Akhtar Hussain

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Akhtar Hussain,
a prisoner at HMP Manchester,
on 8 July 2021
A report by the Prisons and Probation Ombudsman
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© Crown copyright, 2024
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Akhtar Hussain died in hospital from pneumonia due to hypoxic/ischaemic brain
damage on 8 July 2021, after he was found hanging in his cell at HMP Manchester three
days earlier. He was 32 years old. I offer my condolences to his family and friends.
Mr Hussain was segregated for three days before he was found hanging. I am concerned
that his segregation was managed poorly. His health was not properly assessed at the
start of the segregation. There is little evidence that staff interacted with him as required,
he did not have access to any of his property or distraction materials, and his cell bell went
unanswered shortly before he was found hanging.
In the time before he was segregated, Mr Hussain was subject to three separate uses of
force. I am concerned that force was used too quickly and not as a last resort, with not
enough thought given to alternative solutions. I am particularly troubled that Mr Hussain
was segregated, seemingly unlawfully, for a two hour “period of reflection” after the first
use of force.
Mr Hussain was a man with several long-standing risk factors for suicide and self-harm,
including a diagnosis of schizophrenia and a history of self-harm. The events of the last
days of his life exposed Mr Hussain to significant new risk factors and potential triggers. I
am concerned that no one identified that he might be at risk or considered starting suicide
and self-harm prevention procedures.
As in previous investigations at Manchester, I found that it took too long to summon
emergency medical assistance when Mr Hussain was found hanging.
I am concerned about the number of poor decisions and actions by staff at Manchester
and the impact that these had on Mr Hussain. This is not the first case in recent years in
which we have made critical findings at Manchester, and I note that HMIP identified poor
outcomes for prisoners in several key areas during their most recent inspection. It is
important that the Governor recognises and seeks to address any underlying cultural or
staffing issues at the prison.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 5
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 9
Findings ......................................................................................................................... 21
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Summary
Events
1. On 8 April 2020, Mr Akhtar Hussain was remanded to HMP Forest Bank, charged
with robbery and assault. Mr Hussain had a history of mental ill-health and had
been diagnosed with schizophrenia. In February 2021, prison staff monitored him
under suicide and self-harm prevention procedures (known as ACCT) for around
four weeks. On 19 May, prison staff segregated Mr Hussain after he assaulted an
officer.
2. On 21 June, Mr Hussain was transferred to the segregation unit at HMP
Manchester. On 24 June, he moved to the prison’s reverse cohort unit for a period
of COVID-19 isolation.
3. On 1 July, staff used planned force to restrain Mr Hussain after he refused to move
wings. He was taken to the prison’s segregation unit for around two hours before
returning to a normal wing.
4. On 2 July, Mr Hussain blocked his cell door observation panel and barricaded his
cell door. Staff used planned force to enter the cell and restrained him before
taking him to the segregation unit. A further unplanned use of force was used soon
afterwards to take Mr Hussain from a holding cell. The following day, Mr Hussain
was found guilty of disobeying a lawful order and was given a punishment of seven
days’ cellular confinement.
5. At around 12.54pm on 5 July, prison staff found Mr Hussain in his cell, with a
ligature tied around his neck. Nurses and officers tried to resuscitate him, and
paramedics later assisted. Paramedics took Mr Hussain to hospital, where he died
on 8 July.
Findings
Assessment of Hr Hussain’s risk of suicide and self-harm
6. Mr Hussain had several long-standing risk factors for suicide and self-harm. In the
days before his death, he was exposed to significant new risk factors. There is no
evidence that prison or healthcare staff considered whether his risk had increased
or considered starting ACCT procedures.
Use of force
7. Mr Hussain was subject to three uses of force in the days before his death. We
have concerns about each of these. Staff did not communicate effectively and did
not take enough time to consider alternative options to force. We are not satisfied
that planned use of force was used as a last resort, as national guidelines instruct.
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Segregation
8. Mr Hussain was inappropriately segregated for two hours on 1 July for a “period of
reflection”. Prison staff did not complete any segregation unit paperwork and there
is no record that he was held under a specific prison rule.
9. When he was formally segregated the next day, we are concerned that there was
little evidence that staff tried to engage with Mr Hussain. He was segregated
without any of his property, and he did not access the regime at any time.
Segregation health screens, an important tool in determining whether a prisoner is
well enough to be segregated, were completed without consideration of Mr
Hussain’s medical history.
10. On the day that he hanged himself, Mr Hussain pressed his cell bell a number of
times. On several occasions, staff reset the bell without speaking to Mr Hussain.
An officer completed a roll check shortly before Mr Hussain was found without
looking into his cell.
Disciplinary hearing
11. We are concerned that Mr Hussain’s punishment of cellular confinement was
excessive for the circumstances of his offence. Although he said at his disciplinary
hearing that he wanted to speak to the mental health team, no one referred him to
them.
Emergency response
12. When staff found Mr Hussain hanged, there was a delay of around three minutes
before anyone radioed a medical emergency code. We have highlighted this issue
in previous investigations at Manchester.
Clinical care
13. The clinical reviewer found that Mr Hussain’s medication compliance was not
appropriately monitored at Buckley Hall, and he did not have the detailed care plan
that his diagnosis merited. It is concerning that Mr Hussain’s mental health was not
fully assessed at Manchester, even though he had been segregated and had asked
to be seen.
Recommendations
• The Governor and Head of Healthcare should ensure that all staff have a clear
understanding of their responsibilities to identify prisoners at risk of suicide
and self-harm, including that:
• segregation unit staff consider and record all the known risk factors
and triggers of a segregated prisoner, including environmental factors;
• monitor changes in the prisoner’s behaviour or circumstances when
determining the risk of suicide and self-harm; and
• start ACCT procedures when indicated.
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• The Governor should ensure that staff use force in line with national
guidelines, including that:
• planned use of force is only used when it is reasonable and necessary,
and only as a last resort when all other means of de-escalating the
incident have been repeatedly tried and failed;
• all staff wear and switch on body-worn video cameras during planned
use of force interventions;
• staff remain professional and do not use inappropriate language; and
• CM A and SO B receive additional advice and guidance on the lawful
use of force and de-escalation techniques.
• The Governor should ensure that staff manage prisoners held in segregation
in line with national guidelines, including that:
• segregation is used appropriately, in line with Prison Rules, and with
the authority of an operational manager;
• each prisoner is assigned a designated officer responsible for their
welfare;
• staff engage in purposeful dialogue with each prisoner at least three
times a day, and that this is recorded in the prisoner’s history sheet;
and
• prisoners are able to access all aspects of the regime every day and
have access to basic personal property and distraction materials.
• The Governor and Head of Healthcare should ensure that healthcare
professionals completing segregation unit health screens have access to the
prisoner’s medical history and are always given the opportunity to speak to
the prisoner.
• The Governor should commission a disciplinary investigation into the actions
of segregation unit staff on the morning of 5 July 2021.
• The Governor should ensure that segregation unit staff complete their duties
satisfactorily and in line with local and national requirements, including that:
• staff observe prisoners subject to cellular confinement at least once
every hour;
• staff observe prisoners at roll checks and take appropriate action if
they have concerns for a prisoner’s welfare; and
• staff answer cell bells promptly, take reasonable steps to answer the
query and take appropriate action if they have concerns for the
prisoner’s welfare.
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• The Governor should ensure that managers conducting disciplinary hearings
impose punishments in line with local tariff guidelines and take into
consideration mitigating circumstances when considering awarding periods
of cellular confinement.
• The Governor should ensure that managers imposing punishments of cellular
confinement fully consider the likely impact on the health and welfare of the
prisoner, including referring the prisoner to the mental health team, where
appropriate.
• The Prison Group Director for the Long Term and High Security Estate should
take steps to satisfy himself that all staff at HMP Manchester understand their
responsibilities during medical emergencies, including calling an immediate
emergency code when there is a threat to life.
• The Head of Healthcare at HMP Buckley Hall should ensure that all prisoners
identified as having a severe and enduring mental illness have
comprehensive care plans.
• The Heads of Healthcare at HMP Manchester and HMP Buckley Hall should
ensure that:
• liaison between prisons takes place when prisoners with a history of
severe and enduring mental illness are transferred to Manchester and
that the outcome is fully documented in the prisoner’s medical records;
• all prisoners identified as requiring an urgent mental health
assessment are assessed promptly and within 48 hours; and
• all prisoners with a significant and current mental illness are discussed
at the weekly mental health multidisciplinary meeting to ensure
continuity of care.
• The Governor and Head of Healthcare at HMP Manchester should ensure that
a copy of this report is shared with all staff named in this report and that a
senior manager discusses the Ombudsman’s findings with them.
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The Investigation Process
14. The investigator issued notices to staff and prisoners at HMP Manchester informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Hussain’s prison and
medical records.
16. NHS England commissioned a clinical reviewer to review Mr Hussain’s clinical care
at the prison.
17. The investigator interviewed twenty-seven members of staff at Manchester, some
jointly with the clinical reviewer. Some of the interviews were conducted remotely.
18. We informed HM Coroner for Manchester City of the investigation. He provided us
with a copy of the post-mortem and toxicology report. We have sent the Coroner a
copy of this report.
19. We contacted Mr Hussain’s next of kin to explain the investigation and to ask if they
had any matters they wanted us to consider. They asked a number of questions
including:\
• Had Mr Hussain been assessed by the prison’s mental health team?
• What medication was Mr Hussain prescribed, when was it prescribed and
why he did not take it?
