Trevor Burchell

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Trevor Burchell,
a prisoner at HMP/YOI Elmley,
on 12 February 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, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Trevor Burchell was found hanged in his cell on 6 February 2022 at HMP Elmley. He
died in hospital on 12 February. He was 56 years old. I offer my condolences to Mr
Burchell’s family and friends.
Mr Burchell was serving an indeterminate sentence for public protection (IPP). He was first
released in February 2017, seven years and three months past his minimum tariff. He was
recalled to prison five months later after he breached the conditions of his licence. Mr
Burchell was then released again in November 2021, before he was recalled 12 days later.
In September 2023, we issued a learning lessons bulletin in response to the worrying
increase in self-inflicted deaths of prisoners serving Imprisonment for Public Protection
(IPP) sentences in 2022. We have continued to see self-inflicted deaths of IPP prisoners in
2023. Our investigations have found that IPP prisoners struggle with their uncertain status
leading to feelings of hopelessness and frustration. This can cause a lack of engagement
with the parole process and sentence planning and create a lack of trust in the system. Mr
Burchell’s story serves to illustrate these concerns.
Prison staff knew Mr Burchell well and ACCT procedures provided him with some support.
The lack of multi-disciplinary attendance at case reviews meant that staff did not fully
explore how Mr Burchell’s recall impacted on his belief that he was being set up to fail.
The clinical reviewer found that Mr Burchell did not receive appropriate mental health
support and his overall mental health care was not equivalent to what he could have
expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman February 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 11
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Summary
Events
1. In March 2007, Mr Trevor Burchell was given an indeterminate sentence for public
protection (IPP) with a minimum time to serve of 2 years, 7 months and 16 days, for
wounding with intent. He absconded from prison in 2012 and 2013. Mr Burchell was
released on licence from HMP Elmley in February 2017, but was recalled five
months later. He was then released again on 19 November 2021, and recalled to
Elmley on 1 December.
2. Mr Burchell had a history of poor mental health and self-harm. He refused to take
his medication and said that he understood the impact on his physical and mental
health.
3. Mr Burchell was managed under Prison Service suicide and self-harm monitoring
procedures (known as ACCT) from 20 December, after he told his prison offender
manager that he would leave prison in a box. Mr Burchell said he had no hope for
the future and had stopped taking his medication to help him die.
4. At 5.22pm on 6 February 2022, Mr Burchell had placed his mattress against his cell
door and turned his bedframe upright. Prison officers used an anti-barricade key
(used to unlock a door outwards) to enter Mr Burchell’s cell and found him ligatured
from the bedframe.
5. Paramedics took Mr Burchell to hospital, but he did not recover. Mr Burchell died at
8.05am on 12 February.
Findings
6. Mr Burchell had a number of risk factors which indicated that he was at risk of
suicide and self-harm. He felt hopeless about his recall to prison and that he would
continue to fail when he was released into the community because of the trauma he
had suffered in the past.
7. ACCT procedures provided some support to Mr Burchell. Prison staff were aware of
his previous history and how it affected his ability to cope. Case reviews were not
consistently multi-disciplinary which meant staff missed the opportunity to explore
how the wider issues associated with his release and recall impacted on his low
mood.
8. Mr Burchell had complex mental health needs. He had raised concerns that he was
not receiving the support he needed and was non-compliant with his antidepressant
medication. The mental health team did not complete a mental health assessment
after his recall to Elmley or after he threatened to attempt suicide and it was unclear
why he did not meet their criteria for support.
9. The clinical reviewer concluded that Mr Burchell’s mental health care was not
equivalent to what he could have expected to receive in the community.
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The Investigation Process
10. On 14 February 2022, HMPPS notified us of Mr Burchell’s death. The investigator
issued notices to staff and prisoners at HMP Elmley informing them of the
investigation and asking anyone with relevant information to contact her. No one
responded.
11. The investigator visited Elmley on 24 February. She obtained copies of relevant
extracts from Mr Burchell’s prison and medical records.
