Article 2 Investigations

The Secretary of State for Justice commissioned an independent investigation in the case of ‘SP’, who was in prison custody during 2003 to 2005 and repeatedly self-harmed to the extent that life-threatening injuries were sustained. The investigation was conducted in two stages, chaired respectively by Barbara Stow and His Hon. Brian Barker C.B.E., KC. It has concluded and reported its findings, which have been shared with the relevant organisations to consider so that lessons can be learned.

The report of the independent investigation conducted by Barbara Stow into the life-threatening incident involving ‘PL’ at HMP Stocken on 29 July 2019 is published here.  Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison. ‘PL’ was discovered lying unresponsive on the floor of his cell at HMP Stocken on 29 July 2019.  Staff administered first aid before paramedics arrived and ‘PL’ was taken to hospital.  ‘PL’ sustained long-term injuries that may have affected his ability to live independently.

The report of the independent investigation conducted by Mark Boother into the incident of life-threatening self-harm involving ‘AR’ at HMP Norwich on 25 October 2018 is published here.  Also published is the response to the investigation from His Majesty’s Prison and Probation Service (HMPPS). ‘On 25 October 2018 ‘AR’ was discovered hanging in his cell at HMP Norwich. Staff administered first aid, including CPR, before paramedics arrived and ‘AR’ sustained a serious and long-term brain injury and resides in a nursing home.

Independent investigation into a life-threatening incident  involving ‘Mr Midland’1at HMP Featherstone on 28 April 2016 The report of the independent investigation conducted by Dr Deborah Brooke into the life-threatening incident involving ‘Mr Midland’ at HMP Featherstone on 28 April 2016 is published here.  Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison

Independent investigation into an incident of life-threatening self-harm involving ‘CR’1at HMP Swansea on 3 December 2015 The report of the independent investigation conducted by Barbara Stow into the incident of life-threatening self-harm involving ‘CR’ at HMP Swansea on 3 December 2015 is published here.  Also published are the responses to the investigation from His Majesty’s Prison and Probation Service (HMPPS) and the Swansea Bay University Health Board.

Independent investigation into an incident of serious assault involving ‘HM’1at HMP High Down on 30 October 2015 The report of the independent investigation conducted by Andy Smith into the serious assault on ‘HM’ at HMP High Down on 30 October 2015 is published here.  Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison.

The report of the independent investigation conducted by Andy Smith into the serious assault on ‘SR’ at HMP Durham on 16 April 2015 is published here.  Also published is the response to the investigation from His Majesty’s Prison and Probation Service (HMPPS). On 16 April 2015, ‘SR’ was seriously assaulted by another prisoner in a shower area at HMP Durham, sustaining serious injuries that have left him requiring some assistance with daily living.  The incident was referred to the police and the perpetrator was found guilty of grievous bodily harm with intent.   He received a sentence of 12 years and six months, to be served consecutive to his original sentence.

Independent investigation into an incident of life-threatening self-harm involving ‘DM’1at Southampton Magistrates’ Court on 16 March 2015 The report of the independent investigation conducted by Barbara Stow into an incident of life-threatening self-harm involving ‘DM’ at Southampton Magistrates’ Court on 16 March 2015 is published here.  Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at Southampton Magistrates’ Court.

The report of the independent investigation conducted by Rob Allen into the serious assault on ‘AD’ at HMP Bristol on 26 June 2014 is published here. Allegations about the actions of the senior manager in HM Prison and Probation Service responsible for overseeing a previous internal investigation into the incident were made in evidence given to Mr Allen.

Independent investigation into an incident of life-threatening self-harm involving ‘Mr Everest’1at HMP Altcourse on 22 February 2014 The report of the independent investigation conducted by Professor Jenny Shaw into the incident of life-threatening self-harm involving ‘Mr Everest’ at HMP Altcourse on 22 February 2014 is published here.  Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison.

The report of the independent investigation conducted by Barbara Stow into the  incident of life-threatening self-harm involving ‘TA’1at HMP Chelmsford on 1 July 2013 is published here. Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison.

