Timothy Smith

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Independent investigation into
the death of Mr Timothy Smith,
a prisoner at HMP Risley, on 20
May 2020
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
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 Timothy Smith was found hanged in his cell at HMP Risley on 20 May 2020. He was
29 years old. I offer my condolences to his family and friends.
Mr Smith had only been at Risley for seven weeks when he died. He had a history of
substance misuse, attempted suicide and self-harm, and while he denied any suicidal
intent, he said he was struggling to cope with the restricted COVID-19 regime, and this
had impacted on his mental health.
Staff faced significant challenges due to the restrictions imposed in response to the
COVID-19 pandemic, with significantly less meaningful contact with prisoners. If staff had
more opportunities to interact with Mr Smith, it is possible that they might have identified
he needed additional support, was using drugs and may have been the victim of bullying.
I am concerned that when he told a mental health nurse that he was having thoughts of
self-harm three weeks before his death, she did not open suicide and self-harm
procedures (known as ACCT) and did not share this information with prison staff.
The post-mortem examination confirmed that Mr Smith had used psychoactive substances
(PS) before his death. Although this was not found to have caused his death, PS is known
to affect mental health adversely. I am concerned that Mr Smith was able to obtain PS
with apparent ease at Risley, even though strict restrictions had been put in place during
the current COVID-19 lockdown. Risley needs to continue in its efforts to reduce the
supply of and demand for drugs.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman September 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. In October 2016, Mr Timothy Smith was sentenced to two and a half years in prison
for actual bodily harm. He was released from prison on licence on 29 January 2020
but was recalled to HMP Forest Bank on 11 March. He was transferred to HMP
Risley on 25 March.
2. Mr Smith had a long history of mental health issues, substance misuse and self-
harm. The mental health team at Risley supported him and prescribed medication
to treat his symptoms of depression and anxiety. He was compliant in taking his
medication.
3. Mr Smith expressed some unhappiness at the very limited time that prisoners were
permitted to spend out of their cells due to the COVID-19 pandemic. On 27 April,
he told a mental health nurse during a telephone review that this resulted in him
having thoughts of self-harm and in hearing voices. However, neither healthcare
nor prison staff raised any concerns about him or considered starting suicide and
self-harm procedures.
4. Although Mr Smith’s mother raised her concerns with prison staff that he had
accumulated drug debts, Mr Smith did not tell staff about this and there was no
evidence that he had misused illicit substances, was in debt or had been bullied.
Mr Smith did not express any thoughts of suicide or self-harm in the period before
his death.
5. At around 3.19pm on 20 May 2020, an officer found Mr Smith hanged at the back of
his cell. Staff were unable to resuscitate him and at 3.27pm, the prison GP
pronounced that he had died. Post-mortem toxicology results identified that he had
taken psychoactive substances (PS) before he died.
Findings
Assessment of risk
6. Mr Smith had a number of risk factors when he was recalled to Risley: he had a
long history of mental health issues and was taking antipsychotic medication, he
had substance misuse issues and a history of suicide attempts and self-harm.
7. We are concerned that staff placed too much emphasis on Mr Smith’s assertions
that he was ‘fine’ and did not give sufficient weight to his risk factors.
8. When Mr Smith told a mental health nurse that he had thoughts of self-harm and
was hearing voices, she should have started suicide and self-harm prevention
procedures, known as ACCT. At the very least, she should have shared this
information with prison staff.
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COVID -19 restrictions
9. The very restricted COVID-19 regime meant that prison staff had fewer
opportunities to engage with Mr Smith and this would have reduced their ability to
identify possible signs of distress, drug taking, bullying or a deterioration in his
mental health.
10. The COVID-19 restrictions also meant that Mr Smith’s only contact with mental
health staff was conducted over the telephone by a nurse who had never met him in
person.
11. Despite his risk factors, Mr Smith was not considered a priority prisoner who
needed extra support in the form of more frequent contact with staff. This meant
that he was not allocated a key worker at Risley during the pandemic. This resulted
in fewer opportunities for prison staff to have meaningful contact with him and
potentially identify his risks and address his needs.
