Dear Sir,

Re: Matthew David Harris

I would like to acknowledge receipt of your Regulation 28 report to prevent future deaths, prepared following the conclusion of your investigation and inquest in relation to Mr. Matthew David Harris on 20th June 2023.

I am cognisant of your finding that Mr. Harris died as a result of suicide.

In light of the fact that you have expressed an opinion that action should be taken to prevent future deaths, I have caused a review to be undertaken.

As a result of this review, action has both been identified and implemented via my Head of Custody Services, Chief Inspector .

It is clear that on 14th May 2022 when Mr Harris was interviewed by my officers whilst detained at Haverfordwest Police Station, he disclosed his recent suicidal ideation whereby prior to the murder taking place he had intended to take his own life

I am mindful that the aforementioned information was not contained within the Person Escort Record (PER) and Suicide and Self-Harm (SASH) Warning forms, both of which accompanied Mr Harris to Haverfordwest Magistrates Court on 16th May 2022 and thereafter with him to HMP Swansea later that same day.

I have noted that you are satisfied that the omission of information regarding Mr Harris’ recent suicidal ideation from the aforementioned documents made no difference to the very sad outcome in this case.

That said, I agree that learning can and should be derived from this omission, learning and action that should assist in minimizing the risk of suicide / self-harm amongst those in custody.

To confirm, on 1st August 2023 via my Head of Custody Services, all staff involved in investigations and those responsible for the care of detainees whilst in police custody have been informed, in an anonymized manner of the nature of the omission in this case.

Custody Officers have been instructed to specifically ask interviewing officers whether they have any information that is relevant to the ongoing duty of risk assessment; information needed to best manage the welfare of the detainee.

Further, investigators have been reminded of their duty to inform the custody officer of any information disclosed to them that should be considered as part of ongoing risk management.

Thank you for bringing this to my attention.

Dear Mr Reid,

Thank you for your Regulation 28 report of 21 June 2023, addressed to the Governor of HMP Swansea and the Director General Chief Executive of HM Prison and Probation Service. I am responding on behalf of His Majesty’s Prison and Probation Service (HMPPS) as Director General of Operations.

I know that you will share a copy of this response with Mr Harris’s family, and I would first like to express my condolences for their loss. Every death in custody is a tragedy and the safety of those in our care is my absolute priority.

You have raised some concerns following evidence heard at the inquest, regarding the management of the Assessment, Care in Custody and Teamwork (ACCT) process at HMP Swansea and the impact this has on supporting individuals at risk of self-harm and suicide. Thank you for bringing your concern to my attention.

HMP Swansea have reviewed the management of the ACCT process and introduced a thorough ACCT assurance procedure to ensure there is consistency and effective completion of all ACCT documents. A dedicated safer custody officer now conducts a comprehensive review of all open ACCT documents to ensure they are completed in line with national policy. A number of additional checks are included in this process, with a random sample also conducted by custodial managers and the senior management team. This ensures that any inconsistencies or issues are addressed almost immediately.

The findings from the assurance checks are now discussed at safety custody meetings to identify common themes and inform improvements, and are included on the prison duty Governor Reports, which are sent daily to all HMP Swansea staff. Further to this, Governor Orders and Notices to Staff are published on a bi-monthly basis to stress the importance of effective ACCT case management.

Further ACCT training is currently being rolled out to all ACCT case managers at HMP Swansea, which highlights the importance of consistency in case management, information sharing, and record keeping. We are committed to ensuring ACCT management remains a key focus of our work and so training in this area will be continuous.

Thank you again for bringing your concerns to my attention. I trust that this response provides assurance that action is being taken to address this matter.

Director General Operations