• Was Mr Hussain being monitored under suicide and self-harm prevention
procedures or had he spoken to prison Listeners?
• Why did Mr Hussain move to Manchester’s segregation unit and what
safeguarding procedures were in place? Did Mr Hussain’s behaviour
deteriorate in the days leading to his death and, if so, what action was taken?
• Did Mr Hussain have access to or make telephone calls from prison?
• Did Mr Hussain leave a note after his death?
• Why were prison officers present at the time of Mr Hussain’s death in
hospital?
We have tried to address these questions in this report. Mr Hussain’s family also
asked several questions about the care he received while in hospital, which we
have been unable to review as it falls beyond the remit of our investigation.
20. Mr Hussain’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Manchester
21. HMP Manchester is a Category B raining prison, with a small Category A function.
It holds up to 744 prisoners spread across nine residential units, a segregation and
specialist intervention unit and a healthcare centre. Greater Manchester Mental
Health NHS Foundation Trust provides 24-hour healthcare services.
HM Inspectorate of Prisons
22. HMIP’s most recent inspection of Manchester was carried out in September 2021.
Inspectors reported that Manchester had made improvements since the last
inspection, including an improvement in staff-prisoner relations. However,
inspectors reported that there was much to be done about the lack of engagement
and poor attitude of some officers. Inspectors observed that some officers
remained distant and disengaged but they also saw some positive relationships
between staff and prisoners. Inspectors reported on improvements in the
management of the segregation unit, including that prisoners on the unit could use
the phones and showers daily.
23. Inspectors found that although the use of force used was less than on previous
inspections, de-escalation attempts were inadequate in many of the incidents that
they reviewed. They reported that the governance and oversight of the use of force
was also weak and that there was a lack of focus on learning lessons following
incidents involving force. Inspectors also reported on the reluctance of officers to
switch on body-worn cameras routinely during incidents. They reported that the use
of special accommodation was not always justified, and oversight of its use was
weak.
24. Inspectors reported that prisoners’ trust in staff was being negatively affected by
weaknesses in the management of property, and prisoners lacked confidence in the
management of their personal property. Inspectors cited how some prisoners had
moved to a different cell and their property had been misplaced during the move,
which caused frustration and mistrust.
25. Inspectors reported that although death in custody action plans were raised in
response to PPO recommendations, there was little evidence to show that
improvements were embedded in practice.
Independent Monitoring Board
26. 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 ending February 2021, the IMB
reported that the segregation unit operated a well-managed regime. The IMB
reported that the use of body-worn cameras was not being used during incidents
involving the use of force. They also highlighted their continuing concerns about
the security of prisoner property when prisoners moved internally between wings or
to the segregation unit.
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Previous deaths at HMP Manchester
27. Mr Hussain was the fourth prisoner to take his life at Manchester since January
2019. We found no significant similarities between our findings about Mr Hussain’s
death and those in our previous investigations.
28. There were also nine natural cause deaths and four drug-related deaths at
Manchester during this period. Our reports into three of those deaths found delays
in calling medical emergency response codes.
29. A further three deaths have occurred at Manchester since Mr Hussain’s death,
including one apparent self-inflicted death.
Assessment, Care in Custody and Teamwork (ACCT)
30. 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. As part
of the process a Care Plan (a plan of care, support and intervention) should be put
in place. The ACCT plan should not be closed until all the actions of the risk
reduction plan have been completed. After closure, a follow-up interview should
take place within seven days.
Segregation units
31. Segregation units are used to keep prisoners apart from other prisoners. This can
be because they feel vulnerable, under threat from other prisoners or if they behave
in a way that prison staff think would put people in danger or cause problems for the
rest of the prison. They also hold prisoners serving periods of cellular confinement
after disciplinary hearings. Prisoners who are segregated are assessed by a
member of healthcare staff. A senior operational manager must then be satisfied
that the prisoner is fit for segregation. The unit at Manchester can hold fourteen
prisoners but in the months before Mr Hussain was segregated, the unit held an
average of around eight prisoners.
32. Segregation unit regimes are usually restricted, and prisoners are permitted to
leave their cells only to collect meals, shower, make phone calls and to exercise
outside. (At the time of Mr Hussain’s death, all prisoners could exercise daily but
those serving periods of cellular confinement were only able to take showers and
make telephone calls on alternate days.)
33. Staff explain to prisoners when they arrive in Manchester’s segregation unit that
they should be dressed and ready to submit their daily application to access the
unit’s regime by 8.00am on weekdays and 9.00am on weekends. If prisoners are
not out of bed or refuse to interact with staff, they forfeit the chance to make
applications or to access the regime for that day.
Use of force
34. Prison Service Order (PSO) 1600 on the use of force in prisons says that the use of
force without consent is unlawful unless justified, and that the use of force in prisons
will be justified, and therefore lawful, only if it is reasonable in the circumstances, is
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necessary, no more force than necessary is used, and it is proportionate to the
seriousness of the circumstances.
35. PSO 1600 also says that staff should always try to prevent a conflict whenever
possible and defuse the situation through communication and de-escalation skills
before using force, and that force “must only be used as a last resort after all other
means of de-escalating the incident have been repeatedly tried and failed”.
36. PSO 1600 is clear that the refusal to comply with an order alone is insufficient
grounds to initiate force. It states that force should only be used when it is
necessary to prevent harm to life, limb, property or the good order of the
establishment. The PSO goes on to say that it is clearly easier to justify force as
necessary if there is a risk to life or limb.
37. PSO 1600 gives examples of when a planned use of force would be reasonable or
necessary. It states that the refusal of a lawful order in itself (where there is no
immediate threat to life, limb, property or good order) would not usually be sufficient
to justify the use of force. However, subsequent refusals may eventually lead to a
planned intervention once all other alternatives, such as persuasion and de-
escalation, have been tried and failed.
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Key Events
38. Mr Hussain had served previous custodial sentences. He had a history of self-harm
and had been monitored under ACCT procedures. He also had a history of illicit
drug use and of violent and aggressive behaviour and had been managed in prison
segregation units.
39. Mr Hussain had been involved with mental health services in the community and
had been in prison since 2013. In 2015, he was diagnosed with clinical depression
and in 2016, he was diagnosed with schizophrenia. Mr Hussain periodically did not
comply with treatment, which meant he became increasingly paranoid and
complained of hallucinations. In May 2017, he was referred to a medium secure
psychiatric hospital for assessment but was not accepted as he appeared to
respond to treatment when he took his medication. Mr Hussain was released from
prison in July 2017, but returned in March 2018 before he was re-released in April
2019.
40. On 8 April 2020, Mr Hussain was remanded to HMP Forest Bank, charged with
robbery and assault. He was prescribed antipsychotic medication and he engaged
well with mental health services. However, he continued to have some periods of
non-compliance with his medication and episodes of violence. In June 2020, a
prison psychiatrist noted that Mr Hussain was sensitive to missed doses of his
antipsychotic medication and as a result, he could quickly develop psychotic
symptoms. For most of this period, Mr Hussain complied with his medication.
41. On 16 October, Mr Hussain was sentenced to six years in prison.
HMP Buckley Hall
42. On 7 December, Mr Hussain was transferred to HMP Buckley Hall.
43. On 4 February 2021, Mr Hussain was found under the influence of an illicit
substance. He threatened staff and was moved to the prison’s segregation unit.
Staff started ACCT procedures after Mr Hussain expressed thoughts of suicide due
to issues about accessing his vapes, canteen and medication. While segregated,
Mr Hussain displayed “bizarre” behaviour and threatened to refuse food when told
that he would remain on the unit for ten days due to COVID-19 isolation
procedures.
44. On 16 February, a prison psychiatrist reviewed Mr Hussain. She told us that he
displayed no overt psychotic symptoms. She stopped Mr Hussain’s antipsychotic
medication as she considered that his risks appeared to be adequately managed by
the prison’s mental health team. She said that she believed some of Mr Hussain’s
issues were anxiety-related and recommended he discuss options for managing his
anxiety with the mental health team.
45. On 21 February, Mr Hussain described an increase in psychotic symptoms to a
mental health nurse, but said that he was managing them. At an ACCT case review
the next day, he said that voices he had previously heard had stopped. Mr Hussain
said that he was remorseful of his previous actions and wanted a fresh start. Prison
staff told Mr Hussain that he would be transferred if he acted inappropriately again.
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46. At an ACCT case review on 3 March, Mr Hussain presented with some signs of
paranoia. A mental health nurse tried to persuade Mr Hussain to restart his
antipsychotic medication, but he refused.
47. On 5 March, Mr Hussain told the mental health nurse that he believed his mental
state was deteriorating. The nurse noted that he was increasingly paranoid and
that he believed he was the victim of a conspiracy about missing property. The
nurse suggested that Mr Hussain restart his antipsychotic medication, which he
agreed to do. On 9 March, he told the nurse that he still heard voices and agreed to
discuss a change of medication with the psychiatrist.
48. At an ACCT case review on 10 March, Mr Hussain said that he had vivid dreams
and voices which told him that if he killed himself, he could “remain in the dream
world”.
49. On 16 March, the psychiatrist reviewed Mr Hussain. She told us that she did not
see any evidence of overt psychotic symptoms, that Mr Hussain did not appear
depressed and that there was no evidence of a deterioration in his mental health
after he had stopped taking his medication. She planned to review him again in
three months.