Drug strategy at HMP Risley
12. Although Risley has a comprehensive drug strategy, Mr Smith was still able to
obtain drugs in the prison. The prison revised its drug strategy following Mr Smith’s
death but must continue to work towards reducing supply and demand.
Clinical care
13. The clinical reviewer concluded that that the care that Mr Smith received was
equivalent to that which he could have expected to receive in the community.
Recommendations
• The Governor and Head of Healthcare should ensure that staff take into account all
relevant risk information about prisoners when assessing their risk of suicide and
self-harm and start ACCT procedures when appropriate.
• The Head of Healthcare should ensure that healthcare staff share important
information about a prisoner’s risk to himself with prison staff.
• The Head of Healthcare should share this report with Nurse A and discuss the
Ombudsman’s findings with her.
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The Investigation Process
14. The investigator issued notices to staff and prisoners at HMP Risley informing them
of the investigation and asking anyone with relevant information to contact him. No-
one responded.
15. The investigator obtained copies of relevant extracts from Mr Smith’s prison and
medical records.
16. The investigator interviewed five members of staff at Risley. The interviews were
completed by telephone due to the restrictions imposed in response to the COVID-
19 pandemic.
17. NHS England commissioned a clinical reviewer to review Mr Smith’s clinical care at
the prison. The clinical reviewer conducted joint interviews with the investigator.
18. We informed HM Coroner for Cheshire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
19. We contacted Mr Smith’s family to explain the investigation and to ask if they had
any matters they wanted us to consider. Mr Smith’s family wanted to know if he
had used drugs in prison.
20. Mr Smith’s family received a copy of the draft report. They did not make any
comments.
21. The initial report was shared with HM Prison and Probation Service (HMPPS).
They identified three factual inaccuracies in the report which have been amended
and the report updated accordingly. All recommendations were accepted.
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Background Information
HMP
22. HMP Risley is a resettlement prison. Greater Manchester Mental Health NHS
Foundation Trust provides healthcare services in the prison. Change Grow Live
provides substance misuse services. There is 24-hour healthcare cover.
HM Inspectorate of Prisons
23. The most recent full inspection of HMP Risley was in June 2016. Inspectors
reported that support for prisoners at risk of suicide and self-harm was adequate,
but the quality of ACCT documentation varied, and some did not demonstrate
sufficient interaction between staff and prisoners. Inspectors found that the mental
health team was enthusiastic and well led. They noted that a weekly meeting
identified prisoners who needed immediate attention and that those who needed
routine assessment were usually seen within two weeks.
24. In November 2020, inspectors completed a scrutiny visit to Risley on the conditions
and treatment of prisoners during the COVID-19 pandemic. They noted that for
most prisoners, the regime was severely limited to around one hour a day unlocked,
which was a serious concern. A lack of in-cell telephony placed pressure on
prisoners to make their calls during the short time available out of their cell.
25. Inspectors noted that the amount of violence and self-harm had reduced at the start
of the COVID regime restrictions. There had been a subsequent rise in the number
of incidents, but this remained below pre-pandemic levels. They found evidence of
good staff engagement with prisoners, key work had been well embedded in the
prison before the pandemic, and weekly checks on the wellbeing of more vulnerable
prisoners and those near to release had continued during the COVID-19 period.
However, the impact of the lack of time spent unlocked for most prisoners was a
serious concern.
Independent Monitoring Board
26. 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 31 March 2018, the IMB reported
that 53% of prisoners on A-E Wings did not feel safe. The number of prisoners on
suicide and self-harm monitoring procedures at Risley had decreased.
Previous deaths at HMP [Prison]
27. Mr Smith was the third prisoner to take his life at Risley since May 2018. There
were no similarities between our findings in the investigations of those deaths and
those of Mr Smith’s.
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Assessment, Care in Custody and Teamwork
28. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and 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.
29. As part of the process, a caremap (a plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
Exceptional Delivery Model for Key Work
30. The keyworker scheme aims to improve safer custody by engaging with prisoners,
building better relationships between staff and prisoners and helping prisoners
settle into life in prison. It provides that all adult male prisoners will be allocated a
key worker who will spend an average of 45 minutes a week on key worker
activities, including having meaningful conversation which each of their allocated
prisoners.