12. NHS England commissioned a clinical reviewer to review Mr Burchell’s clinical care
at the prison.
13. The investigator interviewed six members of staff at Elmley. She and the clinical
reviewer jointly interviewed clinical staff.
14. The investigation was delayed while we waited for the clinical review report.
15. We informed HM Coroner for Kent of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
16. We wrote to Mr Burchell’s sister to explain the investigation and to ask if she had
any matters she wanted the investigation to consider. She did not have any
questions but asked for a copy of the report.
17. Mr Burchell’s sister received a copy of the initial report. She did not raise any further
issues, or comment on the factual accuracy of the report.
18. 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 Elmley
19. HMP Elmley holds up to 1,252 men, remanded and sentenced, in six houseblocks
with a mixture of single, double and triple cells. Integrated Care 24 Ltd provides 24-
hour primary healthcare services, with input from Minster Medical Group. Oxleas
NHS Foundation Trust provides mental health services.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Elmley was in February and March 2022.
Inspectors reported that there had been four self-inflicted deaths since the last
inspection. The prison had begun implementing PPO recommendations, but
implementation was not monitored over time to ensure on-going compliance.
Reported self-harm was lower than in most comparable prisons but had increased
since the last inspection. Prisoners supported through ACCT case management
were generally positive about the care they received, although there were some
weaknesses in the process itself.
21. In February 2023, an independent review of progress took place. The report said
that Elmley faced substantial staff shortages, but leaders were focused on how to
make improvements with the resources they had and were delivering more than
many prisons with a similar or better staffing position.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to November 2021, the IMB
reported that there should have been greater, more formal analysis of self-harm.
ACCT documents were valuable for recording such events and their possible
triggers, but the underlying causes seemed never to be identified in relation to the
prison environment.
Previous deaths at HMP Elmley
23. Mr Burchell was the nineteenth prisoner to die at Elmley since February 2019. Of
the previous deaths, three were self-inflicted, 13 were from natural causes and two
were drug related. There have been two natural cause deaths since. There were no
similarities with the previous investigations.
Assessment, Care in Custody and Teamwork
24. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
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irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
25. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
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.
Parole Board
26. The Parole Board for England and Wales is an independent public body. Its role is
to make risk assessments about prisoners to decide whether they can safely be
released into the community once they have served the minimum term imposed by
the courts.
Indeterminate sentence for Public Protection (IPP)
27. IPP sentences were abolished in 2012. They were intended to protect the public
against offenders whose crimes were not serious enough to merit a normal life
sentence, but who could only be released once they had served their minimum tariff
and had demonstrated to the satisfaction of the Parole Board that they had
sufficiently reduced their risk. There are currently about 3,000 IPP prisoners, of
which half have never been released.
28. Since June 2022, all Parole Board recommendations for the transfer to open
conditions and release of IPP prisoners must be approved by the Secretary of State
for Justice.
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Key Events
29. On 20 March 2007, Mr Trevor Burchell received an indeterminate sentence for
public protection (IPP) for wounding with intent. He was given a tariff of 2 years, 7
months and 16 days (the minimum he would have to spend in prison before he
could be released) and was sent to HMP Swaleside. Mr Burchell had a history of
offending and had been in prison before.
30. In June 2012, Mr Burchell absconded from HMP Blantyre House and in June 2013,
from HMP Stamford Hill. He was released from HMP Elmley on 22 February 2017
and recalled on 17 July after he failed to comply with the conditions of his licence.
31. Mr Burchell had been managed under Prison Service suicide and self-harm
monitoring procedures (known as ACCT) on 18 occasions since June 2013, after he
reported suicidal thoughts caused by a low mood.
32. The prison’s mental health team saw Mr Burchell throughout his time in prison and
before his release on licence. Mr Burchell said that he had suffered both physical
and sexual abuse as a child. In 2015, Mr Burchell was diagnosed with post-
traumatic stress disorder (PTSD - an anxiety disorder caused by a very stressful,
frightening or distressing event).
