispatched, and the first vehicle arrived at the
prison at 10.24pm. At 10.27pm, critical care paramedics arrived at Mr Atkinson’s
cell and moved him onto the floor in the corridor for easier access. They conducted
an assessment and, at 10.33pm, a critical care doctor pronounced that Mr Atkinson
died.
Contact with Mr Atkinson’s family
121. At around 12.30am on 10 July, the prison appointed a family liaison officer (FLO).
In the meantime, the Governor established that they only had a phone number for
Mr Atkinson’s friend, whom he had appointed as his next of kin, and left a voicemail
message. A short while later, the Governor spoke to Mr Atkinson’s next of kin by
phone and broke the news.
122. At 10.10am, the FLO phoned Mr Atkinson’s next of kin to introduce herself and to
explain her role. She asked Mr Atkinson’s friend whether she could visit her later
that day, but she said she was going to the prison to visit another prisoner, so she
arranged to meet her then. At 2.10pm, the FLO and a manging chaplain and family
liaison officer met Mr Atkinson’s next of kin and another friend of Mr Atkinson’s, who
was on his approved visitors list. They offered their support and went over the next
steps.
123. The FLO provided ongoing support to Mr Atkinson’s friend until his funeral, which
took place on 15 August. The prison contributed towards the cost, in line with
national policy.
Support for prisoners and staff
124. After Mr Atkinson’s death, a prison manager 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.
125. The prison posted notices informing other prisoners of Mr Atkinson’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 Atkinson’s death.
Post-mortem report
126. A post-mortem examination found that Mr Atkinson died of severe blood loss and
an air bubble trapped in the right side of the heart caused by a slashed wound to
the neck that involved the jugular vein. The pathologist noted that although there
was a short cut in the jugular vein, it was possible that Mr Atkinson could have bled
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from the neck wound for a considerable time and that he had already cut his neck
when staff conducted an ACCT check at 9.50pm. The post-mortem report also
stated that Mr Atkinson had concealed several unspecified tablets and razor blades
in his vagina and anus.
127. Toxicology tests of Mr Atkinson’s blood found methadone and paracetamol at levels
higher than is considered therapeutic. However, the pathologist noted that the level
of methadone was not high enough to result in toxicity and that paracetamol does
not result in rapid death after overdose. The pathologist concluded that there was
no evidence to indicate use of methadone, or any other medication accounted for
Mr Atkinson’s death.
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Findings
Management of Mr Atkinson’s risk of suicide and self-harm
128. Prison Service Instruction (PSI) 64/2011 on safer custody requires all staff in
contact with prisoners to be aware of the risk factors and triggers that might
increase a prisoner’s risk of suicide and self-harm and to take appropriate action.
Any prisoner identified as at risk of suicide or self-harm must be managed under
ACCT procedures.
129. Prison staff at Eastwood Park responded appropriately when Mr Atkinson
experienced periods of emotional instability or harmed himself and monitored him
under ACCT procedures on several occasions. While we are satisfied that staff
tried to engage with Mr Atkinson and completed a comprehensive ACCT
assessment on 21 May 2022, we are concerned about the overall management of
the ACCT process.
Care plans
130. PSI 64/2011 states that completing a care plan is an integral part of the ACCT
process and that it must reflect the prisoners needs, level of risk and the triggers of
their distress. The annex to PSI 64/2011 states that the care plan, including
individual and meaningful support actions, must be updated following case reviews.
131. Staff only updated Mr Atkinson’s care plan once, at the first case review on 21 May.
The two support actions were specific to Mr Atkinson’s needs but failed to address
all the risks identified in the risks, triggers and protective factors section of the care
plan. Staff did not review the care plan after they re-started ACCT procedures on 8
June or at following case reviews. The failure of the case review team to develop
the care plan meant that there was no co-ordinated ongoing plan for monitoring the
progress of Mr Atkinson’s emotional stability, his re-application for ROTL and a
return to Res 7. We are particularly concerned that staff did not identify that Mr
Atkinson’s parole review period was due to start in September and did not formulate
a plan to address the impact this was likely to have on his risk of suicide and self-
harm.
