On 21s June 2012 | commenced an investigation into the death of Matthew Thomas Purser aged 29. The investigation concluded at the end of the inquest on 24th of February 2014. The conclusion of the inquest was a Narrative conclusion. The cause of death as given by the Pathologist was: Ia) Hanging A summary of the Narrative conclusion of the Jury is that the deceased took his own life by hanging himself on 13th June 2012 at H.M. Prison Swansea_ The deceased intended to take his own life due to contributory factors of severe depression and relationship breakdown: ACCT reviews should have taken place after incidents at noon and 4 pm on 13th June 2012 and the sharing of information between prison staff by way of recording significant interactions in the ongoing record of the ACCT plan were inadequate However, these matters were not considered to have more than minimally contributed to the deceased' s death:

Matthew Purser hanged himself in his cell at Swansea Prison about 7.25 pm on 13th June 2012. He had been on remand from 9" June 2012 and was in the drug recovery wing because of his substance misuse. He was receiving medication for alcohol withdrawal and had been placed on an ACCT (self harm monitoring document) from the time of his initial assessment by a Nurse on arrival at the Prison. At this initial assessment Mr. Purser referred t0 recent bereavement, attempted self harm about three weeks before and very high alcohol intake: He stated he was hearing voices and that he had an appointment later that month in the community with a psychiatrist. He was given anti withdrawal medication and a referral was made by the Nurse to the in-reach mental health team ie, the Local Health Board ran secondary mental health service working in the prison_ Under the ACCT observations were set at two hourly_in the day_with three meaningful conversations to be conducted:. On the following a second health screen was carried out involving seeing the prison GP and a mental health nurse on two occasions_ Mr. Purser was booked into the "lighthouse clinic" (primary care prison mental health service) On the same the deceased underwent his ACCT assessment and first ACCT review. The triggers for further review were recorded as "loss of contact with partnerlbreakdown in relationship"_ During the assessment interview for the ACCT the deceased had shown himself to be very dependent on being able to speak to his partner and the prison tried to facilitate this contact with one of the officers ringing partner on that to give her information about visiting and after which the deceased was said to be much improved in mood Mr: Purser continued to have telephone contact with his partner on 11th and 12th June but on 13" June in a telephone call to her shortly before midday he was seen by officers to become visibly upset and was noticed punching the metal hood over the telephone An officer who witnessed this took the Mr. Purser to an interview room to calm him down: An entry was made at midday on the ACCT that Mr. Purser had stated his girlfriend had had a miscarriage and wanted to leave him: officer said that he would see Mr; Purser after the lunch break and at 2.30 pm he took him t0 a staffroom and rang the partner on behalf of Mr: Purser, saying that Mr: Purser was sorry to put pressure on her and that Mr Purser would not telephone her again for 24 hours as the calls were upsetting them both_ After this Mr, Purser seemed more settled. No was made in the ACCT concerning the interaction of the officer Mr. Purser after lunch Despite the agreement which the officer had reached between Mr. Purser and his partner Mr Purser telephoned her again at about 3.50 pm. The same officers saw Mr. Pursher on telephone and when challenged he said he was calling his mother but one of the officers asked control to check the number called and was told it was the partner. An ACCT entry was made at 4 pm stating that Mr. Purser was a manipulative individual, willing to say anything to his own way, but the officer who had made the agreement with the partner did not challenge him about his behaviour and decided to leave speaking to him until the next day After 6 pm there were two further telephone calls between Mr. Purser and his partner in which they argued and he threatened to hang himself These were not observed by officers_ At about 6.35 pm Mr. Purser asked to go back into his cell to use the toilet The officer who allowed this had no concerns about his demeanour although his cell mate he was very upset. At about 7.25 pm the same officer noticed the observation hatch covered and on investigating found Mr. Purser hanging: This was about twenty minutes after he was last observed.

In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action,