Akash Akeel

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Independent investigation into
the death of Mr Akash Akeel,
a prisoner at HMP Leeds,
on 31 December 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 HM 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 Akash Akeel was found hanging in his cell at HMP Leeds on 31 December 2022. Staff
and paramedics tried to resuscitate him but were unsuccessful. He was 28 years old. I
offer my condolences to Mr Akeel’s family and friends.
This was the fourth self-inflicted death at Leeds in 2022 and the eleventh in three years.
There have been a further four self-inflicted deaths since.
My investigation found that there was a missed opportunity to assess Mr Akeel’s risk of
suicide when he asked for antidepressant medication six weeks before his death.
Healthcare staff prescribed antidepressants but failed to monitor that Mr Akeel was taking
them. He had not collected any of his antidepressant medication by the time he died.
The clinical reviewer concluded that Mr Akeel’s mental health care at Leeds was not
equivalent to that which 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 December 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. Mr Akash Akeel was remanded into custody at HMP Leeds on 27 October 2022,
charged with attempted burglary, stalking and harassment. He had been in prison
many times before.
2. Reception staff noted that Mr Akeel had a history of suicide attempts and self-harm
but these incidents were over three years before and they had no current concerns.
Mr Akeel had previously been on medication for anxiety and depression
(mirtazapine) but not since 2021.
3. On 18 November, Mr Akeel asked to restart mirtazapine. A nurse assessed him by
telephone on 2 December and agreed to prescribe mirtazapine at a low dose for
one week and then a higher dose. She did not refer Mr Akeel to the mental health
team.
4. On 16 December, a pharmacy technician noticed that Mr Akeel had not collected
his medication. She asked a GP if she could issue the higher dose and he agreed.
No action was taken to establish the reasons why Mr Akeel had not collected his
medication.
5. On the morning of 29 December, Mr Akeel told a nurse that he was not being
unlocked to get his medication. The nurse highlighted this to the pharmacy but no
one took any action.
6. That evening, Mr Akeel got into a fight with another prisoner. Staff moved him to the
segregation unit.
7. On 30 December, staff moved Mr Akeel from the segregation unit back to a
standard wing. He was in a cell on his own and, due to his involvement in the fight,
staff had removed his television.
8. On the morning of 31 December, Mr Akeel had an adjudication with a prison
manager at which he pleaded guilty to the charge of fighting. The manager told him
that he could keep his television (she was unaware it had already been removed). It
was not returned to him.
9. At around 8.00pm on 31 December, during a routine check, staff found Mr Akeel
hanging from his bed rail. He had used a sheet as a ligature. Staff immediately
called a medical emergency code, cut the ligature and started cardiopulmonary
resuscitation (CPR). Healthcare staff arrived shortly afterwards. Ambulance staff
arrived at 8.14pm and took over attempts to resuscitate Mr Akeel. However, they
were unable to do so and at 8.56pm, confirmed that he had died.
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Findings
10. There was no indication that Mr Akeel was at imminent risk of suicide when he died.
However, opportunities were missed to assess his mental health when he asked for
antidepressant medication six weeks before.
11. The nurse who prescribed Mr Akeel’s antidepressant medication did not do a
mental health referral as she should have done. The clinical reviewer considered
that an assessment tool should have been used to risk assess Mr Akeel given his
history of mental health issues.
12. Mr Akeel had not collected any of his antidepressant medication by the time he
died. Staff failed to follow this up when a pharmacy technician noticed it on 16
December. They again failed to follow it up properly when it became apparent
during a medication review.
13. The clinical reviewer concluded that Mr Akeel’s mental healthcare was not
equivalent to that which he could have expected to receive in the community.
Recommendations
• The Head of Healthcare should review the procedures in place for assessing the
mental health needs of prisoners who have requested mental health support.
• The Head of Healthcare should review processes to ensure prescribed treatments
are effectively administered and issues are promptly resolved.