The independent investigation conducted by Barbara Stow into the life-threatening self-harm of WA at HMP Ranby on 18 February 2012 is published. Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison.

The independent investigation conducted by Andy Smith into the serious assault on ‘Mr Adakite’ at HMP Birmingham on 16 June 2011 is published.  Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison. On 16 June 2011 staff found ‘Mr Adakite’ with serious head injuries in the shower room of the inpatients unit in the healthcare centre at HMP Birmingham.  ‘Mr Adakite’ had been seriously assaulted by another prisoner.  Staff gave immediate first aid until paramedics arrived and ‘Mr Adakite’ was taken to hospital.

The independent investigation conducted by Simon Draycott into the circumstances surrounding the incident at HMP Pentonville on 24 August 2010 that led to Mr Atlantic sustaining serious injuries is published.  Also published is the National Offender Management Service (NOMS) response to the investigation. Mr Atlantic was received at HMP Pentonville on 21 August 2010 and admitted to the prison healthcare inpatient unit following his assessment in the prison reception area.  He was placed on constant supervision on an open ACCT document (Assessment, Care in Custody and Teamwork – the care planning system for prisoners identified as being at risk of suicide and/orself-harm).

The independent investigation conducted by Rob Allen into the life-threatening attempted suicide of AC at HMP Brixton on 4 June 2010 is published.  Also published are the responses to the investigation from NHS England and Her Majesty’s Prison and Probation Service (HMPPS). AC was received at HMP Brixton on 6 March 2010. On 4 June he was seen by staff to have placed a noose around his neck, and he stood upon and jumped off a pipe in his cell.  He had barricaded his door using his bed and staff were not able to enter the cell for some time.

The independent investigation conducted by Professor Jenny Shaw into the life-threatening attempted suicide of Mr Quartz at HMP Doncaster on 2 December 2008 is published. Also published is the National Offender Management Service (NOMS) response to the investigation. Mr Quartz was serving a sentence with an extended licence period, and having been recalled to prison was received into HMP Doncaster on 14 July 2008.  On 2 December 2008, Mr Quartz seriously self-harmed by using a ligature which was attached to his bed. He lost consciousness and was taken to outside hospital.

The independent investigation conducted by Kevin Bradford into the serious assault on ‘Mr North’ at HMP Whitemoor on 6 September 2008 is published.  Also published is the HM Prison and Probation Service (HMPPS) response to the investigation. On 6 September 2008 ‘Mr North’ was found in his cell with injuries suggesting that he had been assaulted.  He was taken to hospital, where he received treatment for a head injury, and returned the same day to the healthcare centre at HMP Whitemoor.

The independent investigation conducted by Rob Allen into the life-threatening attempted suicide of AB at HMP Bedford on 24 June 2008 is published. Also published is The National Offender Management Service response to the investigation. AB was remanded into custody at HMP Bedford on 5 June 2008. Later that day he was discovered hanging in a holding room in the prison’s reception. Nursing staff administered oxygen and he was taken to HMP Bedford’s health care centre.

Ana was 21 years old when she attempted suicide on 2 May 2004 at HMP & YOI Holloway.  She was discovered by staff suspended by a ligature in a shower room. Ana was taken to hospital where her condition stabilised but subsequent medical tests revealed that Ana had sustained substantial brain damage as a result of the incident. A detailed internal investigation by the Prison Service was carried out into the circumstances of Ana’s attempted suicide.

The National Offender Management Service (NOMS) response to the independent investigation conducted by Selena Lynch into the life-threatening self-harm of JL at HMYOI Feltham on 19 August 2002 is published. JL was remanded into custody at HMYOI Feltham on 19 July 2002. On 19 August at 14.30 hours he was discovered hanging. After being resuscitated he was taken to hospital. He temporarily returned to custody but was subsequently transferred to a brain injury unit in hospital. He remains significantly injured in a Community Rehabilitation Centre.