33. Mr Burchell completed psychological therapy but his engagement was often
inconsistent. In September 2021, he was referred to the prison psychologist, but he
was not considered suitable for further psychological intervention. A prison
psychologist noted that Mr Burchell had completed Step 4 therapy (a therapeutic
process to increase a patient’s understanding of their problems and how these
influence relationships) and no appropriate treatment was available for him.
34. Mr Burchell had regular appointments with his Prison Offender Manager (POM) and
Community Offender Manager (COM) to prepare for his release. He also received
support from The Forward Trust (a charity which helps people with drug and alcohol
dependence).
35. On 13 September, The Parole Board directed Mr Burchell’s release on licence to
Fleming House Approved Premises (AP). The panel noted Mr Burchell’s concerns
that he would be associating with sex offenders, specifically at mealtimes, and the
trauma he had suffered as a child. Mr Burchell would be provided with his own room
and would not be expected to eat with other residents.
36. On 19 November, Mr Burchell was released from Elmley. Shortly after he arrived at
Fleming House, Mr Burchell threatened another resident with violence, as he was
aware the resident had committed a sexually related offence. AP staff issued Mr
Burchell with a warning for his behaviour. Mr Burchell’s behaviour did not improve
and he continued to display threatening and abusive behaviour towards other
residents. Mr Burchell refused to engage with AP staff, demanded to be returned to
prison and threatened to harm staff. He also used homophobic language towards
another resident and told staff that he did not want to live with sex offenders. AP
staff noted Mr Burchell’s index offence of wounding with intent and that his
behaviour indicated that his risk of committing a violent offence had increased.
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37. Mr Burchell’s COM agreed with AP staff that Mr Burchell’s behaviour could not be
managed in the community and there were no suitable alternatives to recall. Mr
Burchell had breached the conditions of his licence. The COM told the investigator
that withdrawing Mr Burchell’s place at the AP meant that he was homeless through
the loss of his accommodation and there was no other suitable address available to
him.
38. On 1 December, Mr Burchell was recalled to prison and he was returned to Elmley.
HMP Elmley
39. During an initial health screen, a nurse identified that Mr Burchell had a history of
angina, type 2 diabetes and high cholesterol. She noted that Mr Burchell had been
prescribed metformin (to regulate blood sugars) atorvastatin (to lower cholesterol)
bisoprolol (for high blood pressure) and escitalopram (antidepressant). Mr Burchell
refused to take his medication. He denied any thoughts of suicide and self-harm.
She referred Mr Burchell to the mental health team.
40. Prison staff completed a cell sharing risk assessment (CSRA) and recorded that Mr
Burchell was high risk because of his mental health. Mr Burchell was allocated a
single cell on Houseblock 1, the induction wing. Mr Burchell refused to engage with
the prison’s resettlement team and staff noted that he refused to take responsibility
for his recall to prison.
41. On 10 December, a nurse spoke to Mr Burchell because he was still refusing to
take his medication. Mr Burchell said that he felt like he had given up but did not
want to hurt himself and denied any thoughts of suicide and self-harm. He
understood the effects of not taking his medication on his physical and mental
health. The nurse made another referral to the mental health team. That day, Mr
Burchell refused to attend a GP appointment.
42. On 13 December, mental health staff discussed Mr Burchell at a multi-disciplinary
team meeting and decided he did not need further input or support, but they did not
record the reasons for this. A mental health nurse saw Mr Burchell on 16
December. She did not record any details about Mr Burchell’s presentation in his
clinical record.
43. On 20 December, a POM, began ACCT monitoring after Mr Burchell told her that
the only way out of prison was in a body bag and the only option left was to attempt
suicide.
44. Mr Burchell told Officer A at his ACCT assessment that he had no hope for the
future and had stopped taking his medication on 13 December to help him die. Mr
Burchell said that he wanted a transfer to another prison because he was unhappy
that he was released to an AP in Kent.