31. The key worker scheme was suspended across the prison estate on 24 March 2020
due to the COVID-19 pandemic. To ensure that meaningful interaction continued
for priority prisoners, such as those who were at risk of suicide or self-harm, the
Prison Service introduced the Exceptional Delivery Model for keywork in May
2020. This provides that an officer will have a weekly conversation with prisoners
identified as vulnerable.
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Key Events
32. Mr Timothy Smith had a history of mental health issues, including low mood,
anxiety, depression and attempted suicide and self-harm (including taking an
overdose and jumping off a bridge in 2015). He had a history of substance misuse
which was often linked to hallucinations and anti-social behaviour. He had spent
time in a mental health hospital but had not been diagnosed with a mental health
illness.
33. In October 2016, Mr Smith was sentenced to two and a half years in prison for
actual bodily harm. He received an indefinite restraining order against the two
victims, one of whom was his partner. This was his first time in prison.
34. Mr Smith served time in a number of prisons. In January 2017, he was sentenced
to a further four years in prison for robbery and assault.
35. Mr Smith was monitored under suicide and self-harm procedures (known as ACCT)
on two occasions in prison: once in 2016 when he harmed himself after he was
sentenced and once in July 2019 when he expressed thoughts of suicide after a
panic attack.
Release from prison
36. On 29 January 2020, Mr Smith was released on licence to an approved premises
(probation hostel). Mr Smith’s community probation officer recorded that he had
been stable in prison, though his anxiety had significantly increased before his
release.
37. After his release, the community probation officer noted that Mr Smith breached the
conditions of his licence, began to use crack cocaine and amassed debts which
affected his anxiety. Despite warnings about his behaviour, Mr Smith continued to
misuse illicit substances daily. He subsequently reported that he was hearing
voices and he tested positive for crack cocaine on eight occasions. He declined
support for his substance misuse and presented with indications of possible self-
harm. The probation officer noted that Mr Smith’s behaviour suggested he was
deliberately trying to be recalled into custody.
38. On 12 February, a community consultant psychiatrist saw Mr Smith, who admitted
using alcohol and crack cocaine. He said that he felt low and struggled to sleep.
The consultant noted that Mr Smith had a depressive illness, suicidal thoughts and
auditory hallucinations. He prescribed him citalopram (an antidepressant) and
asked his GP to follow up his care and refer him to the community mental health
team.
Mr Smith’s return to custody
39. On 10 March 2020, the Probation Service recalled Mr Smith to prison because of
his behaviour. On 11 March, he was taken to HMP Forest Bank. Mr Smith’s
person escort record (PER) that travelled with him to Forest Bank noted that he had
psychosis.
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40. A nurse completed Mr Smith’s initial health screen when he arrived at Forest Bank.
She recorded in his medical record that he had a history of mental health issues,
self-harm and substance misuse, namely cocaine and cannabis. She noted that he
had psychosis and anxiety for which he was prescribed olanzapine (an
antipsychotic) and citalopram. Mr Smith admitted that he had used drugs the
previous day but declined the support of substance misuse services. The nurse
referred Mr Smith to the mental health team, and he was subsequently prescribed
olanzapine.
41. Over the next few days, Mr Smith completed his prison induction and received his
recall pack which explained why he had been returned to custody.
42. A substance misuse worker saw Mr Smith on 16 March. Mr Smith wanted to stop
smoking and was prescribed nicotine replacement therapy treatment.
43. A community probation officer recorded that Mr Smith had phoned him and told him
that he was happy to be back in prison. He said he was no longer taking drugs and
therefore did not need to participate in drug support programmes. He said that
whenever he was next released from prison, he intended to comply with his licence
conditions.
44. A community probation officer was due to meet Mr Smith at the prison on 19 March,
but all prison visits were stopped due to the COVID-19 pandemic.
45. On the morning of 25 March, healthcare staff assessed Mr Smith as fit to transfer to
HMP Risley. His prescribed medication was recorded as olanzapine.
HMP Risley
46. Mr Smith arrived at Risley on the afternoon of 25 March. A nurse completed Mr
Smith’s initial and second health screen as a full health assessment in line with the
standard procedure at Risley.