132. The sources of support section of the ACCT documents show that staff identified Mr
Atkinson’s friend and next of kin as a provider of ongoing support for him. However,
they did not consider a support action to involve them in the ACCT process. PSI
64/2011 states that case co-ordinators should identify and discuss potential sources
of support for the prisoner at case reviews. However, there is no record that staff
discussed the possibility of involving Mr Atkinson’s next of kin in the ACCT process
despite them contacting the prison to raise concerns about his wellbeing. We
consider that the involvement of Mr Atkinson’s next of kin (which would have
required Mr Atkinson’s consent) might have added an extra layer of support for Mr
Atkinson and should at least have been explored.
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Case reviews
133. PSI 64/2011 states that a case co-ordinator must be appointed at the first case
review. The case co-ordinator should lead all case reviews, where possible, to
promote consistency in managing the ACCT plan, assessing risk and care planning.
134. We are concerned that there is no record that the prison appointed an ACCT case
co-ordinator for the ACCT procedures started between May and July. While there
was some consistency when staff started and re-started ACCT procedures, a
different SO chaired each case review after staff re-started ACCT monitoring on 4
July. Our view, particularly when considering Mr Atkinson’s complex history, is that
a consistent approach might have led to a better understanding of his risk and
reasons underlying his deteriorating presentation.
135. PSI 64/2011 also states that ACCT case reviews should happen periodically, have
multidisciplinary input that is driven by support actions and that, wherever possible,
case review teams should agree the time and date of the next case review during
the present one in order to ensure attendance.
136. On several occasions, prison staff held case reviews that may have benefitted from
healthcare input, without their involvement. The Acting Head of Safety told us that
at the time Mr Atkinson was monitored under ACCT procedures, Eastwood Park
used a system that meant a member of staff from the healthcare team and/or the
chaplaincy could only attend case reviews on set days. She said that this
arrangement had since changed, and that the case review team now agreed the
date of the next case review at the end of a review to ensure attendance. We are
satisfied that this action is appropriate.
137. PSI 64/2011 instructs that the prisoner must attend case reviews unless unwilling or
unable. It says that the prisoner should be encouraged to engage in the review,
which includes being given the option of providing written input ahead of time. If a
prisoner does not attend a case review, the case co-ordinator must update them
about the outcome.
138. When a SO chaired an ACCT case review on 8 July, she did not invite Mr Atkinson
to participate in person or by providing written input. While we appreciate that she
spoke to Mr Atkinson before and after the review, we consider that Mr Atkinson
should have been given the opportunity to participate in the review so that
attendees could discuss his request to stop ACCT monitoring and explore the
possibility of constant supervision with him. The SO told us that there was no
particular reason for not involving Mr Atkinson in the review process and that it was
just something they did at times.
Closing and re-starting ACCT procedures
139. PSI 64/2011 instructs that after stopping ACCT monitoring, prison staff must
complete the seven-day post-closure monitoring form for a minimum of seven days
to inform the post-closure review. When staff stopped ACCT monitoring on 24 May
and 21 June, they did not complete a seven-day post monitoring review form or
post-closure review. This meant that there was little consideration of how Mr
Atkinson had progressed since the ACCT had been closed.
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140. PSI 64/2011 states that an ACCT document can be re-started at any point during
and up until six weeks post-closure if the level of risk is deemed to have increased.
It requires prison staff to complete an immediate action plan within one hour of the
decision to re-start ACCT monitoring and to determine whether the circumstances
for re-starting are different to those addressed in the original plan. If they are, staff
must complete a new assessment within 24 hours of the decision to re-start the
ACCT.
141. When a SO re-started ACCT procedures on 4 July, he did not complete an
immediate action plan or record whether he considered another assessment. While
we do not consider that another assessment was required, we are concerned that
he used a new ACCT document and did not include any information on risk from the
previous ACCT. At interview, the Acting Head of Safety told the investigator that
she expected staff who re-start ACCT procedures to obtain the original ACCT and
to review it. This did not happen in Mr Atkinson’s case, which meant that important
information from the original assessment and the risk and triggers section was not
available to staff at case reviews. We consider it vital that staff have access to as
much relevant information from the original ACCT as possible so that continuity is
maintained, and staff are able to make a more accurate assessment of risk.