45. A Senior Officer (SO) was appointed as ACCT case manager and held a case
review on 21 December with Mr Burchell, Officer A and the prison chaplain. Mr
Burchell said that he was destined to fail at Fleming House because he had
suffered sexual abuse as a child and he did not want to live with sex offenders. The
SO added four actions to Mr Burchell’s caremap (designed to identify the main
areas of concern and the actions required to reduce risk): that he should see the
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psychology team, continue to access the wing regime, engage with the Forward
Trust and continue to seek support from his family. She assessed Mr Burchell’s risk
of suicide and self-harm as medium and decided that he should have two quality
conversations with staff during the day and he should be monitored five times
during the night. She decided that Mr Burchell would remain on Houseblock 1
because staff knew him well and were able to provide support.
46. On 28 December, Mr Burchell refused to attend a case review with the SO. He
denied any thoughts of suicide and self-harm. Because Mr Burchell would not
engage with the case review, she increased his observations to one every hour.
47. During a case review on 29 December, Mr Burchell said that he could not cope at
Fleming House and was suffering from PTSD. A mental health nurse told the review
she would refer Mr Burchell to the Bradley Therapy Service (psychological therapy
services for prisoners in Kent) for additional support. Mr Burchell said he was still
refusing to take his medication because he felt that it did not work. That day, Mr
Burchell did not attend his appointment with a mental health nurse.
48. On 5 January 2022, a prison psychologist noted that she had not accepted Mr
Burchell’s referral because there was no change in his presentation since the
previous referral in September 2021. She said that Mr Burchell’s previous
engagement with psychology was sporadic and there was no appropriate treatment
available for him.
49. During a mental health team referral meeting on 6 January, a nurse noted that the
mental health nurse had continued to see Mr Burchell despite him being previously
discharged. The mental health team decided that Mr Burchell did not need any
further input and discharged him from their care again.
50. On 9 January, the SO held an interim case review because wing staff were
concerned that Mr Burchell’s mood had deteriorated. Mr Burchell was sitting on his
cell floor, visibly distressed. He was worried that staff were going to hurt him but
said that nothing had happened. Mr Burchell said he was not taking his medication
and denied any thoughts of suicide and self-harm. The SO told Mr Burchell that she
was concerned for his safety. Mr Burchell refused to move to a safer cell (a cell
designed with fewer known ligature points) and said that he wanted to remain in his
cell where he felt safe. She noted that Mr Burchell had not recently self-harmed, but
she increased Mr Burchell’s observations to two every hour and made wing staff
aware of the change.
51. On 18 January, Mr Burchell refused to attend a case review and asked to see the
mental health team. A nurse saw Mr Burchell in his cell and noted that he was
distressed and crying. Mr Burchell said that he felt that his mental health was
deteriorating and nobody was helping him. On 19 January, Mr Burchell attended a
case review with a SO and the nurse. Mr Burchell said he felt better and wanted to
move to a prison outside of Kent for a fresh start and would discuss this with his
prison offender manager. The SO reduced Mr Burchell’s observations to one every
hour. A GP appointment was made for 25 January to discuss his medication.
52. During the appointment on 25 January, a GP at the prison advised Mr Burchell of
the importance of taking his medication. Mr Burchell refused to discuss taking an
alternative antidepressant medication and said that he would continue to refuse his
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prescribed medication. The GP discussed the impact this could have on his blood
pressure. Mr Burchell became angry and left the appointment. The GP made a
referral to the Cardiology Department and arranged an electrocardiogram (ECG- to
diagnose and monitor conditions affecting the heart). There is no evidence that Mr
Burchell had an ECG before he died.
53. That day, the prison psychologist told the mental health team manager that she
would provide information about Mr Burchell to the safety intervention meeting (SIM
- a weekly multi-disciplinary meeting to discuss prisoners who are at risk). She
attended the SIM on 2 February. There is no evidence that the meeting discussed
Mr Burchell.