50. On 18 March, at an ACCT case review, Mr Hussain described how his dreams had
“turned scary” but denied thoughts of self-harm. At a review on 24 March, a nurse
noted that there was no evidence of psychotic symptoms, and that Mr Hussain was
happy that his medication was available. Prison staff agreed to close the ACCT
procedures.
51. Over the following month, Mr Husain appeared to settle at Buckley Hall. Staff noted
that he had stopped taking illicit substances, exercised regularly, mixed with other
prisoners and behaved appropriately.
52. On 19 May, Mr Hussain seriously assaulted an officer. Prison staff started
disciplinary procedures, which were later referred to an independent adjudicator but
never heard. Staff moved Mr Hussain to the segregation unit, where he refused to
eat, which he said was because he was upset at being segregated. Mr Hussain
said that he had no intention to end his life and staff considered that he did not need
to be monitored under ACCT procedures.
53. On 24 May, staff noted that Mr Hussain continued to refuse food or let healthcare
staff take clinical observations. He also refused to engage with staff or accept any
of the prison regime offered to him. Mr Hussain started eating again on 28 May,
when it was noted that he appeared to be giving staff “the silent treatment”.
54. On 1 June, a mental health nurse noted that Mr Hussain was angry because he
said he had been told that he would be transferred, that he felt he should be
admitted to hospital and that he was possessed by “jinns”. Mr Hussain said that he
had not taken illicit substances and the nurse recorded that he presented with no
symptoms of schizophrenia. (Mr Hussain had no further contact with mental health
staff at Buckley Hall.)
55. On 6 June, prison staff recorded that Mr Hussain displayed “bizarre” behaviour and
accused staff of stealing his money. They used force to return him to his cell on 6
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and 11 June. Over the following days, staff again noted that he had displayed
“bizarre” behaviour. They referred him to the mental health team.
56. On 16 June, and over the following days, staff noted that Mr Hussain made full use
of the prison regime and raised no concerns. During the day, it was confirmed that
he was to be re-categorised to a Category B prisoner due to his assault of the
officer.
57. On 21 June, Mr Hussain was transferred to the segregation unit at HMP
Manchester. A mental health nurse assessed him before the move and confirmed
that he was medically fit to be transferred. She recorded that Mr Hussain had
refused to take his antipsychotic medication for several weeks and would need to
be reviewed when he arrived at Manchester.
HMP Manchester
58. A nurse completed a reception health screen when Mr Hussain arrived at
Manchester. She noted that he appeared in good spirits. Mr Hussain told her
about his diagnosis of schizophrenia and said that he was not taking his medication
as he wanted to try and manage without it. She recorded that Mr Hussain had
recently been monitored under ACCT procedures but said that he had no thoughts
of suicide or self-harm. She referred him to the prison’s mental health team.
59. A mental health nurse also reviewed Mr Hussain as part of the reception health
screen and noted that he was reluctant to answer questions. He confirmed his
diagnosis of schizophrenia, and that Mr Hussain was not taking any medication. He
recorded that Mr Hussain required an urgent mental health assessment.
60. An officer interviewed Mr Hussain as part of the first night process. He noted that
Mr Hussain had previously been monitored under ACCT procedures, denied
thoughts of self-harm and raised no issues. Mr Hussain was offered the chance to
make a telephone call (which he did not do) before he was taken to the segregation
unit. No one assessed his fitness for segregation.
61. On 22 June, an officer asked Mr Hussain if he wanted to make any applications to
access the segregation unit’s regime. The officer noted that Mr Hussain was in his
bed, refused to sit up and said that he was “not interested”. As Mr Hussain had
only just arrived on the unit, the officer explained what was expected of him, the
regime available to him and how applications were made.
62. A nurse completed Mr Hussain’s secondary healthcare screen. She identified no
additional issues and noted that he did not want to discuss his schizophrenia. Mr
Hussain declined support from the substance misuse team. A medical technical
officer recorded that Mr Hussain’s medication should be reviewed by a prison GP.
63. On 23 June, Mr Hussain declined to take part in any of the segregation unit regime.
64. That day, a prison GP saw Mr Hussain as part of her regular segregation unit
rounds. She noted that he was medically fit to be segregated. (There is no
indication that Mr Hussain’s antipsychotic medication was reviewed by the GP.)
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65. On 24 June, Mr Hussain moved from the segregation unit to H Wing, the induction
unit and reverse cohort unit, where he was to spend a period of isolation in line with
COVID-19 prevention procedures.
66. That day, Mr Hussain made two calls on his telephone account, requesting a
balance. He made no further telephone calls during his time at Manchester.
67. On 30 June, an officer noted that Mr Hussain had refused to return to his cell and
displayed “petulant, obnoxious behaviour”. The officer noted that when Mr Hussain
was unlocked for his evening meal, he “glared dismissively”. The officer took Mr
Hussain’s response as a refusal and noted he “might not be of sound mind”. He
referred Mr Hussain him to the prison’s mental health team.
1 July 2021
68. On 1 July, a Supervising Officer (SO) A told Mr Hussain that he would be moved to
B Wing as his COVID-19 isolation had ended and space was needed on H Wing.
Mr Hussain initially agreed to move, but later told staff that he did not want to do so.
The SO told him that force would be used to move him if he continued to refuse.
He said that Mr Hussain was calm and understood what he was being told. He told
the prison’s use of force team that a planned intervention and use of force might be
necessary to move Mr Hussain. He also told SO B, his relief on H Wing.
69. SO B told us that he could not recall SO A telling him about Mr Hussain. He said
that when he arrived on the wing, the use of force team had assembled to move Mr
Hussain to B Wing, if required. He said that he learnt from wing staff that Mr
Hussain had been asked three times to move cells. He therefore decided that force
should be used to move Mr Hussain because of his continued non-compliance and
because he had no justifiable reason not to move. A Custodial Manager (CM)
approved the use of force.
70. SO B told us that it was agreed that he would give Mr Hussain a further chance to
move. He said that if Mr Hussain did not agree, the use of force team would move
him by force. He said that they agreed that if Mr Hussain did not comply, he would
be taken to the segregation unit for a “period of reflection”.
71. SO B and the use of force team then went to Mr Hussain’s cell. He had not spoken
to Mr Hussain before they did so. He asked him if he was going to comply with the
order to move to B Wing. Mr Hussain said that he would not. He told Mr Hussain to
step back from the door, which he refused. Mr Hussain tried to prevent the use of
force team from entering. Handheld camera footage shows that Mr Hussain fought
with the officers after they entered the cell.
72. Mr Hussain was taken to the floor by prison staff and put in the prone position. SO
B then handcuffed Mr Hussain, after which he stopped struggling. (The camera
footage does not record exactly what happened in the cell. However, an
unidentified officer from the use of force team appeared to raise his elbow and bring
it down towards Mr Hussain’s body, twice in succession. Due to the camera angle,
it is not possible to see if any contact was made with Mr Hussain or the
circumstances of the apparent strikes and as we can see no contact, we cannot
come to a conclusion on this. Camera footage shows that during the use of force,
Mr Hussain received an injury to his forehead. It was apparently a graze.)
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73. Mr Hussain was brought to his feet and staff used the under-hook technique to keep
his head down as he was walked, under restraint, from the cell. SO B asked him if
he was “going to comply with instructions”. Mr Hussain asked the SO what the
instruction was, and he told him that it was to “comply with the instruction”. No
further explanation was offered, and Mr Hussain was walked under restraint to the
segregation unit.
74. When Mr Hussain arrived at the segregation unit, he complied with the instructions
of the receiving officer. He was put in a holding cell, which had no furniture or other
facilities, and he was searched.
75. Mr Hussain then spent an unknown “period of reflection” in the cell, likely to have
been less than two hours. He was then moved to B Wing, during which he co-
operated fully, walked unaided, and was allocated a regular cell. (Mr Hussain’s
property and other personal effects remained in his cell on H Wing until after his
death.)
2 July 2021
76. On the morning of 2 July, staff discovered that Mr Hussain had blocked his
observation panel and barricaded his cell door. He did not respond to any attempts
to engage with him. An officer said that he saw Mr Hussain lying on the top bunk of
the bed, that he was breathing and had his hands down his trousers. He did not
respond to staff who tried to engage with him. The officer remained at the cell door
and continued in his attempts to engage with Mr Hussain.
77. Shortly afterwards, a nurse went to carry out a mental health triage assessment on
Mr Hussain, but officers told him that it would not be appropriate to open Mr
Hussain’s cell door. The nurse noted that he would try to see Mr Hussain the
following day.
78. An operational manager authorised for the use of force team to enter the cell and, if
necessary, use force to remove Mr Hussain. He recorded that this was to prevent
self-harm or harm to others. He told us that the reason for removing Mr Hussain
was because he had a duty of care as he might, or might have already, self-harmed
and that he had taken into consideration his previous custodial history. CM A, a
use of force instructor, noted in the use of force paperwork that because of events
the previous day, it had been decided to remove Mr Hussain from his cell.
79. During the briefing, the operational manager told the use of force team that
intervention was necessary as Mr Hussain had restricted access to his cell and was
being monitored under ACCT procedures. (Mr Hussain was not subject to ACCT at
the time.) He told the use of force team that Mr Hussain was lying on the top bunk
of his bed, had his hands down his trousers and might be concealing a weapon. He
said that if Mr Hussain remained non-compliant force would be used to restrain him
and move him to the segregation unit, but if compliant he would be told to stand at
the back of his cell.