47. The nurse noted Mr Smith’s history of attempted suicide and self-harm and that he
had anxiety, depression and intermittent psychosis and had spent time in a
psychiatric hospital. Mr Smith said he had last misused drugs three weeks earlier in
the community and had no current thoughts of self-harm. Mr Smith had no
outstanding medical appointments, no physical health issues and had not seen a
doctor recently. Mr Smith said that his olanzapine helped him. She referred Mr
Smith to the prison GP and mental health team.
48. That evening, a prison GP continued Mr Smith’s olanzapine prescription.
49. An officer completed Mr Smith’s first night induction. Mr Smith said that he had
asked to be moved to Risley because they could support his mental health, and that
he was aware of the channels to use if he needed any help.
50. Mr Smith arrived at Risley at the start of the COVID-19 pandemic. To minimise
transmission of the virus, prisoners spent 23 hours a day in their cells, association
with other prisoners was very limited, the key worker scheme was suspended, visits
from family and others were stopped, and much face-to-face contact between
prisoners and healthcare staff was also stopped.
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51. On 2 April, a prison GP wrote to Mr Smith saying he could not see him to review his
medication, olanzapine, due to the COVID-19 situation. He said that if Mr Smith
was happy with his current medication, it would continue to be prescribed but, if it
was not working or if he wanted to change his medication or have a different dose,
he should speak to the nursing staff or send a letter to the prison doctors.
52. On 20 April, an officer from the Offender Management Unit (OMU) introduced
herself to Mr Smith as his Offender Manager. Mr Smith raised concerns that his
probation officer would be unable to visit him due to the COVID-19 lockdown. She
told him she would support him as much as she could, and that Mr Smith’s
keyworker could also help him. Mr Smith said that he had previously completed a
number of prison courses and wanted to get a job at Risley. He also asked for
substance misuse support and she referred him to the substance misuse team.
53. On 21 April, a community mental health nurse asked the prison’s mental health
team for an update about Mr Smith as he had been referred to the community
mental health team. A nurse told them that Mr Smith was currently under the care
of the prison’s mental health team and that his care would be transferred to relevant
community services on his release.
54. That day, the Offender Manager visited Mr Smith to give him the parole decision
paperwork about his recall. Mr Smith said he intended to ask for an oral hearing,
for which his solicitor would have to submit an application on his behalf. He also
wanted to contact his probation officer.
55. On 22 April, a medical record entry noted that Mr Smith had not attended his
appointment with the pharmacy. The Head of Healthcare told the investigator that
this was not a missed appointment as the pharmacist would not have seen Mr
Smith in person and was only reviewing prescriptions.
56. On 24 April, a substance misuse worker wrote to Mr Smith with a welcome pack
and said that she would await his response to engage with him.
57. On 27 April, Nurse A, a mental health nurse, assessed Mr Smith by telephone. She
noted his history of attempted suicide, self-harm, mental health issues and contact
with community psychiatric services. Mr Smith told her that he was just about
managing to cope in prison at that time. He said that he was hearing voices, which
had increased when he felt stressed, and that he also had paranoia. Mr Smith said
that his medication, olanzapine, worked. He told her that he had previously been
prescribed citalopram in the community and did not know why this had stopped
when he arrived at Forest Bank. She sent a task to her healthcare colleagues to
restart prescribing citalopram for him and noted that he would remain on the mental
health team’s caseload.
58. Nurse A noted that Mr Smith said that he had some thoughts of self-harm, which he
attributed to having long periods locked in his cell. However, Mr Smith said that he
had no suicidal thoughts. He admitted using crack cocaine approximately seven
weeks earlier. She told the investigator that Mr Smith did not give her any
significant cause for concern. She noted that Mr Smith needed substance misuse
support.
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59. On 28 April, the Offender Manager met Mr Smith to complete his public protection
paperwork, which related to his restraining order. Mr Smith said he fully understood
the implications of the paperwork. She noted that Mr Smith was a little anxious and
she agreed to help him make sure that his probation officer’s telephone number
was registered on his PIN phone contact list.
60. The prison GP authorised Mr Smith’s citalopram prescription which started on 1
May 2020. He was permitted to have the medication in possession, alongside his
already prescribed olanzapine.
61. On 6 May, the community probation officer recorded that she had received a phone
call from Mr Smith’s mother who said that she had sent Mr Smith £265 over the last
week to pay debts that he had amassed before he was recalled to prison.