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The Investigation Process
14. HMPPS notified us of Mr Akeel’s death on 31 December 2022.
15. The investigator issued notices to staff and prisoners at HMP Leeds informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
16. The investigator obtained copies of relevant extracts from Mr Akeel’s prison and
medical records.
17. NHS England commissioned an independent clinical reviewer to review Mr Akeel’s
clinical care at the prison.
18. The investigator and clinical reviewer interviewed eight members of staff at Leeds.
The interviews were conducted remotely by telephone and video in March 2023.
19. We informed HM Coroner for West Yorkshire Eastern District of the investigation.
The Coroner provided us with a copy of the post-mortem report. We have sent the
Coroner a copy of this report.
20. The Ombudsman’s family liaison officer contacted Mr Akeel’s father to explain the
investigation and to ask if he had any matters he wanted us to consider. Mr Akeel’s
father asked why his son was in a cell on his own and he expressed concerns about
the number of deaths of Asian men at Leeds. We have addressed these issues in
this report. Mr Akeel’s father also raised additional concerns, via his local MP, most
of which were not directly related to Mr Akeel’s death. We have responded to these
additional concerns in separate correspondence.
21. We shared our initial report with Mr Akeel’s father. He did not raise any factual
inaccuracies.
22. We shared our initial report with the Prison Service. The Prison service requested
revised wording to one paragraph which has been amended within our report. The
action plan has been annexed to this report.
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Background Information
HMP Leeds
23. HMP Leeds is a local prison holding up to 1,100 men who are on remand, convicted
or sentenced. The prison serves the courts of West Yorkshire. Practice Plus Group
provides healthcare services, including mental health services. Midlands
Partnership Trust provides psychosocial substance misuse services.
HM Inspectorate of Prisons
24. The most recent full inspection of HMP Leeds was in June 2022. Inspectors found
that Leeds was a well-led prison where leaders and managers were visible about
the wings and supportive staff-prisoner relationships were observed. Although
levels of self-harm were falling, there had been eight self-inflicted deaths since the
last inspection in 2019 but inspectors acknowledged the work that the prison was
doing to address this major issue. Inspectors reported reduced levels of violence
since the last inspection with significantly fewer prisoners saying that they felt
unsafe.
25. Inspectors reported that mental health services were reasonably good, although
there were some gaps in non-urgent care. They reported that a 40% vacancy rate
had affected the ability to deliver services in 2022 but all vacancies had since been
filled. Pharmacy services were safe and effective but risk assessments were not
always followed adequately, including those for some prisons who had daily in-
possession medication. Inspectors found that prisoners not attending for medication
were usually followed up robustly.
26. Inspectors reported that the availability of key work sessions was better than at
other local prisons, with 69% of prisoners saying they had a key worker and 61%
saying the sessions were helpful. Inspectors found that most key work sessions
were delivered by the same person.
27. The prison had a clear commitment to equality and diversity with an appointed
equality manager and an equality action plan. The Governor chaired an Equality
Assurance meeting every two months but inspectors found little evidence that
analysis of data provided led to any action. There had been 61 discrimination
incidents in a six-month period to which the prison provided an adequate response,
although inspectors noted investigation into the incidents was limited.
Independent Monitoring Board
28. 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 December 2020, the IMB
reported concerns about the standard of accommodation and pressures on mental
health services due to severely mentally ill prisoners arriving from the courts. They
were also concerned about the impact of staffing levels on the delivery of key work
sessions.
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Previous deaths at HMP Leeds
29. Mr Akeel was the 31st prisoner to die at Leeds since December 2019. Of the
previous deaths, 18 were due to natural causes, ten were self-inflicted, one was
drug related, and one is awaiting classification. There have been seven deaths
since of which four were self-inflicted and three were due to natural causes. We
found no evidence that there was a disproportionate number of Asian men taking
their own lives at Leeds.
30. In a previous investigation at Leeds, we found that the prisoner’s mental health care
was not equivalent to that which he could have expected to receive in the
community. We were told that changes had been made to the mental health referral
process.