80. The use of force team arrived at Mr Hussain’s cell and an SO opened the cell door.
He did not speak with Mr Hussain. The use of force team went into the cell,
removing the barricade as they did.
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81. CM A was one of the first officers to enter the cell. He said that Mr Hussain was
lying on his bed, had his eyes shut and his hands down his trousers. He shook Mr
Hussain’s arm and asked him several times to get out of his bed and stand up. Mr
Hussain did not respond and ignored the instructions to remove his hands from his
trousers. He took hold of Mr Hussain’s arm and an SO took hold of his other arm.
Mr Hussain, who was still not responding, was taken by force from his bed to the
floor of the cell and put in the prone position. An officer said Mr Hussain remained
non-compliant, did not respond and was clearly “feigning unconsciousness”. The
SO applied handcuffs.
82. Mr Hussain was brought up from the floor, so that he was sat on his haunches. He
continued not to cooperate. A nurse went into the cell to assess him and raised no
concerns about him being moved but noted that his eyes were shut tightly. Staff
brought Mr Hussain to his feet by using the under-hook technique as he refused to
comply with instructions.
83. Mr Hussain was taken from the cell under restraint and moved to the segregation
unit. He was passive throughout the move, and he lifted his legs, making it difficult
for the officers to carry him. At the top of the landing stairs, Mr Hussain was asked
if he would comply, but he did not respond. On the way to the segregation unit, a
nurse told officers that they might damage Mr Hussain’s shoulder if they continued
to carry him in the way that they were and asked them to carry him also by his legs.
He was carried by four members of staff, face down. CM A noted that this “was not
ideal” but thought that it was the best way, given that Mr Hussain continued to
refuse to cooperate or comply with staff instructions.
84. When Mr Hussain arrived on the segregation unit, he was put into the holding cell
and the handcuffs were removed. An officer commented to the handheld camera
operator that it was like something that “might be on Channel Four”.
85. A nurse completed an initial segregation health screen to ascertain if there were
any health reasons why Mr Hussain could not be segregated. She noted he had
not harmed himself in the current period of custody, showed no signs of psychosis
or being acutely unwell, and was not taking any antipsychotic medication. The
nurse concluded that Mr Hussain was able to cope with a period of segregation and
that no further healthcare intervention was needed at the time. She also noted
redness to Mr Hussain’s wrist and to the front of his shoulders following the use of
force. A senior manager signed the segregation algorithm, approving Mr Hussain’s
segregation.
86. The nurse told us that she had not checked Mr Hussain’s medical records before
approving his segregation. However, she said that before completing the algorithm,
she had spoken to healthcare colleagues to see if there was any reason why he
might not be suitable for segregation. She said that her colleagues raised no
concerns about Mr Hussain, but she could not recall if she was told about his
diagnosis of schizophrenia.
87. Segregation paperwork noted that Mr Hussain had been segregated under Prison
Rule 53 (to allow prisoners to be held in segregation before a disciplinary hearing),
and that he was not subject to ACCT procedures but had previously been.
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88. SO C, and two officers then went to the holding room to tell Mr Hussain that he
would stay on the segregation unit. The SO noted in the use of force paperwork
that Mr Hussain was sitting on the heating pipes at the back of the cell and refused
to sit up or acknowledge the officers. He said that because of Mr Hussain’s non-
compliance, he and Officer A initiated an unplanned use of force to move Mr
Hussain from the holding cell to a regular cell on the unit.
89. Officer A noted that the SO tried several times to engage with Mr Hussain and that
Mr Hussain refused to engage. He recorded that it was apparent that Mr Hussain
would have to be moved by force. He said that he approached Mr Hussain with the
intention of taking control of his arm but, as he got closer, he became aware that Mr
Hussain had clenched his fist. He said that he was aware that Mr Hussain
displayed “unpredictable behaviour”. He recorded that he was concerned for his
immediate safety and that he therefore extended his right knee into the “centre
mass” of Mr Hussain’s body. The officer said that he did not apply much force, as it
was a pre-emptive strike to prevent Mr Hussain from having the opportunity to get
close enough to be able to punch him.
90. The officers used force to restrain Mr Hussain, who offered a small amount of
resistance, and he was moved to a regular cell on the segregation unit. Mr Hussain
did not walk and dragged his legs. The use of force paperwork completed by
officers noted that positive communication was used to de-escalate the situation,
that a guiding hold, pain-inducing techniques and shoulder control were also used.
It was noted that Mr Hussain had not sustained any further injuries during the move.
91. In their Use of Force forms, staff recorded that the use of force was captured on
body-worn video camera (BWVC) footage. When we asked for this, we were told
that it was unable to be downloaded. We have not therefore been unable to view it.
SO C said that although he noted that BWVC was used, he could not recall whether
anyone switched on their camera.
92. That morning, Mr Hussain refused to engage with the duty governor during their
daily round of the segregation unit. An officer noted that Mr Hussain had collected
his lunchtime and evening meals. Officer A recorded that Mr Hussain appeared to
have a bad attitude towards staff.
93. An officer said that a segregation unit officer went to B Wing to collect Mr Hussain’s
property. However, there was no property in the cell as it had not been brought
over from H Wing the previous day.
94. In the afternoon, Officer A issued Mr Hussain with disciplinary paperwork about
three separate charges of indiscipline which had led to him being restrained by staff
and located in the segregation unit. (The charges were for his refusal to obey a
direct order to move cells on 1 July, that he had denied access to his cell on 2 July,
and for disobeying a lawful order to move cells, also on 2 July.)
3 July 2021
95. At around 8.00am on 3 July, officers went to Mr Hussain’s cell and asked if he
wanted to make any applications to access the prison regime. Officer B said that as
Mr Hussain remained in bed, he was not permitted to make applications to access
the regime under local rules.
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96. The interim Deputy Governor chaired Mr Hussain’s disciplinary hearings. He heard
the charge that Mr Hussain had disobeyed a lawful order to move cells on 1 July, to
which Mr Hussain pleaded guilty. He asked Mr Hussain if he had anything to say in
mitigation. Mr Hussain apologised for his behaviour and said that he had just
wanted to get his medication sorted out and to speak to the mental health team.
The Deputy Governor punished him with seven days of cellular confinement.
(Prison rules require all prisoners segregated under cellular confinement to receive
a welfare check every hour.)
97. The interim Deputy Governor also heard Mr Hussain’s charge of denying access to
his cell on 2 July. Mr Hussain said that he could not recall the incident as he had
mental health issues and sometimes did things that he could not remember doing.
The Deputy Governor adjourned the hearing for further evidence. He heard Mr
Hussain’s final charge for disobeying a lawful order to move cells in the segregation
unit on 2 July. Mr Hussain said that although he understood the evidence, he could
not recall if it was correct as he could not remember what he was told. Again, the
Deputy Governor adjourned the hearing for further evidence.
98. A nurse completed a further segregation health screen as Mr Hussain was now
subject to cellular confinement. She did not have access to Mr Hussain’s medical
records. She noted that he presented with no evidence of mental illness, was not
acutely unwell, was not receiving any antipsychotic medication, had not harmed
himself in his current period of custody and denied thoughts of self-harm. She
concluded that Mr Hussain could cope with a period of cellular confinement and that
no healthcare intervention was needed. The nurse planned for the GP to review Mr
Hussain during the segregation round the following day. The interim Deputy
Governor signed the algorithm to confirm that he had read the assessment and
agreed that Mr Hussain could be segregated.
99. In the afternoon, Mr Hussain requested a newspaper. Officer B told us that Mr
Hussain was “fixated” with getting his newspaper and became angry when told that
it and his purchases from the prison shop were not on B Wing. He described Mr
Hussain as “disruptive” and a “discipline problem”.
100. A nurse saw Mr Hussain during the mental health team’s daily check of prisoners in
the segregation unit. He told us that he also intended to complete Mr Hussain’s
mental health assessment. He noted that Mr Hussain refused to engage and that
he was due a mental health triage assessment, which would be attempted on 5
July.
4 July 2021
101. No one recorded whether Mr Hussain was asked if he wanted to access the wing
regime.
102. A mental health nurse saw Mr Hussain as part of the routine daily healthcare round.
Mr Hussain told her that he would like to restart his antipsychotic medication as it
helped to “slow down his brain”, which he said he felt was “moving too fast”. She
said that Mr Hussain did not express any urgency about his medication and did not
appear distressed. She referred Mr Hussain to the prison GP and told him that he
could discuss his medication at his mental health assessment the following day.
She said that Mr Hussain did not present with any acute psychotic symptoms that
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warranted urgent intervention and he did not need medication urgently. Mr Hussain
had no further contact with mental health services before his death.
103. Mr Hussain was given his lunch. He raised no issues with the duty governor during
their daily round. During the afternoon, staff noted that he appeared asleep.
104. Although the officers we interviewed could not recall much about Mr Hussain,
Officer B said that Mr Hussain did not engage with staff, was disruptive, abusive,
“anti-everything”, seemed very angry towards staff and questioned staff when they
went to his cell door. He described Mr Hussain as a “disciplinary problem”.
105. Officer A noted that Mr Hussain had shown a bad attitude towards staff and had no
intention of complying with the segregation regime. He noted that staff would
continue to try to engage positively with Mr Hussain over the coming days. (There
is no evidence that this happened.)
106. That evening, Mr Hussain asked an officer for his newspaper, but the officer could
not find it. He said that Mr Hussain caused staff no concerns.