However, his mother believed that her son’s debts had actually been accumulated
since his return to prison. The probation officer agreed that this was likely. Mr
Smith’s mother said that her son had called her again that day and told her that he
had been beaten up for an outstanding debt of approximately £90 and that she had
paid this as well. The probation officer told Mr Smith’s mother that she should stop
sending him money, and that Mr Smith appeared to be replicating the behaviour he
had shown in the community. The probation officer said she would contact his
offender supervisor.
62. On the morning of 7 May, the community probation officer emailed the prison’s
Offender Management Unit and shared her concerns about Mr Smith and asked
them to look into the matter.
63. Later that afternoon, the Offender Manager spoke to wing staff and asked them to
follow up on the community probation officer’s concerns about Mr Smith. Wing staff
visited Mr Smith that day. Mr Smith said that he was ‘fine’ and thanked staff for
checking on him. He denied that he had been assaulted, and said he was fine.
The prison staff did not see any marks on Mr Smith that could have been attributed
to an assault.
64. The Offender Manager relayed this information to Mr Smith’s mother, who said she
was unsure if he was lying to her and trying to manipulate her into sending him
money. The Offender Manager submitted a security intelligence report to ask staff
to keep an eye on Mr Smith.
65. On 11 May, Mr Smith phoned his mother and a friend from the prison PIN phone.
66. That day, Mr Smith also phoned his community probation officer. Mr Smith told her
that he was ‘okay’ but ‘fed up’ with the COVID-19 situation. He asked about his
parole date. The community probation officer told him that he could expect a review
in around 12 months’ time. She advised him that he needed to work with the
prison’s substance misuse services and that he may have to complete a Thinking
Skills Programme course before his release from prison. Mr Smith said that he had
not taken drugs since he returned to prison and assured her that everything was
okay. Mr Smith did not mention any debt issues nor raise any concerns about his
mental health.
67. The Offender Manager next saw Mr Smith on 14 May for another welfare check
after the community probation officer had raised concerns. Mr Smith said he had
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spoken to the probation officer and believed he would be in custody for another 12
months before a parole hearing. He talked about his time at HMP Kirkham, a
Category D prison and he said how supportive it was. Mr Smith said that he was
bored being locked up for extended periods. The Offender Manager told Mr Smith
that the prison regime would change once it was safe, but he had to be patient.
68. On the morning of 19 May, the community probation officer received a phone call
from Mr Smith’s mother, who said that he had asked her for money to pay off his
drug debts. She said that she was worried about him and thought that he might be
harmed as a result of his debts. She had told him that she would not send him any
money. She noted that Mr Smith’s mother was clearly angry with her son but was
also worried about his safety. She said that she would ask his offender supervisor
to check on him.
69. That evening, the Offender Manager checked on Mr Smith, who was in bed
watching television. He said he was ‘fine’. She asked Mr Smith twice if he wanted
to talk about anything or raise any concerns. Mr Smith said, “No, I’m fine, Miss”.
Wing staff had not reported any concerns about Mr Smith. The Offender Manager
relayed this information to the community probation officer and submitted a security
intelligence report noting that concerns had been raised about Mr Smith.
20 May
70. Risley told the investigator that they were unable to download a copy of the CCTV
footage for 20 May as the file was too large, and the investigator was unable to visit
the prison to view it due to the COVID-19 pandemic.
71. Mr Smith telephoned his mother in the morning. (After his death, Mr Smith’s mother
told prison staff that this had been a “bad” phone call.) The investigator was unable
to listen to the recording as he could not visit the prison, and Risley did not provide
a summary of the call.
72. In his police statement, Officer A said he completed a roll check on the wing at
around midday. He said he opened the cell door and spoke to Mr Smith who was
standing at the back of his cell. He said that he had no concerns about him.
73. That afternoon, an administrator in the Safer Custody Team reviewed the security
intelligence report submitted the previous evening. She telephoned B Wing at
3.15pm and spoke to Officer B and asked for a member of prison staff to conduct a
further welfare check on Mr Smith. In his police statement, he said he passed the
concerns onto Officer A, who said he left the wing office to check Mr Smith around a
minute later. Mr Smith’s cell was located around 20 to 25 metres from the office.