31. We have previously made recommendations about the operation of the key work
scheme at Leeds. The prison told us that they had changed the allocation process
so that it was based on location rather than using an auto allocation tool, with the
aim that key workers would be more accessible and could have ad hoc
conversations outside the allocated key worker time.
Key work scheme
32. The key work scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners and helping people
settle into life in prison. Details of how the system should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available for
an average of 45 minutes per prisoner per week for delivery of the key worker
role, which includes individual time with each prisoner.
• Within this allocated time, key workers can vary individual sessions in order to
provide a responsive service, reflecting individual need and stage in the
sentence. A key work session can consist of a structured interview or a range of
activities such as attending an ACCT review, meeting family during a visit or
engaging in conversation during an activity to build relationships.
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Key Events
33. Mr Akash Akeel was remanded into custody at HMP Leeds on 27 October 2022,
charged with theft, stalking and harassment. The alleged offences were against his
ex-partner who had a restraining order in place against him. Mr Akeel had been in
prison many times before.
34. Reception staff noted a history of suicide attempts and self-harm and discussed this
with Mr Akeel. He said that he had not tried to harm himself for a long time and had
no current thoughts of suicide or self-harm. (Mr Akeel’s records noted that he had
attempted to hang himself in prison in 2019.) Mr Akeel had a history of depression
and anxiety for which he had previously taken medication (mirtazapine) but was not
currently taking it. He had no other mental health or substance misuse issues and
staff had no concerns about him.
35. Mr Akeel told staff that he was racist and homophobic so could only share a cell
with a heterosexual person of the same ethnicity. His cell sharing risk assessment
(CSRA) was therefore assessed as high risk. After his induction, he was moved to a
suitable shared cell on D Wing.
36. On 28 October, Mr Akeel had his first key work session with Officer A. Officer A
noted that Mr Akeel was keen to speak to his family and did not want to engage
with her.
37. On 30 October, Mr Akeel had his second key work session with Officer B. Mr Akeel
asked to speak to a Listener (prisoners trained by Samaritans to provide emotional
support to fellow prisoners) so Officer B discussed this with a male colleague who
subsequently went to speak to Mr Akeel. He told Officer B that Mr Akeel was feeling
better after they had spoken and that he had been embarrassed to talk to her
because his offence was related to domestic violence. Officer B noted that she
thought Mr Akeel would benefit from having a male key worker.
38. On 31 October, Mr Akeel had his third key work session with Officer C, another
female officer. He asked if he could move to another wing with his current cellmate
and she agreed to request this on his behalf. Mr Akeel moved to C Wing on 3
November.
39. On 18 November, Mr Akeel requested to restart mirtazapine medication for
depression (which he had not been prescribed since 2021). Healthcare staff noted
that his request would be reviewed by a doctor.
40. On 22 November, Mr Akeel had his fourth key work session with Officer D, another
female officer. He told Officer D that he had no phone credit and needed to phone
his family as his grandfather was unwell. She was unable to help him but said she
would ask one of the wing supervising officers (SO). An SO later spoke to Mr Akeel
and said she was unable to help him with emergency phone credit. She described
him as ungrateful and displaying a poor attitude. A prison manager later approved
emergency phone credit for Mr Akeel to contact his family.
41. On 29 November, Mr Akeel had his fifth key work session with Officer D. She noted
that he did not want to engage with her and described him as ungrateful.
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42. On 2 December, an Advanced Nurse Practitioner (ANP) carried out a telephone
triage with Mr Akeel. He told her that he was having trouble sleeping, had no
appetite and no concentration. He said that he was not having any visits but he had
been in touch with his family by telephone. He was worried about his grandfather
who had cancer. Mr Akeel said he had no thoughts of suicide or self-harm but the
ANP did not use any assessment tools to establish his level of depression. She
agreed to restart mirtazapine and prescribed a dose of 15mg for one week and then
30mg. She said that she expected Mr Akeel to have his medication in possession
for seven days at a time. She planned that he would be reviewed again in four to six
weeks.