5 July 2021
107. At around 7.57am, three officers went to Mr Hussain’s cell to ask if he wanted to
make applications to access the wing regime. Two of the officers completed a cell
fabric check. Officer C later noted that as Mr Hussain remained in his bed, he
would not have access to the wing regime. The other two officers told us that they
could not recall if they had spoken to Mr Hussain, and Officer B said that it was
likely that Mr Hussain had ignored them.
108. At 9.12am, a prison chaplain noted that Mr Hussain appeared asleep.
109. At 9.42am and 10.40am, Officer B checked on Mr Hussain, who still appeared to be
asleep. When he checked on him at 10.54am, he noted that Mr Hussain had been
lying on his bed, talking to himself.
110. At 11.15am, Officer D answered Mr Hussain’s cell bell. She said that she could not
recall what they talked about.
111. At 11.20am, Mr Hussain rang his cell bell again. At 11.23am, three officers went to
Mr Hussain’s cell to give him his lunch. Mr Hussain refused to stand at the back of
the cell and therefore they could not open the door, in line with segregation unit
procedures. Although the officers appeared to reset the cell bell before leaving, it
continued to flash.
112. At 11.25am, Officer E walked past Mr Hussain’s cell and pushed the door to check
if it was locked. (It was.) This was not a scheduled roll check, and she did not look
into the cell or reset the cell bell. At 11.35am, Officer D reset Mr Hussain’s cell bell
and looked into the cell as she did.
113. At 11.39am, Mr Hussain rang his cell bell. Officer D reset it 30 seconds later but did
not look into the cell. At 11.49am, Mr Hussain rang his cell bell again. Officer E
reset it around seven minutes later, without looking into the cell. At 11.57am, Mr
Hussain rang his cell bell again.
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114. At 11.59am, the Head of Safer Custody and Equalities, who was completing the
duty governor’s segregation daily round, arrived at Mr Hussain’s cell with several
officers. She remained at the cell door for around fifteen seconds before she and
the officers moved on to check on other prisoners on the unit. She noted that Mr
Hussain refused to speak, and she said that he had no concerns.
115. At 12.00pm, Mr Hussain rang his cell bell. Officer B reset the bell without looking
into the cell. Seconds later, Mr Hussain rang the bell again. An officer went to the
cell and appeared to listen before he moved away from the door to stand with other
colleagues on the landing. The officer did not reset the bell and it continued to
flash.
116. At 12.02pm, Officer E reset the bell outside Mr Hussain’s cell, but did not speak to
him. Seconds later, Mr Hussain rang his cell bell again. Officer B reset the bell
around a minute later but again, did not look into the cell. Mr Hussain then rang the
cell bell again. Around a minute later, the officers who accompanied the Head,
walked past Mr Hussain’s unanswered bell and left the wing.
117. At 12.07pm, Officer B completed the lunch time roll check. He walked down the
landing and checked the cell doors, including Mr Hussain’s, but did not look into Mr
Hussain’s cell or the other cells on the unit. He did not reset Mr Hussain’s cell bell.
118. At 12.20pm, Officer F started his shift on the unit and Officer A gave him a brief
handover. Officer F said that he was told that Mr Hussain had recently arrived on
the unit from B Wing, had been kicking his cell door persistently, ringing his cell bell
and shouting. He said that he was told that Mr Hussain was unhappy that he was
not given his newspaper or canteen. He told us that Mr Hussain was not kicking his
cell door when he arrived. There is no record in Mr Hussain’s segregation records
that he had ever kicked the cell door.
119. At 12.24pm, Officer G, who had just started his shift, answered Mr Hussain’s cell
bell. Mr Hussain said that he wanted his newspaper. The officer told him that he
would chase it up. When he asked Mr Hussain which wing he was from, Mr
Hussain said, “It doesn’t fucking matter”. The officer said that given Mr Hussain’s
response, he shut the observation panel and walked away. He then made an entry
in Mr Hussain’s records about his contact with him. This is the last time that Mr
Hussain was seen alive.
120. At around 12.40pm, Officer G told Officer F that Mr Hussain had asked for his
newspaper and canteen. Officer F said that he would try to deal with it that
afternoon.
121. At 12.54pm, Officer F went to carry out Mr Hussain’s hourly cellular confinement
check. He looked through the cell door observation panel and saw Mr Hussain on
his knees, facing the back wall of the cell, with a bed sheet tied around his neck
which he had tied to the window bars. He told us that he was about to radio for
assistance when he remembered that he was in a radio blind spot and could not
rely on it working. He did not therefore use his radio but instead immediately left
the cell and walked to the room used for the unit’s disciplinary hearings and told
colleagues there that Mr Hussain was hanging.
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122. Staff responded and walked back to the cell with Officer F. At 12.55pm, Officer F
opened the cell door, and the officers went in.
123. An officer cut the ligature from around Mr Hussain’s neck and, at 12.57pm, another
officer called a medical emergency code blue (used when a prisoner is
unresponsive or has breathing difficulties). Control room staff telephoned for an
ambulance. The officer who called the emergency code said that Mr Hussain
appeared to be unconscious and that there were no apparent signs of life. An SO
checked for a pulse but could not find one. The officers immediately started
cardiopulmonary resuscitation (CPR) and took turns giving chest compressions.
124. At 1.01pm, two nurses arrived with the medical emergency response bag. Another
nurse arrived a minute later. The nurses went into the cell and with the support of
officers, they continued resuscitation efforts. A defibrillator was attached and
initially advised no shock but later advised that a shock should be applied.
125. At 1.07pm, the first emergency paramedic arrived and led resuscitation efforts, with
the continued assistance of healthcare staff and a prison GP, who arrived at around
the same time.
126. Paramedics stabilised Mr Hussain and at around 1.32pm, he was taken from the
cell. He was transferred to hospital at around 1.58pm.
127. On the afternoon of 8 July, Mr Hussain’s life support was switched off in hospital.
He was pronounced dead at 3.40pm. Family members were present when he died.
Contact with Mr Hussain’s family
128. At around 3.00pm on 5 July, a prison family liaison officer telephoned Mr Hussain’s
sister and told her that her brother had been taken to hospital.
129. After Mr Hussain’s death, Manchester contributed to the funeral expenses in line
with national instructions.
Support for prisoners and staff
130. Following the incident on 5 July, the interim Deputy Governor 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.
On 8 July, a safer custody manager held a further debrief for the staff who had
accompanied Mr Hussain in hospital.
131. The prison posted notices informing other prisoners of Mr Hussain’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 Hussain’s death.
Post-mortem report
132. The post-mortem examination found that Mr Hussain died from pneumonia due to
hypoxic/ischaemic brain damage after hanging. The pathologist noted the
possibility that pre-existing ischaemic heart disease made a lesser, albeit potentially
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significant, contribution to his death. Toxicology results found no illicit substances
in Mr Hussain’s body when he was admitted to hospital.
133. The post-mortem examination found that Mr Hussain had some very minor
superficial incised wounds on his left wrist, which might have represented an
attempt to harm himself. We do not know when this injury occurred.
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Findings
Assessment of Mr Hussain’s risk of suicide and self-harm
134. Prison Service Instruction (PSI) 64/2011 on safer custody requires all staff who
have contact with prisoners to be aware of the risk factors and triggers that might
increase the risk of suicide and self-harm and to take appropriate action. Any
prisoner identified as at risk of suicide or self-harm must be managed under ACCT
procedures.
135. When Mr Hussain arrived at Manchester, he had several risk factors for suicide and
self-harm, including a significant mental health diagnosis and a history of self-harm.
136. In the days before his death, Mr Hussain was exposed to a number of significant
new risk factors. He was subject to three uses of force. He was concerned about
getting his mental health medication and wanted to speak to the mental health
team. He was segregated under cellular confinement and had no access to
property or distraction materials, including a radio (which all segregated prisoners
should be allowed to have in their cell) and the newspaper that he often requested.
He did not engage with staff, remained in his bed for much of the time and did not
leave his cell for three days to access the regime available. We also note that Mr
Hussain’s last period of ACCT monitoring in March 2021, resulted from the stress
he felt at being segregated and his lack of access to his canteen and vapes.
137. There is no evidence that prison or healthcare staff considered whether Mr
Hussain’s risk had increased or whether he should have been monitored under
ACCT procedures. We consider that his increased risk, including environmental
risks, would likely have affected his mental health and feelings of isolation and
paranoia which he experienced during his time in custody. We are concerned that
staff appeared to accept Mr Hussain’s isolation and lack of communication as
‘normal’ for prisoners who lived on the unit, and there is no evidence that they tried
proactively to engage with him.
138. While we cannot say whether starting ACCT procedures would have led to a
different outcome for Mr Hussain, it would have given staff the opportunity to
identify and address Mr Hussain’s issues and triggers and to encourage him to
engage with them and with the prison regime. Starting ACCT procedures should
also have led a multidisciplinary team of staff to reconsider whether the segregation
unit was an appropriate place for Mr Hussain. We make the following
recommendation:
The Governor and Head of Healthcare should ensure that all staff have a clear
understanding of their responsibilities to identify prisoners at risk of suicide
and self-harm, including that:
• segregation unit staff consider and record all the known risk factors
and triggers of a segregated prisoner, including environmental factors;
• monitor any changes in the prisoner’s behaviour or circumstances
when determining the risk of suicide and self-harm; and
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• start ACCT procedures when indicated.