Assessing the level of risk
142. PSI 64/2011 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. Staff judgement is fundamental to the ACCT system. The
system relies on staff using their experience and skills, as well as local and national
assessment tools, to determine risk. While a prisoner’s presentation is obviously
important and reveals something of their level of risk, it is only one piece of
evidence in assessing risk. Staff should make a considered, objective evaluation of
all risk factors when assessing the risk of suicide and self-harm.
143. We are concerned that despite Mr Atkinson making a significant cut to his neck on 4
July, staff did not place more emphasis on restricting access to razors. A SO told
us that the case review team on 8 July did not consider removing razors from Mr
Atkinson. She said that it was difficult to restrict razors from prisoners as they can
get access to them from their peers on the wing. We consider that access to razors
was a significant risk factor, and that staff should have put more stringent measures
in place to restrict Mr Atkinson’s access to them. While we cannot say whether it
would have prevented Mr Atkinsons’ death, particularly as he had concealed razors
internally, it might have made it more difficult for him to harm himself.
144. Staff provided Mr Atkinson with a book about human anatomy shortly after he
harmed himself by cutting on 4 July. While this was identified in the ongoing ACCT
record, there is no evidence that staff considered this an indicator of potential future
self-harm. We consider that as Mr Atkinson had recently made a significant cut to
his neck, staff should have at least highlighted this as a risk and sought advice from
the safer custody department before enabling him to have access to such material.
The importance of this is evidenced by the fact that when Mr Atkinson spoke to his
friend on 8 July, he appeared shocked and surprised that staff had enabled him to
access the book.
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145. We are also concerned that there is no record that the ACCT case review team on
8 July considered a period of constant supervision for Mr Atkinson. PSI 64/2011
states that constant supervision is a response to acts of self-harm or other
behaviours which could lead to a prisoner accidentally or intentionally killing
themselves, which staff can implement to reduce the risk and intervene in the case
of an emergency. This includes self-harm that is likely to result in a high degree of
harm and where there are credible and persistent plans to inflict acts of self-harm
that are considered to be life-threatening.
146. Both the Acting Head of Safety and a SO told the investigator that they discussed
constant supervision during the ACCT review on 8 July but did not feel that it was
appropriate as Mr Atkinson was a private person and did not like the ACCT process
which he found intrusive. They both said that they felt constant supervision would
be negative for Mr Atkinson and that they could sufficiently manage his risk under
his current observation requirement of four an hour. The SO added that when she
spoke to Mr Atkinson on 8 July, he presented the same as always and despite his
recent self-harm and high observation level, she did not detect a heightened level of
risk.
147. While we appreciate that Mr Atkinson could display confrontational behaviour and
did not like being observed, he had recently made a significant cut to his neck,
continued to report feelings of hopelessness and had asked for a book about
human anatomy. He also asked for ACCT monitoring to stop, which when
considered along with the other risk factors, is an indicator of intention. Mr Atkinson
had also been recorded as telling other prisoners that the next time he harmed
himself, nobody would find him. We consider that Mr Atkinson’s risk factors had
increased and that as he was already subject to four observations an hour, the next
step to manage his cumulative risk appropriately should have been a period of
constant supervision.
Incentive and Earned Privileges
148. PSI 64/2011 states that there will be cases where it may be necessary for a
prisoner receiving support through ACCT to be moved up or down an incentive
level. Wherever there is a change in the incentive level for a prisoner receiving
support through ACCT, the case review team must consider how this impacts the
prisoner’s risk of suicide or self-harm. Mr Atkinson’s IEP status was not
downgraded while subject to ACCT monitoring, but the removal of his enhanced
status following the ROTL incident appears to have impacted negatively on his
emotional wellbeing.