43. On 16 December, a pharmacy technician noticed that Mr Akeel had not been
collecting his mirtazapine medication. She was due to issue a 30mg dose and
consulted a doctor to ask if she should do so, as he had not yet taken the lower
15mg dose. The doctor agreed Mr Akeel could start taking the 30mg dose. No
further action was taken to find out why Mr Akeel had not been collecting his
medication.
44. On 26 December, Mr Akeel had his sixth key work session with Officer E, another
female officer. She noted that he had just woken up and did not want to engage
with her. He said he was keen for the wing to return to normal regime the next day
(after Christmas).
45. On the morning of 29 December, Mr Akeel had a telephone medication review with
a nurse. He told her that staff were not unlocking him so that he could get his
medication. The nurse noted in his medical record that he said he was still low in
mood but did not have any thoughts of suicide or self-harm. The nurse told the
investigator and clinical reviewer that she was unable to assess how the medication
was working for him so she simply highlighted to the pharmacy department that
staff needed to ensure that Mr Akeel was unlocked to collect his medication. She
said she did not check what, if any, medication he had received since it was
prescribed on 2 December (in fact he had not collected any medication). She
expected that he would have a further review in two weeks.
46. On the evening of 29 December, Mr Akeel got into a fight with another prisoner.
Staff moved him to the segregation unit under restraint and noted that he was
compliant throughout. A nurse assessed him in the segregation unit. She noted he
had received a bang to his head during the fight so she gave him head injury
advice. He declined an ice pack for his injury. The nurse noted that he had no
mental health or substance misuse concerns and she considered he was fit for
segregation. She said she had reviewed Mr Akeel’s medical notes before she
assessed him but she had not noticed the entry which stated he had not been
receiving his mirtazapine. She noted that he would be assessed the following
morning by a general nurse or a mental health nurse (but this did not happen).
Events of 30 and 31 December
47. On 30 December, Mr Akeel was due to be checked by healthcare staff in the
segregation unit. A healthcare assistant made a note in his medical record that she
tried to see him but he refused. It is not clear why she was trying to see him but, as
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a healthcare assistant, she would not have been the qualified nurse responsible for
assessing him in the segregation unit.
48. Later that day, staff moved Mr Akeel from the segregation unit to a different cell on
E Wing. Due to Mr Akeel’s involvement in the fight, a custodial manager (CM)
reviewed his incentives and earned privileges (IEP) status and reduced it to basic
level. The CM also removed Mr Akeel’s television for seven days and scheduled a
review of his IEP status for 5 January. Due to his high risk CSRA, Mr Akeel was
placed in a cell on his own. Prior to going into the segregation unit he had been in a
shared cell.
49. Around 10.00am on 31 December, a prison manager chaired a disciplinary hearing
for the charge of fighting. Mr Akeel told her that the fight occurred after he went to
the other prisoner’s cell to return some music CDs and they argued. He pleaded
guilty to the charge. The manager noted a negative conduct report on C Wing,
stating that he had difficulty following instruction and was often rude and
disrespectful to staff. She said Mr Akeel agreed that a move to a different wing
would be beneficial to him and she noted he had already moved to E Wing where
he could have a fresh start.
50. The manager told Mr Akeel that she would impose a minimum punishment and he
could keep his television. However, Ms Littlewood said she did not know that the
CM had already removed Mr Akeel’s television under the IEP process. As the
adjudication and IEP processes are different, she could not have reversed the CM’s
decision in any case. Mr Akeel would not have been aware of this difference. The
manager said that she had no concerns about Mr Akeel and, when he left the room,
he was smiling and wished her a happy new year.
51. At around 4.50pm, Mr Akeel pressed his cell bell and an officer responded. Mr
Akeel wanted to know when he could have his television as the manager had told
him during his adjudication that he could keep it. The officer said he told Mr Akeel
he would need to check with managers and get confirmation of this before his
television could be returned. He said Mr Akeel seemed satisfied with the response.