Use of force
139. Mr Hussain was subject to the use of force on three occasions in the days before he
was found hanged in his cell. He did not sustain any serious injuries as a result,
and we do not consider that it contributed directly to his death. However, it did
result in his segregation. The use of force, even when performed in line with control
and restraint procedures, is likely to be a painful and humiliating experience for a
prisoner and may have contributed to Mr Hussain’s state of mind, particularly as he
felt low.
Use of force on 1 July 2021
140. When Mr Hussain was asked to move cells on 1 July, he initially agreed but later
told staff that he did not want to move. He spoke calmly and was “matter of fact”
but despite being asked several times, he refused to move. Given his non-
compliance and refusal to comply with an order, staff decided to move Mr Hussain
using planned force.
141. When SO B arrived at Mr Hussain’s cell, he asked him if he was going to comply
with the order to move cells. Mr Hussain said that he would not and prevented
access to his cell by standing behind the cell door as the use of force team entered.
142. We are concerned that staff took the immediate decision to use planned force to
move Mr Hussain. We would have expected them to consider other options,
particularly as he had not threatened the safety of others or himself, and he had not
posed a risk to the operation of the prison regime. Prison staff should have
considered alternative options such as leaving him in his cell on H Wing, trying to
discuss the issue with him again or dealing with his refusal to move as a disciplinary
issue. These options would have been proportionate, legitimate and reasonable in
the circumstances. We consider that the planned use of force was excessive at this
point. (It also appears that there was no urgent operational need for Mr Hussain to
vacate his cell on H Wing as the cell remained locked and unused, with his property
left inside, until after the incident on 5 July.)
143. Staff might have believed that the planned use of force was necessary as a last
resort. However, we do not consider that three lawful orders, in these
circumstances, were enough and SO B should have done more to try and persuade
Mr Hussain to move. Even if we accept that force was necessary to protect the
good order of the prison, the SO made no effort to persuade Mr Hussain to move
once the use of force team had arrived at the cell door. We also note that Mr
Hussain later said that he was unsure which instruction he had not complied with.
We recognise that Mr Hussain had to move cells at some point but there was no
immediate threat to the good order of the prison at the time staff intervened.
144. We recognise that there are occasions when a prisoner is so verbally aggressive
and threatening that officers might reasonably feel at imminent risk of assault, even
if the prisoner has not been physically aggressive. In such situations, the pre-
emptive use of force to prevent harm may be justifiable. However, we do not
consider that this was the case with Mr Hussain, and we are concerned that staff
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escalated the incident unnecessarily by wearing PPE because this should only have
been done as a last resort.
145. We conclude that the planned use of force on 1 July was unreasonable and
excessive in the circumstances. Had Mr Hussain been allowed a “period of
reflection” in his own cell on H Wing, rather than in the segregation unit, the safety
of Mr Hussain and the prison staff who used force would not have been put at risk.
First use of force on 2 July 2021
146. Two staff members, one of whom was a trained negotiator, spent an hour trying to
communicate with Mr Hussain, trying to get a response and convince him to remove
the barricade from his cell door. This form of extended negotiating and de-
escalation is good practice and aligns with PSO 1600.
147. The duty manager reported that the use of force team wanted to go into the cell
because they had a duty of care to Mr Hussain, and they were concerned that he
might have harmed himself or was at risk of self-harm. He said that his decision-
making process included consideration of Mr Hussain's previous custodial and
mental health history.
148. Prison staff were also concerned that Mr Hussain might have posed a risk of
violence. They thought that he may be hiding a weapon because he had his hands
down the front of his trousers. Staff were also aware that Mr Hussain had a history
of violence and had physically resisted a restraint the day before.
149. When an SO arrived at the cell door, he did not give Mr Hussain a further
opportunity to comply with orders before sending the use of force team into the cell.
This was poor practice.
150. The use of force team entered the cell and removed the barricade. During this time,
Mr Hussain was still lying on his bed, unresponsive, with his eyes closed and his
hands down his trousers.
151. Once in the cell, CM A twice asked Mr Hussain to remove his hands from his
trousers. Mr Hussain did not respond.
152. CM A and other staff then decided to initiate force by pulling Mr Hussain's hands
from his trousers, moving him from his bed to the floor, and restraining him. He was
then carried, under restraint, to the segregation unit.
153. Mr Hussain did not respond. He had a history of staff assault and was potentially
concealing a weapon. Considering these circumstances and the policy
requirements of PSO 1600, we are satisfied that at the point of physically removing
Mr Hussain's hands from the front of his trousers, the force was necessary because
it was reasonable for the prison staff involved to consider that Mr Hussain posed a
potential risk to himself and staff. We are satisfied that this force was reasonable,
proportionate, and that no more force was used than necessary.
154. However, it would have become apparent at this point that Mr Hussain did not have
a weapon and that he did not pose a risk of harm to himself or others. He had not
been violent and was not searched in his cell, which indicates that staff were not
concerned that he had a weapon. It also would have been apparent that Mr
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Hussain had not harmed himself. Alternatives to segregation such as leaving him in
his cell to calm down should have been considered. This would have reduced the
need for staff resources and lessened the impact on the wing regime. CM A told us
that he had not considered alternatives as the use of force team had been
instructed to take Mr Hussain to the segregation unit. This is concerning.
155. At this point, as the perceived risk was no longer present, the use of force was no
longer necessary, and the continuation of force was no longer justifiable.
Second use of force on 2 July 2021
156. We are concerned that, after Mr Hussain was moved to the segregation unit, force
was used for a second time after he had only spent around ten minutes in the unit's
holding cell.
157. When the prison officers went into the cell to tell Mr Hussain that he would remain in
the segregation unit, he was sitting on the pipes at the back of the cell and refused
to engage with them or move. Officer A said that it was apparent that Mr Hussain
would have to be moved by force and that he and his colleagues then initiated a
further use of force to remove him from the holding cell. Mr Hussain, who offered
some resistance by dragging his legs, was moved to a standard cell in the
segregation unit.
158. PSO 1600 states that, “Force must only be used as a last resort after all other
means of de-escalating the incident without the use of force (for example, through
persuasion or negotiation) has been repeatedly tried and failed". Our view is that
there was no imminent threat to the good order of the prison, property or anyone’s
safety. Officer A and the other staff present spent insufficient time considering
alternative options to force and did not try to de-escalate the incident or negotiate
with Mr Hussain, particularly as Mr Hussain did not pose a risk to anyone while in
the holding cell. Attempts to find alternatives to force should have been extended
for a longer period, and we conclude that the use of force was not “necessary” and
therefore in breach of PSO 1600.
159. We are also concerned about Officer A’s attitude after Mr Hussain was put in the
segregation holding cell. He made a comment that appeared to refer to prison
documentaries broadcast on Channel Four television. We recognise that the use of
force, where the safety of officers and the prisoner may be at risk, is a stressful
situation but throwaway comments made at such moments are inappropriate and
unprofessional.
Officer A’s knee to Mr Hussain
160. Officer A said that as he approached Mr Hussain to take his arm, Mr Hussain
clenched his fist. He said that because of Mr Hussain's unpredictable nature and a
concern for his safety, he extended his right knee into the centre of Mr Hussain's
body as a pre-emptive strike to prevent Mr Hussain from getting close enough to
punch him.
161. Officer A said that he did not use much force when performing this pre-emptive
strike. When asked about Mr Hussain clenching his fist, he said, "It was almost as if
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when we moved towards him, it was almost like he was sitting there waiting. It's like
he almost wanted us to come and put hands on him".
162. PSI 30/2015, which contains amendments to the use of force policy, states that a
knee to a prisoner from staff can be justifiable in a “personal protection” scenario,
where staff reasonably perceive an imminent threat to their safety. No BWVC
footage covers what happened inside the holding cell, and we have no evidence to
either support or challenge Officer A’s account that Mr Hussain clenched his fist.
Therefore, we cannot say whether or not his action of kneeing Mr Hussain was
justified.
Use of Body-Worn Video Cameras (BWVC)
163. PSI 04/2017 on body-worn video cameras (BWVC) states that BWVC must be used
when a user has or may be required to exercise force against a person.
164. We were only given BWVC footage for the second use of force, and even then, we
do not know which officer wore the camera (the camera was booked out to an
officer who was not involved in the incident). A member of staff recorded that
BWVC was used during the third use of force, but it is unclear if this was the case,
and we were not given any footage.
165. We were initially told by Manchester that BWVC footage could not be downloaded,
which suggested that it was used. However, we also note that HMIP reported on
the reluctance of officers to switch on body-worn cameras routinely during incidents.
The absence of BWVC footage for two uses of force is concerning.
Use of force conclusions
166. Being subjected to use of force is likely to be traumatic and to be experienced as an
assault. It is possible that the trauma experienced by Mr Hussain due to the force
used on him on 1 and 2 July was still fresh in his mind when he chose to end his
life.
167. However, we recognise that it is not automatically the case that force is unjustified
or incorrectly applied on a prisoner because a prisoner takes his own life shortly
after an incident.
168. We are keenly aware of ‘hindsight bias’, where learning the outcome of an event,
particularly a serious event such as someone’s death, can lead to an overestimation
of our ability to have foreseen the outcome. To challenge such bias, we remind
ourselves that the test for what staff should have done in these incidents is not what
we think that we would have done. Instead, the test is ‘what was a reasonable and
policy-compliant response’ in these incidents.
169. We are concerned about some elements of the use of force incidents involving Mr
Hussain on 1 and 2 July. Staff, at times, did not communicate effectively. They did
not take enough time to consider alternative options to using force, to de-escalate
or negotiate with Mr Hussain. We have concluded that force was used unlawfully,
breaching PSO 1600.