149. We appreciate that prison staff identified that having a computer games console
was an important factor in reducing Mr Atkinson’s risk and arranged for him to have
access to his games while subject to a standard regime. However, we are
concerned that staff did not appear to recognise or consider the positive impact of
an enhanced IEP regime on Mr Atkinson’s level of risk. This is evidenced by the
fact that Mr Atkinson’s ability to manage his emotions improved significantly during
the 12 months he was an enhanced prisoner on Res 7 and that incidents of self-
harm reduced significantly.
150. Eastwood Park’s local incentives policy states that while it is separate to the
disciplinary system, Governors have the authority to determine when the thresholds
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for both processes are met. It states that to move up to an enhanced incentive
level, prisoners must abide by the prison’s behaviour principles and demonstrate
the required types of behaviour to a consistently high standard, including good
attendance at activities education/work and interventions.
151. While we accept that Mr Atkinson did not meet the criteria for enhanced status as
he received two negative IEP entries between 13 June and 2 July, his rule-breaking
was relatively minor. We therefore consider that staff should have at least explored
the possibility of Mr Atkinson being given enhanced prisoner status as an
exceptional circumstance because the benefit of the enhanced regime significantly
outweighed the risk of him remaining on a standard regime.
Observations and conversations
152. PSI 64/2011 states that staff must follow the level of conversations stated on the
ACCT document and must record these immediately or as soon as practical. PSI
64/2011 states that conversations with prisoners should be meaningful and that
staff must be aware of what is contained in a prisoner’s care plan to understand the
context of any conversation. It also notes that written summaries also need to be
meaningful and sufficiently detailed to convey the key details of what was
discussed. HMPPS user guidance states that observations must be carried out in
the least intrusive manner possible, while ensuring the individual’s welfare.
153. Despite some evidence that staff completed detailed written summaries and held
good quality conversations with Mr Atkinson, a lot of their recorded interactions with
him were brief and descriptive. For example, on 5 July, Officer A recorded that he
had a chat with Mr Atkinson and that he raised no issues. The conversation could
well have been meaningful, but it is difficult to know, as insufficient detail was
recorded. While we appreciate that there may be challenges in engaging prisoners
in meaningful conversations, it is an essential part of the ACCT process and will
help staff to understand and mitigate a prisoner’s risk.
154. When staff conducted ACCT observations in the hours leading to Mr Atkinson’s
death on 9 July, they were not always able to see him because he was behind a
curtain that he had made to cover the toilet area at the back of his cell. At interview,
Officer A told us that prisoners often made their own curtain as the fixed screens
offered very little privacy. While we appreciate that prisoners want increased
privacy, we are concerned that this might have given Mr Atkinson the time he
needed to cut himself without staff seeing him. This is evidenced by the post-
mortem report which states that as there was only a short cut in the jugular vein, it
was possible that Mr Atkinson had already cut his neck when the officer conducted
an ACCT check at 9.50pm.
155. We consider that as Mr Atkinson was subject to four observations an hour, he
presented a high risk of suicide and self-harm, and staff should have ensured that
they had sight of him. This is particularly concerning when considering that Mr
Atkinson had made a comment the previous day about staff being unable to find
him in time when he next harmed himself and that he had asked them to stop ACCT
monitoring. We cannot say whether the removal of his curtain would have changed
the outcome for Mr Atkinson, but it would have made it more difficult for him to cut
himself without staff seeing him. We make the following recommendation:
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The Governor and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide and self-harm in line with national instructions,
including that:
• a case co-ordinator is appointed at the first ACCT case review;
• ACCT support actions are specific and meaningful, consider all of the
issues identified at assessments and case reviews, and are updated at
each review;
• ACCT case reviews are multidisciplinary and include healthcare staff
where relevant, and that prisoners are invited to contribute to all case
reviews;
• case reviews consider and document all relevant information that affects
risk, including considering the removal of razor blades, items that might
impact their vision of the prisoner, and other items when relevant;
• staff review the risk of suicide and self-harm whenever an event occurs
which indicates an increase in risk, including starting constant
supervision when necessary;
• observations and comprehensive conversations are carried out as
directed and documented in the ACCT record;
• staff review the previous ACCT document when re-staring ACCT
procedures and include all important information relevant to the
assessment of risk; and
• staff complete the seven-day post-closure monitoring form and ensure
that post-closure reviews take place at the proper time and consider
events following the closure of the ACCT.