74. When Officer A arrived at Mr Smith’s cell, he looked through the cell door
observation panel. He saw Mr Smith hanging at the back of the cell from a ligature
(made from a cut piece of bed sheet), attached to the mesh on the window. Mr
Smith was facing towards the cell door and was in a kneeling position. He shouted
for staff assistance and immediately entered the cell. He supported Mr Smith’s
body while he cut the ligature.
75. Two officers arrived at Mr Smith’s cell in seconds, just as Officer A had placed Mr
Smith on the cell floor. Officer B radioed a medical emergency code blue and
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asked for an ambulance to be called. (A code blue tells the control room that a
prisoner is unresponsive or not breathing and that an ambulance must be called
immediately). The control room recorded that this occurred at 3.17pm.
76. Officer A said that Mr Smith was cold to the touch and his body was clammy and
rigid. He started chest compressions. Within a minute, another officer arrived at Mr
Smith’s cell with the emergency medical bag. They took turns trying to resuscitate
Mr Smith.
77. Two nurses arrived at the cell at 3.24pm. While the staff continued with CPR, a
nurse attached a defibrillator to Mr Smith, but it advised no shock. The officers
continued with chest compressions, but Mr Smith showed no signs of life. He had
no pulse, his pupils were fixed and dilated, and his face was cyanosed (a blue-
purple discolouration of the skin due to insufficient oxygen in the blood).
78. A prison GP arrived at the cell at 3.26pm. After examining Mr Smith, he stopped
CPR efforts and pronounced at 3.27pm that he had died. Paramedics arrived at the
prison at 3.34pm and completed an electrocardiogram (ECG) to monitor heart
activity. They agreed that Mr Smith had died.
Contact with Mr Smith’s family
79. Risley appointed a prison manager as the family liaison officer (FLO). Mr Smith’s
nominated next of kin was his mother. Due to the COVID-19 pandemic, a Deputy
Governor phoned Mr Smith’s mother at around 4.30pm and broke the news of Mr
Smith’s death. Risley maintained contact with Mr Smith’s family, and in line with
national instructions, they contributed to the costs of his funeral.
Support for prisoners and staff
80. A duty governor debriefed prison staff involved in the emergency response
individually. All staff and prisoners were offered the support of the prison’s care
team.
81. The prison posted notices informing other prisoners of Mr Smith’s death and
offering support. Staff reviewed all prisoners considered to be at risk of suicide and
self-harm, in case they had been adversely affected by Mr Smith’s death.
Post-mortem report
82. A pathologist concluded that Mr Smith died from compression of the neck due to
hanging. Toxicology tests found that Mr Smith had used psychoactive substances
(PS) before he died. Traces of olanzapine and citalopram (both of which he had
been prescribed) were also found.
Inquest
83. An inquest was concluded in November 2024 which concluded that Mr Timothy
Smith deliberately applied a ligature whilst alone in his cell; but it cannot be said
whether he intended the act to be fatal. Given that prisoners were in their cells for
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23 hours per day, in response to COVID-19, failure to increase routine checks and
a lack of (insufficient) sufficient face to face support contributed to his mental state.
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Findings
Assessment of risk of suicide and self-harm
84. Prison Service Instruction (PSI) 64/2011 on safer custody requires that all staff who
have contact with prisoners are aware of the risk factors and triggers that might
increase the risk of suicide and self-harm and that they manage prisoners identified
as at risk under ACCT procedures. The PSI lists several risk factors and states that
potential triggers should be continually assessed. It notes that any member of staff,
who observes behaviour which may indicate a risk of suicide or self-harm, must
start ACCT procedures.
85. When Mr Smith was recalled to custody, he had a number of risk factors: apart from
the fact that he had been recalled, he had a long history of mental health issues and
was taking antipsychotic medication, he had substance misuse issues and a history
of suicide attempts and self-harm. He had not, however, been monitored under
ACCT procedures since July 2019, and there was no immediate reason to monitor
him under ACCT at that point.
86. Mr Smith’s transfer to Risley coincided with the COVID-19 pandemic which resulted
in a severely restricted prison regime and reduced access to support services.