52. In-cell telephone records show that Mr Akeel used his phone at 7.27pm. The
investigator listened to Mr Akeel’s calls. (All calls made by prisoners using the
prison telephone system are recorded and staff listen to a selection either based on
intelligence or suspicion, or at random. There is no evidence that staff had listened
to any of Mr Akeel’s calls before his death.) The call at 7.27pm lasted only a few
seconds. Mr Akeel said ‘I’ve only gone and done it’ and sounded distressed, but
would not explain what he meant. His partner asked what he had done and said she
would call the prison. Mr Akeel then hung up. There is no record that Mr Akeel’s
partner did call the prison that evening.
53. Around 8.00pm on 31 December, an officer was carrying out the evening routine
check when she came to Mr Akeel’s cell and found that the observation panel was
covered with tissue. She knocked on the door and tried to get a response from him
but he did not respond. She alerted an operational support grade (OSG), and he
came to the cell to try to get a response from Mr Akeel. At around 8.05pm, after
failing to get a response, the officer called a code blue (a medical emergency code
which tells the control room that a prisoner is unresponsive or not breathing and an
ambulance is required immediately). The officer and the OSG tried to get into the
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cell but it was blocked by a privacy board which delayed their entry. Once in the
cell, they found Mr Akeel suspended from the top bunk. He had used a sheet as a
ligature. Staff cut the ligature and started cardiopulmonary resuscitation (CPR)
while waiting for healthcare staff to arrive.
54. Healthcare staff arrived around 8.08pm and took over CPR. Ambulance staff arrived
at 8.14pm and continued attempts to resuscitate Mr Akeel. However, they were
unable to do so and at 8.56pm, confirmed that he had died.
Information received after Mr Akeel’s death
55. Mr Akeel had been making telephone contact with his partner, despite there being a
no contact order in place. He managed to do this by providing the prison with a
different name and number for his partner. In the days leading up to his death, he
told his partner that he was going to take his life but she dismissed this. He told her
he was unhappy about the outcome of his disciplinary hearing and being moved to
a different wing with no television.
Contact with Mr Akeel’s family
56. Shortly after midnight on 1 January 2023, the prison’s family liaison officer and the
prison’s imam visited the home address of Mr Akeel’s mother and brother to break
the news of his death. The prison contributed to the funeral expenses in line with
national instructions.
Support for prisoners and staff
57. 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.
58. The prison posted notices informing other prisoners of Mr Akeel’s death and offered
support. Staff reviewed all prisoners assessed as at risk of suicide or self-harm in
case they had been adversely affected by Mr Akeel’s death.
Post-mortem report
59. The post-mortem report concluded that Mr Akeel died from hanging. Toxicology
results are not yet available.
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Findings
Assessment and management of Mr Akeel’s risk
60. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others or from others (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 manage prisoners identified as at risk under
ACCT procedures.
61. Mr Akeel had been in prison many times before and had last been released from
prison in November 2021. He had not been subject to ACCT monitoring since May
2019 and there was no evidence that he had self-harmed or attempted suicide
since that time. Staff identified that he had no substance misuse issues but he had
a history of depression and anxiety for which he had previously taken medication.
Although staff did not make a mental health referral at that time, they ensured that
Mr Akeel was aware of how to raise any mental health concerns, which he
subsequently did on 18 November. We consider that staff assessed Mr Akeel’s risk
appropriately on reception and reasonably concluded that he did not require the
support of ACCT monitoring at that time. We found no evidence that Mr Akeel
required the support of ACCT monitoring at any other time. Although Mr Akeel
expressed suicidal thoughts to his partner on the telephone in the days before his
death, staff would not have been aware of this as there was no reason for them to
monitor his calls and his partner did not inform the prison.
Clinical care
62. When the ANP carried out a telephone triage assessment with Mr Akeel on 2
December, she agreed to restart mirtazapine but she did not make a referral to the
mental health team. She told the investigator and clinical reviewer that she was not
a mental health nurse but she considered there was no need for a mental health
referral. However, the Head of Healthcare said that she would have expected a
mental health referral to be made in circumstances where medication for anxiety
and depression was considered necessary. The clinical reviewer also considered
that a mental health referral should have been made given that Mr Akeel had a
history of mental health issues.