156. Mr Atkinson was the second prisoner take their own life at Eastwood Park in a
period of three days. In our investigation into the death of the prisoner who took her
life two days earlier, we identified similar failings in the management of ACCT
procedures. In their last inspection, HM Inspectorate of Prisons found that the
quality of recording in ACCT documents was not sufficiently good. We are
concerned that recording in some instances required improvement and that both Mr
Atkinson’s and the other prisoner’s risks were inadequately managed. We consider
that urgent action is now required to ensure that ACCT procedures at Eastwood
Park improve as soon as possible. We make the following recommendation:
The Director of Women for HMPPS should write to the Ombudsman to set out
what action she has taken to satisfy herself that meaningful improvements
have been made to the assessment and management of the risk of suicide
and self-harm at HMP Eastwood Park.
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Emergency response
Management of incident
157. Prison Service Instruction (PSI) 03/2013 on medical response codes requires
prisons to have a two-code medical emergency response system. Eastwood Park’s
local policy instructs staff to use an emergency code blue to indicate an emergency
when a prisoner is unconscious, or having breathing difficulties, and a code red
when a prisoner is bleeding or has severe burn injuries. Calling a medical
emergency code should automatically trigger the control room to call an ambulance,
and for healthcare staff to attend with the appropriate medical equipment.
158. The OSG responded promptly when she found that Mr Atkinson had cut himself.
She alerted Officer A and radioed the correct emergency code. Officer A went into
the cell without delay and radioed a code blue when he established that Mr
Atkinson was unresponsive and not breathing. Control room staff called an
ambulance immediately but there was a delay of around five minutes before the
ambulance service answered the call due to an excess demand in the area. We
are satisfied that prison staff took appropriate action.
Resuscitation
159. In September 2016, Professor Sir Bruce Keogh, the National Medical Director at
NHS England, wrote to the Heads of Healthcare for prisons, introducing new
guidance to support staff on when not to perform CPR. This guidance was
designed to address the issue of inappropriate resuscitation following a sudden
death in a prison and was taken from the European Resuscitation Council
Guidelines 2015 (updated in 2021) which state, “Resuscitation is inappropriate and
should not be provided when there is clear evidence that it will be futile”.
160. In March 2020, the Nursing and Midwifery Council (NMC) and the Royal College of
Nursing (RCN) issued a joint statement to reiterate their position about CPR
discussions. The guidance states that, “where no explicit decision about CPR has
been considered and recorded in advance, there should be an initial assumption in
favour of CPR”. It also states that, “there will be cases where healthcare
professionals discover patients with irreversible features of death – for example,
rigor mortis. In such circumstances, any decision not to start CPR should be
supported by their senior colleagues, employers and professional bodies”.
161. Officer A, who went into Mr Atkinson’s cell, told the investigator that he could tell
straight away from touching Mr Atkinson and looking at the extent of his injuries that
he had died. He said that he did not consider moving Mr Atkinson onto the floor as
he was concerned about the preservation of evidence and wanted a nurse to check
him. Nurse B told us that when he examined Mr Atkinson, there was no evidence of
life and that they left him in the position that they found him as they could not do
anything. Nurse A told us that when she moved Mr Atkinson’s head and saw the
injury to his neck, she knew that he had died. She added that they did not move Mr
Atkinson onto the floor as he was in an awkward position.
162. However, before any written clinical documentation of the events, Nurse A twice
told an ambulance call handler that they could not be sure if Mr Atkinson had died.
The clinical reviewer considered that the clinical assessment of taking his pulse and
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blood pressure was not sufficient to verify that life was extinct and beyond
attempting CPR. She said that the nurses should have conducted further clinical
assessments and considered the use of a defibrillator to check for a shockable
heartbeat.
163. The RCN and NMC joint guidance states that if a nurse determines that it is not in
the patient’s interests to attempt CPR, it is incumbent on them to document and
explain how they made the decision. The clinical reviewer considered that while
there was some reference to Mr Atkinson’s presentation in the clinical notes, both
nurses provided insufficient detail to justify their reason for not starting CPR.