170. We also note that HMIP reported that de-escalation techniques at Manchester were
inadequate and not always used well enough, of little dialogue between staff and
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prisoners and that the governance and oversight of the use of force was weak and
that there was a lack of focus on learning lessons following incidents involving
force. We make the following recommendations:
The Governor should ensure that staff use force in line with national
guidelines, including that:
• planned use of force is only used when it is reasonable and necessary,
and only as a last resort when all other means of de-escalating the
incident have been repeatedly tried and failed;
• all staff wear and switch on body-worn video cameras during planned
use of force interventions;
• staff remain professional and do not use inappropriate language; and
• CM A and SO B receive additional advice and guidance on the lawful
use of force and de-escalation techniques.
Segregation
Inappropriate use of segregation
171. On 1 July, planned use of force was used to move Mr Hussain from H Wing to the
segregation unit for a “period of reflection”.
172. Several staff told us that it was not unusual for prisoners to be taken to the
segregation unit for a “period of reflection” and it appeared to be an accepted
method of enforcing discipline at Manchester. The segregation unit should not be
used by staff as an alternative form of punishment. We consider that moving
prisoners to a holding cell in the segregation unit for this purpose is a worrying and
inappropriate use of the unit. It is also unclear why staff did not consider that this
“period of reflection” could have been completed on H Wing, which would have
mitigated risks for Mr Hussain and the officers carrying out the use of force.
173. We are concerned that, when Mr Hussain was taken to the segregation unit for a
“period of reflection”, staff did not complete any segregation unit paperwork and
there is no record to explain the reason for his location in the unit or what prison
rule he was held under. We were told that that if prisoners returned to a regular
wing within two hours of arriving on the segregation unit, the completion of
paperwork was not necessary. This is not acceptable practice. The fact that no
record exists of Mr Hussain’s time in the unit meant that no protections would have
been put in place to consider the risk he might have posed to himself, levels of
observation or other security matters. This not only posed a risk to Mr Hussain but
also to staff and was not in line with the requirements of Prison Service Order
(PSO) 1700 on the use of segregation.
Record keeping and engagement with Mr Hussain
174. On 2 July, Mr Hussain was uncommunicative and upset when he arrived in the
segregation unit after being restrained. PSI 30/2015 (which makes some
amendments to PSO 1600) says that after a use of force, there should be a de-brief
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in which someone unconnected with the incident speaks to the prisoner about what
happened. It is concerning that there is no evidence that this took place.
175. PSO 1700 requires each prisoner in segregation to have a designated or personal
officer who is required to engage in purposeful dialogue and record this in the
prisoner’s history sheet, with at least three quality entries required each day. The
PSO also requires that, where possible, the segregation unit officer engages in
dialogue when completing hourly observations of prisoners serving punishments of
cellular confinement.
176. We found general processes and record keeping in the segregation unit were poor.
There is no record that anyone made a meaningful attempt to engage with Mr
Hussain while he was there, and he was not assigned a personal officer. Staff
made very few entries in his segregation records, which is particularly surprising
given the challenging behaviour they described. Visitors to the unit did not sign in.
If staff had been more proactive in engaging with Mr Hussain, and if they had
interacted with him in a more meaningful manner, they might have been aware of
his increased risks.
Access to the segregation regime
177. When prisoners arrive in the segregation unit, prison staff explain what is expected
of them each morning when making applications to access the unit’s regime.
Prisoners are expected to be out of bed, dressed, and standing at the back of their
cell at 8.00am on weekdays or 9.00am on weekends. If prisoners are not ready,
they forfeit the chance to make applications or to access the regime for the whole
day. Prisoners who are serving a period of cellular confinement can exercise in the
open air daily but are only permitted to take a shower or make a telephone call on
alternate days.
178. From Mr Hussain’s arrival in the segregation unit on 2 July until he was found on 5
July, he made no applications to access the regime. He did not shower or take
exercise and appeared to have left his cell only once to attend his disciplinary
hearing on 3 July. As we have previously noted, withdrawal from the prison regime
is a risk factor for suicide and self-harm, and there is no evidence that segregation
unit staff made proper efforts to engage with Mr Hussain.
179. We understand that prisoners in the segregation unit are now required to leave their
cells and walk to a desk on the wing before being asked what aspects of the regime
they want to access. Manchester has introduced this since Mr Hussain’s death to
promote greater staff-prisoner engagement and to encourage greater activity and
interaction with prisoners serving periods of cellular confinement and for staff to
consider their welfare needs.
180. Although we welcome these changes, we remain concerned that prisoners subject
to cellular confinement only have access to showers and telephone calls on
alternate days.
Access to personal property and distraction materials
181. For five days, four of which were in the segregation unit, Mr Hussain had no access
to any of his basic personal property such as his toiletries, prayer mat, reading
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material or a radio, to which he was entitled as a prisoner serving a period of
cellular confinement. During the investigation, it became apparent that neither wing
nor segregation unit staff were clear about whose responsibility it was to transfer Mr
Hussain’s property from his original wing to the segregation unit. We also note that,
given Mr Hussain’s lack of property, there is no evidence that he was offered any
distraction materials during his time in the segregation unit, despite him asking for a
newspaper for several days. (Mr Hussain’s property remained locked in his cell on
H Wing until after he was taken to hospital on 5 July.)
182. It is possible that not having access to any of his property or other distraction
materials on the night of 1 July, might have contributed to Mr Hussain’s reasons for
covering his cell door observation panel, barricading his cell the following morning
and taking his life. The clinical reviewer also noted that this might have impacted
on Mr Hussain’s state of mind. The Head of Healthcare agreed with the clinical
reviewer that healthcare staff should be more mindful of what prisoners have
access to when segregated and how to encourage them to leave their cells.
183. It is essential that segregation and healthcare managers ensure that officers and
nurses work together to facilitate and encourage prisoners to leave their cells in the
segregation unit, when able to, and to ensure that they have access to their basic
property and in-cell distractions. We note that HMIP had also identified issues
about prisoner property, including how some prisoners had moved to a different cell
and how their property had been misplaced during the move, which caused
frustration and mistrust.
Segregation health screens
184. Segregation is stressful for prisoners and can increase their risk of suicide and self-
harm. PSO 1700 therefore requires a member of healthcare staff to complete an
initial segregation safety health screen for all segregated prisoners to assess their
physical, emotional and mental wellbeing when deciding whether it is safe to
segregate them. The health screen must be completed within two hours of a
prisoner being segregated, after a discussion with the prisoner. The screen should
also be completed if a prisoner is awarded a period of cellular confinement at a
disciplinary hearing.
185. On 2 July, a nurse completed a health screen. The nurse said that although she did
not personally check Mr Hussain’s medical records, she would have telephoned
healthcare colleagues to see if there were any reasons why he could not be
segregated. She said that no concerns were raised. (She did not make a record of
any conversation with colleagues.)
186. Another nurse completed a further health screen on 3 July, as Mr Hussain was to
serve a period of cellular confinement. The nurse had not been told that during the
disciplinary hearing that Mr Husain had asked to speak to the mental health team
and, although she checked to see if he was taking any medication, she did not
check his full medical history before completing the assessment. She said that had
she known about Mr Hussain’s mental health history, she would have called the
emergency on-call mental health nurse to complete and sign the assessment.
187. For healthcare professionals to be able to properly assess a prisoner’s physical,
emotional and mental wellbeing before segregation, they must have access to all
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relevant information. This was a missed opportunity. Had the assessing nurse
known of Mr Hussain’s request to speak to a member of the mental health team,
consulted his medical records fully, known of his diagnosis of schizophrenia and the
issue about his antipsychotic medication, she might have identified concerns about
his suitability for segregation. This might have led to additional support for Mr
Hussain or to the conclusion that he was not fit to be segregated.
188. We also note that an officer asked a nurse to complete the segregation unit health
screen, without first seeing Mr Hussain. This was inappropriate. The nurse
correctly refused to complete the assessment without seeing Mr Hussain.
189. We understand that following Mr Hussain’s death, the responsibility for completing
segregation health screens now lies with the emergency response mental health
nurse, who is required to speak to prisoners before completing the algorithm. We
make the following recommendations:
The Governor should ensure that staff manage prisoners held in segregation
in line with national guidelines, including that:
• segregation is used appropriately, in line with Prison Rules, and with
the authority of an operational manager;
• each prisoner is assigned a designated officer responsible for their
welfare;
• staff engage in purposeful dialogue with each prisoner at least three
times a day, and that this is recorded in the prisoner’s history sheet;
and
• prisoners are able to access all aspects of the regime every day and
have access to basic personal property and distraction materials.
The Governor and Head of Healthcare should ensure that healthcare
professionals completing segregation unit health screens have access to the
prisoner’s medical history and are always given the opportunity to speak to
the prisoner.
Emergency cell bell, welfare checks and roll count
190. It became apparent during our investigation that segregation unit staff did not
answer cell bells, complete welfare checks or complete the roll check to a
satisfactory standard.
191. On 5 July, Mr Hussain rang his emergency cell bell several times from 11.35am,
before his death. However, some officers walked past the ringing bell and did not
answer it. When some staff did respond to the cell bell, they reset it without
speaking to Mr Hussain or checking on his welfare. SO C said that his expectation
was for staff to answer the emergency cell bell as soon as possible, and within a
couple of minutes, if possible.