54. On 26 January, Mr Burchell refused to attend a case review. An officer spoke to Mr
Burchell at his cell. Mr Burchell said that staff had stolen money from him in 2017,
and that staff had assaulted him, but he did not say when this had happened. Mr
Burchell felt that staff were not listening to him. Staff did not record taking any
action to investigate Mr Burchell’s claims. He told the officer that he had not eaten
that day but agreed to have a drink and two breakfast packs. That day, Mr Burchell
told staff that he had experienced a seizure. A nurse completed an assessment and
concluded that Mr Burchell was physically stable, and his issues were behavioural,
rather than clinical.
55. On 28 January, Mr Burchell asked the observation, classification and allocation
(OCA) department for information about a transfer to HMP Warren Hill, HMP The
Mount or HMP Coldingley. They advised Mr Burchell that, as he had been recalled
to prison in December 2021, he would need a recall security category review before
he was eligible for a transfer and that he should discuss this with his POM.
56. On 31 January, a SO held a case review with Mr Burchell. Mr Burchell said that he
felt better and denied any thoughts of suicide and self-harm. She decided to
continue ACCT monitoring and reduced Mr Burchell’s observations to two
conversations a day and hourly observations during the night. The next case review
would take place on 7 February.
57. That day, Mr Burchell refused to attend an assessment with the prison psychologist
but agreed to attend on 1 February. She advised Mr Burchell about using
mindfulness to manage his emotions. She agreed to see him again the following
week to offer support with relaxation techniques to manage his anxiety and stress.
She noted that she would also discuss Mr Burchell in the SIM.
58. Over the next few days, prison staff recorded in Mr Burchell’s ACCT record that he
was not fully engaging with the wing regime and preferred to stay in his cell. Mr
Burchell collected his meals but continued to refuse his medication. Mr Burchell did
not make any telephone calls or receive any visits between 31 January and 6
February.
Events of 6 February
59. At 10.45am on 6 February, an officer noted in Mr Burchell’s ACCT record that he
had declined his medication and lunch. Mr Burchell was crying and said that he
wished everyone would leave him alone. The officer checked Mr Burchell again at
3.00pm and noted that he was lying in bed and did not express any concerns.
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During an observation at 4.30pm, another officer noted that Mr Burchell was angry
that staff kept coming to his cell. He told her that he intended to take the next
member of staff he saw hostage. She made an entry in Mr Burchell’s NOMIS
(electronic prison record) and in the wing observation book.
60. At 5.14pm, Mr Burchell rang his cell bell and Officer B responded. As the night light
was not working, the officer used his torch to look into the cell. Mr Burchell was
pacing around his cell and had turned his bedframe upright. He refused to engage
in conversation. At 5.20pm, the officer went to the wing office and spoke to Officer
C about Mr Burchell. Officer C knew Mr Burchell well and said he would try and talk
to him.
61. Both officers returned to Mr Burchell’s cell at 5.22pm, and saw that Mr Burchell was
sitting on the cell floor behind the bed and the cell door was obscured by the
mattress. Officer C said that he tried to persuade him to remove the mattress. Mr
Burchell refused to remove the mattress and the officers decided they would enter
Mr Burchell’s cell. At 5.24pm, both officers left Mr Burchell’s cell and returned with
the anti-barricade key (used to unlock a door outwards).
62. At 5.26pm, both officers entered Mr Burchell’s cell and found Mr Burchell ligatured
from the bedframe. Officer C removed the ligature and Officer B immediately
radioed an emergency code blue (indicating that a prisoner is unconscious or is
having difficulty breathing). Both officers then started cardiopulmonary resuscitation
(CPR). A nurse arrived at 5.33pm and assisted with CPR.
63. At 5.51pm, paramedics arrived and took control of Mr Burchell’s care. He was taken
to hospital at 6.46pm. Two officers accompanied Mr Burchell and did not use
restraints.
64. Mr Burchell’s condition deteriorated and he was placed on life support. On 12
February, hospital doctors decided to remove him from life support and at 8.05am, it
was confirmed that Mr Burchell had died.
Contact with Mr Burchell’s family
65. On 6 February, the prison appointed a family liaison officer. She identified Mr
Burchell’s sister as his next of kin and told her that Mr Burchell was in hospital. Mr
Burchell’s sister visited him in hospital and was present when he died on 12
February.