Most contact with healthcare staff, including mental health reviews, took place by
telephone and not face to face.
87. Approximately four weeks after he arrived at Risley, a mental health nurse who had
never met Mr Smith in person completed a mental health triage by telephone on 27
April. This had been delayed due to the restricted COVID-19 regime. The nurse
recorded that Mr Smith had a number of new risk factors: he had stated that he was
just about coping in prison, he had thoughts of self-harm due to the extended
periods locked in his cell and he had auditory hallucinations.
88. Although the nurse prescribed antidepressant medication and Mr Smith remained
on the mental health team’s caseload, we are concerned that she did not give
sufficient weight to Mr Smith’s risk factors during this telephone assessment and
placed too much emphasis on his assertion that he had no suicidal thoughts.
89. While staff judgement based on a prisoner’s apparent mood and state of mind is
important, it is only one indication of their risk. Staff should also recognise that
prisoners often try to hide their distress, particularly in different settings and with
people they do not know. Assessments based on behaviour and presentation must,
therefore, be balanced against the available risk information.
90. We appreciate the difficulties staff face when conducting assessments by phone, as
a person’s body language cannot be gauged. However, we consider that the nurse
should have recognised Mr Smith’s multiple risk factors: his history of substance
misuse, suicide attempts and self-harm, his potential mental health deterioration
and current thoughts of self-harm and started ACCT procedures. At the very least,
she should have told prison staff that Mr Smith was having thoughts of self-harm.
91. We make the following recommendations:
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The Governor and Head of Healthcare should ensure that staff take into
account all relevant risk information about prisoners when assessing their
risk of suicide and self-harm and start ACCT procedures when appropriate.
The Head of Healthcare should ensure that healthcare staff share important
information about a prisoner’s risk to himself with prison staff.
COVID -19 restrictions
92. The restrictions imposed in response to the COVID-19 pandemic meant that
prisoners were spending long periods locked in their cells, with significantly less
interaction with staff and other prisoners than would normally have been the case.
The key worker scheme was also suspended for prisoners unless they were
identified as priority prisoners (such as those who were considered to be at risk of
suicide or self-harm). We cannot say if the long periods of isolation affected Mr
Smith’s decision to take his life, or whether staff might have picked up on signs of
distress if they had had more contact with him.
93. Staff on Mr Smith’s wing had not known him before the pandemic and had very
reduced opportunities to get to know him once the restricted regime was in place.
Although prison staff took action promptly when Mr Smith’s mother raised concerns
about drug debts and bullying, Mr Smith denied having any problems and said he
was ‘fine’. If staff had had regular daily contact with Mr Smith and had seen him
interacting with other prisoners – as they would have done in normal times – it is
possible that they would have identified that he was taking drugs or being bullied or
that his mental health was deteriorating, although we cannot be sure. Just as
importantly, the restricted regime meant that Mr Smith had not had the opportunity
to get to know staff and this may have limited his willingness to tell them about his
concerns.
Clinical care
94. The clinical reviewer concluded that the care that Mr Smith received from
healthcare staff at Risley was of a good standard and equivalent to that which he
could have expected to receive in the community. The clinical reviewer noted that
Mr Smith was appropriately prescribed antipsychotic and antidepressant
medication.
Substance misuse
95. Mr Smith was appropriately referred to the substance misuse team. Despite his
history of substance misuse and the post-mortem result which identified PS in his
system, there was no intelligence to suggest that Mr Smith was misusing illicit
substances at Risley. It is troubling that he was able to access PS, unknown to
staff, particularly during the COVID-19 lockdown when severe restrictions had been
put in place on prisoner and visitor movement.
96. Risley has a substance misuse strategy that sets out a number of actions to reduce
the demand for and supply of illicit substances. HM Inspectorate of Prisons
completed a scrutiny inspection in November 2020 and noted that violence and
drug-related activity featured regularly. Although they found that Risley took an
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active role in working with the police to reduce drug supply, it is clear that work is
still needed to disrupt the supply and demand for PS.
Learning lessons
97. It is important that staff learn the lessons from the Ombudsman’s investigations.
We recommend:
The Head of Healthcare should share this report with Nurse A and discuss the
Ombudsman’s findings with her.
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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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