164. The clinical reviewer concluded that, on the balance of probability, there was not a
definitive recognition that Mr Atkinson had died when both nurses assessed him,
and that they should have moved Mr Atkinson onto the floor and started CPR.
Although we appreciate the distress of seeing a prisoner in such circumstances, we
agree with the clinical reviewer.
165. We make the following recommendations:
The Governor and Head of Healthcare should ensure that staff are aware of
their responsibilities in medical emergencies, including that;
• staff apply a defibrillator and start CPR when appropriate if there are not
clear signs of irreversible death; and
• when healthcare staff decide not to start CPR, they evidence their decision
making in the medical record.
The Head of Healthcare should undertake a review of the concerns raised by
the clinical reviewer of Nurse A and Nurse B to ensure that appropriate
actions are taken, including consideration of a referral to the NMC.
Clinical care
166. The clinical reviewer considered that the care Mr Atkinson received at Eastwood
Park before the emergency response was equivalent to that which he could have
expected to receive in the community. Mental health staff worked closely with
substance misuse staff, and they reviewed and monitored Mr Atkinson frequently.
Staff regularly discussed his care at multidisciplinary team meetings, attended
ACCT reviews and took appropriate steps to address concerns about his
compliance with prescribed medication. However, the clinical reviewer identified
some areas that required improvement.
Mental health care
167. The clinical reviewer found that Mr Atkinson had been managed under the CPA
framework for many years and had regular CPS reviews. However, he did not have
a formal care plan. She considered that Mr Atkinson should have had a care plan
in place that staff developed with him, which would have helped Mr Atkinson to see
what future plans were in place to enable him to progress and to maintain good
mental health. We consider that a CPA care plan would have also outlined risks
and triggers that staff could have fed into the ACCT process and used to assist in
the management of Mr Atkinson’s risk of suicide and self-harm.
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Physical health care
168. The clinical reviewer considered that Mr Atkinson was at increased risk of excessive
bleeding due to taking rivaroxaban because it thins the blood. (Mr Atkinson was
prescribed rivaroxaban to help prevent blood clots associated with DVT.) She
noted that the National Institute for Care Excellence (NICE) clinical knowledge
summary for rivaroxaban (2020) advised that immediate medical attention was
required if bleeding occurred that could not be stopped.
169. When Mr Atkinson cut his throat on 8 June, healthcare staff reviewed him three
times as his wound continued to bleed. The clinical reviewer found that staff did not
take his clinical observations, which would have been recommended given the
extent of the injury and Mr Atkinson’s long-term prescription of rivaroxaban. The
clinical reviewer also noted that healthcare staff only took Mr Atkinson’s clinical
observations on one occasion after he cut his neck and one of his arms on 4 July.
170. The clinical review concluded that while it was not within her clinical expertise to
determine whether the long-standing prescription of rivaroxaban contributed to the
excessive bleeding that led to Mr Atkinson’s death on 9 July and that this was a
matter for the Coroner, staff should have recorded that they considered the
rivaroxaban prescription after Mr Atkinson harmed himself by cutting and set out a
plan to monitor him. This view is supported by NICE guidance NG225 for self-
harm: assessment, management and preventing recurrence (2020), which
recommends that following an episode of self-harm, a person should have a
medication review. We make the following recommendation:
The Head of Healthcare should ensure that:
• all prisoners managed under the CPA framework have a formal mental
health care plan; and
• when a prisoner is prescribed anticoagulant medication and bleeds, staff
take their clinical observations, record a NEWS score and arrange a
medication review.
Learning lessons
171. We have identified a number of concerns in this report. We consider it is important
that staff learn from our findings. We recommend the following:
The Governor and Head of Healthcare should ensure that a copy of this report
is shared with the staff named in this report and that a senior manager
discusses the Ombudsman’s findings with them.
Inquest
172. At the inquest, which took place on 24 November 2025, the Coroner concluded that
Mr Atkinson died as a result of suicide.
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