63. The clinical reviewer also noted that no consideration was given to undertaking any
standardised assessment tools or assessments of risk, such as the Correctional
Mental Health Screen for men (a tool designed to assist in the early detection of
psychiatric illness during the prison intake process).
64. Mr Akeel never collected his antidepressant medication before he died. It is unclear
whether the ANP, the prescriber, explained to him what he needed to do to collect
his medication. This was not followed up when a pharmacy technician noted two
weeks later that Mr Akeel had not collected his medication. It was again not
properly followed up on 29 December, when it was identified during a medication
review that Mr Akeel had not collected his medication. Although the nurse told the
pharmacy, no further action was taken.
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65. The clinical reviewer concluded that Mr Akeel’s mental health care was not
equivalent to that which he could have expected to receive in the community. We
make the following recommendations:
The Head of Healthcare should review the procedures in place for assessing
the mental health needs of prisoners who have requested mental health
support.
The Head of Healthcare should review processes to ensure prescribed
treatments are effectively administered and issues are promptly resolved.
Key work
66. Within his first four days at Leeds, because he moved between different units, Mr
Akeel had three key work sessions with three different female officers, all
introducing themselves to him as his key worker. We consider the timing of these
sessions at almost daily intervals was unnecessary and would have been confusing
for Mr Akeel. After he moved to C Wing, Mr Akeel had a further three sessions with
two different female officers.
67. Although Officer B noted at the second key work session that she thought Mr Akeel
would benefit from having a male key worker, he continued to have female key
workers, who reported that Mr Akeel was not willing to engage with them and that
he had a poor attitude.
68. Since Mr Akeel’s death, the prison has undertaken work to address shortcomings in
the provision of key work. The Acting Head of Recovery set out the current
activities:
• The formulation of guidance to staff on responding to prisoner non-engagement
with key work.
• Work on the induction unit to improve the provision of key work.
• Rolling out a priority group scheme to ensure that prisoners with specific risk
factors, such as high risk cell sharing, are prioritised for key work.
• Trialling a new quality assurance process to provide robust feedback to key
workers.
• Monitoring key work compliance (53% of key work sessions were delivered in
June 2023, compared with 20% in December 2022.)
69. We are pleased to note the focus on improving key work at Leeds and, as a result,
make no recommendation.
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Governor to note
Segregation
70. While we consider that it would not have changed the decision that Mr Akeel was fit
for segregation, we note that the nurse who carried out the segregation health
screen did not notice that Mr Akeel had not been taking his antidepressant
medication. She should have known this from a review of the medical records.
Removal of television
71. When Mr Akeel was involved in a fight on 29 December, staff automatically
downgraded him to basic regime in accordance with the prison’s violence reduction
policy and removed his television.
72. The manager did not know that this had happened when she told him that she
would not remove his television under the adjudication process. Clearly this was
confusing for Mr Akeel. Access to a television, particularly when the prisoner is in a
single cell, on New Year’s Eve and at times when the regime is limited (such as
over public holidays) can be a distraction and therefore a protective factor against
suicide. However, given Mr Akeel had not been identified as vulnerable or at risk,
and given that removal of his television was appropriate under the IEP process, we
consider staff actions were reasonable.
Autism and learning disability
73. We found some historic evidence in Mr Akeel’s medical notes that he may have had
autism spectrum disorder and possibly other learning disabilities, although he had
no formal diagnosis. This could have impacted on Mr Akeel’s ability to engage with
staff in the typical way they might expect. Staff described him as ungrateful,
unwilling to engage, and with a poor attitude. It is possible that had they been aware
of his history of possible autism and learning disabilities they might have had a
better understanding of his behaviour and communication needs.
Inquest
74. The inquest, held from 27 to 29 January 2025, concluded that Mr Akeel died by
suicide.
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