66. The prison contributed towards the cost of Mr Burchell’s funeral in line with national
policy.
Support for prisoners and staff
67. After Mr Burchell’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.
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68. The prison posted notices informing other prisoners of Mr Burchell’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 Burchell’s death.
Post-mortem report
69. The pathologist gave Mr Burchell’s cause of death as a fatal pressure on the neck.
A toxicological analysis did not detect any illicit substances in Mr Burchell’s blood.
Inquest
70. At an inquest on 16 April 2024 the Coroner concluded that Mr Burchell died as a
result of a self-applied ligature, but the evidence was insufficient to determine
whether he intended to end his life.
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Findings
Assessment of Mr Burchell’s risk
71. Mr Burchell had a number of risk factors which indicated that he was at high risk of
suicide and self-harm. He had a long history of making threats to harm himself and
his mental health was poor and deteriorating by the day. It is clear from this
investigation that Mr Burchell was left feeling hopeless by his recall to prison. Mr
Burchell believed he would continue to fail when he was in the community because
his PTSD meant he was unable to control his emotions, resulting in violent
behaviour towards those he felt aggrieved by.
72. We consider that ACCT procedures provided some support to Mr Burchell. Staff
held regular case reviews, although these were not consistently multi-disciplinary.
They added actions to Mr Burchell’s caremap which reflected the issues with his
medication and his engagement with the psychologist. Staff were aware of his
previous history and how this impacted on his ability to cope. It is evident from the
decision of the ACCT case manager to keep him on houseblock 1, that wing staff
had tried hard to offer Mr Burchell consistent support.
Mental health
73. The clinical reviewer found that Mr Burchell’s mental health care was not equivalent
to what he could have expected to receive in the community. Mr Burchell had
complex mental health needs and had raised concerns that he was not receiving
the support he needed. Prior to his release on 19 November 2021, Mr Burchell
received regular support from the mental health team.
74. The clinical reviewer found that there was no evidence that mental health staff
completed a formal assessment when Mr Burchell returned to prison on 1
December, or when he threatened to attempt suicide. There was no clear rationale
for their decision that he did not meet their criteria for support. Mr Burchell
demonstrated clear issues of concern, such as his non-compliance with his
antidepressant medication and his previous diagnosis of PTSD. Mental health
attendance at case reviews was inconsistent and their input was limited to making a
referral to the psychologist.
75. The clinical reviewer has made some recommendations about mental health
assessments, record keeping and training, which we do not repeat in this report, but
which the Head of Healthcare will wish to address.
Governor to Note
Events of 6 February
76. During the evening of 6 February, officers became concerned about Mr Burchell’s
behaviour after he barricaded his cell, turned his bed frame on end and would not
engage with staff. Staff were right to act on their concerns and decide they needed
to enter the cell. In the two minutes they were gone, Mr Burchell hanged himself.
Clearly the two officers had assessed Mr Burchell as at heightened risk, but had not
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seen him with a ligature, or anticipated the speed with which he would act. The
Governor will wish to consider the sequence of events and whether there is any
learning for the prison.
Case reviews
77. PSI 64/2011 requires that healthcare attend the first review and that a case
manager must be appointed at this time. It also states that ACCT case reviews
must be multi-disciplinary where possible because this is the most effective way to
assess and manage risk, and that the ACCT process will operate more effectively if
there is continuity in the attendance of staff.
78. Mr Burchell was a licence recall and his IPP sentence meant he would remain in
prison for the foreseeable future. Mr Burchell said that he was destined to fail in the
community and he felt that the system had let him down. We note that a SO was
appointed as Mr Burchell’s case manager and she provided him with good,
consistent support. Healthcare staff did not attend the first case review.
79. Mr Burchell’s case reviews were not consistently multi-disciplinary and his prison
offender manager did not attend any case reviews. This was a missed opportunity
to explore how his IPP sentence impacted on his feelings of frustration that he was
destined to fail in the community and that he was trapped in an cycle of release and
recall.
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