192. Some staff told us that they did not answer cell bells because prisoners could be
abusive or aggressive. A CM said that if a prisoner misused the emergency cell
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bell, the reason for the misuse should be documented. There are no records to
indicate that this was the case for Mr Hussain. We cannot know why Mr Hussain
pressed his cell bell, but we are concerned that this was a missed opportunity to
identify and address his concerns or to identify increased risk.
193. PSO 1700 instructs that prisoners serving periods of cellular confinement should be
observed at least once an hour. Although Mr Hussain was observed regularly on 5
July, no check was completed between 7.58am and 9.42am, as it should have
been.
194. The purpose of a roll check is to ensure that all prisoners are accounted for, by
observing the prisoner through their cell door observation panel. If staff see
something that gives them immediate concern for the welfare of a prisoner, they are
expected to take appropriate action. Officer B completed the roll check at lunch
time on 5 July, but he did not look into the cell as he should have done and as he
acknowledged at interview. We make the following recommendation:
The Governor should commission a disciplinary investigation into the actions
of segregation unit staff on the morning of 5 July 2021.
The Governor should ensure that segregation unit staff complete their duties
satisfactorily and in line with local and national requirements, including that:
• staff observe prisoners subject to cellular confinement at least once
every hour;
• staff observe prisoners at roll checks and take appropriate action if
they have concerns for a prisoner’s welfare; and
• staff answer cell bells promptly, take reasonable steps to answer the
query and take appropriate action if they have concerns for the
prisoner’s welfare.
Disciplinary hearings
Award of cellular confinement
195. PSI 47/2011 sets out the process and procedures that must be followed when a
prisoner is charged with a breach of prison rules. It states that any punishment the
adjudicator may impose must be proportionate and in line with the Prison Rules.
The adjudicator must take into account the seriousness of the offence, local
punishment guidelines, the prisoner’s previous disciplinary record, the likely effect
of the punishment on the prisoner, and any mitigation the prisoner may offer. The
punishment and any reasons for departure from local guidelines must be recorded
on the record of hearing and explained to the prisoner.
196. On 3 July, Mr Hussain pleaded guilty to disobeying a lawful order for refusing to
move cells two days earlier. He apologised for his behaviour and offered mitigation:
he said he wanted to “sort” his medication and speak to the mental health team. Mr
Hussain was punished with seven days of cellular confinement. The adjudicator,
the interim Deputy Governor, said that he believed the award to have been at the
lower end of the tariff scale and proportionate to Mr Hussain’s guilty plea.
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197. Manchester’s local adjudication tariff guidelines for disobeying a lawful order state
that adjudicators should consider whether the offence was premeditated, whether
the refusal relates to underlying risk to the prisoner, any previous offences and
whether the refusal formed part of a more serious offence such as a general protest
by several prisoners. The guidelines state that mitigating circumstances include
any medical issues, remorse or apology and a guilty plea.
198. Manchester’s guidelines state that for a minor offence, the prisoner should not
receive cellular confinement. A ‘medium’ offence could receive one to seven days
of cellular confinement. A serious offence could receive seven to 28 days of cellular
confinement.
199. Mr Hussain was punished with seven days of cellular confinement, which is on the
borderline between a medium and serious offence according to local guidelines.
We are not satisfied that this was appropriate. Mr Hussain had pleaded guilty and
provided relevant mitigating circumstances. We also note that Mr Hussain moved
to B Wing without further issue after he had spent two hours in segregation, which
could also have been considered in mitigation. It was his first disciplinary hearing at
Manchester in which he had pleaded guilty, and he had not been found guilty of any
disciplinary offence for some time at his previous prison. We make the following
recommendation:
The Governor should ensure that managers conducting disciplinary hearings
impose punishments in line with local tariff guidelines and take into
consideration mitigating circumstances when considering awarding periods
of cellular confinement.
Referrals to the mental health team following disciplinary hearings
200. After Mr Hussain pleaded guilty, he asked to speak to a member of the mental
health team. The interim Deputy Governor and the Head of Healthcare said that if a
request to see the mental health team had been made during a disciplinary hearing,
the expectation would have been for segregation unit staff to contact the mental
health team to tell them of the request.
201. At his disciplinary hearing, Mr Hussain said that his actions were based on a desire
to speak to the mental health team and for his medication to be “sorted”. It is
concerning that staff did not initiate a mental health referral and instead relied on Mr
Hussain to initiate contact with the mental health team. Not making a referral,
especially when Mr Hussain was punished with cellular confinement which might
have exacerbated his mental ill-health, was a missed opportunity to identify and
support any immediate mental health needs. We make the following
recommendation:
The Governor should ensure that managers imposing punishments of cellular
confinement fully consider the likely impact on the health and welfare of the
prisoner, including referring the prisoner to the mental health team, where
appropriate.
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Emergency response
202. PSI 03/2013 on medical emergency response codes sets out the actions staff
should take in a medical emergency. It stipulates that if an emergency code is
called over the radio, an ambulance must be called immediately. Manchester uses
the emergency codes ‘red’ and ‘blue’ to comply with PSI 03/2013. Examples of the
circumstances in which staff should use code blue are when the prisoner has
difficulty breathing or is unconscious. In July 2020, the prison issued a Governor’s
Order to remind staff of the local protocol.
203. When Officer F found Mr Hussain hanging, he should have immediately called an
emergency code blue to indicate that Mr Hussain was unresponsive and that it was
a life-threatening situation. He told us that he could not do so immediately as there
was a radio blind spot and he could not rely on his radio working. Instead, he
walked to an office nearby to alert staff to the emergency before returning to the cell
with colleagues.
204. It was not until 12.57pm, a delay of around three minutes from when Mr Hussain
was first found, that another officer radioed a code blue. We are concerned that
this was an avoidable delay, and that Officer F should have attempted to radio a
code blue when he found Mr Hussain or, if this did not work, immediately on his
return to the staff office.
205. We appreciate that radio black spots exist in the segregation unit and around other
parts of the prison. However, another officer was able to make the call when
standing outside the cell. Officers should still try to call a code blue even if they
believe this to be the case, and if a radio does not work, they should shout for
assistance or ring the emergency alarm. The delay in calling a code blue led to a
delay in calling an ambulance for Mr Hussain. Any delay can have a significant
impact on a person’s chance of survival. Given that staff and paramedics were able
to establish Mr Hussain’s pulse, we cannot know whether earlier intervention might
have affected the outcome for him.
206. We have made similar recommendations about the delay in staff calling emergency
codes at Manchester in our reports into the death of men in June 2019, August
2020 and November 2020. It is important that staff understand their roles in a
medical emergency, and it is concerning that we have repeatedly made these
similar findings. We make the following recommendation:
The Prison Group Director for the Long Term and High Security Estate should
take steps to satisfy himself that all staff at HMP Manchester understand their
responsibilities during medical emergencies, including calling an immediate
emergency code when there is a threat to life.
Clinical care
207. The clinical reviewer concluded that the clinical care that Mr Hussain received was
of a mixed standard and not wholly equivalent to that which he could have expected
to receive in the community.
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Mental healthcare
208. The clinical reviewer stated that Mr Hussain had a complex presentation of
paranoid schizophrenia and concluded that there had been seamless care between
his previous periods of custody and treatment in the community, with good liaison
between each.
209. The clinical reviewer noted that during periods of custody, there appeared to be a
clear pattern of an increase in Mr Hussain’s apparent psychotic symptoms following
his non-compliance with medication. This was often followed by assaults and
periods of segregation. A prison psychiatrist told us that she could find no overt
psychotic symptoms when she last saw Mr Hussain on 16 March. She told us that
given that Mr Hussain had been without medication at the time, she believed it
reasonable to continue to observe him and review whether antipsychotic medication
was needed.
210. However, the clinical reviewer found a lack of clarity in Mr Hussain’s medical record
about his medication status at Buckley Hall and whether he was taking it, as his
medication compliance was not monitored. The clinical reviewer also reported his
concerns that, given Mr Hussain had a diagnosis of a severe and enduring mental
illness, he did not have a detailed care plan in place at Buckley Hall to set out
required interventions for his treatment.
211. The clinical reviewer noted that when Mr Hussain arrived at Manchester, he was
appropriately reviewed by a mental health nurse who assessed that he needed a
further urgent mental health assessment. However, due to the restrictions in place
due to the COVID-19 pandemic, only emergency mental health assessments were
completed for newly arrived prisoners during their ten-day isolation period. This
meant that despite being segregated, Mr Hussain’s mental health was not assessed
when he requested it. The clinical reviewer reported that it might have been
prudent to have completed Mr Hussain’s assessment during his period of isolation.
212. The Head of Healthcare told us that a prisoner transfer telephone call should have
taken place between Buckley Hall and Manchester before Mr Hussain’s transfer.
She said that he should have been discussed at the weekly mental health
multidisciplinary team meeting on 22 June, given that he had been identified as
needing a full assessment. The clinical reviewer reported that there was no
evidence that the transfer call took place or that he was discussed at the team
meeting.
213. The clinical reviewer also identified a missed opportunity to ensure continuity of
care, given that the psychiatrist provided psychiatry services at both Buckley Hall
and Manchester. Instead, she told us that she was not aware that Mr Hussain had
transferred to Manchester. We make the following recommendations:
The Head of Healthcare at HMP Buckley Hall should ensure that all prisoners
identified as having a severe and enduring mental illness have
comprehensive care plans.
The Heads of Healthcare at HMP Manchester and HMP Buckley Hall should
ensure that:
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• liaison between prisons takes place when prisoners with a history of
severe and enduring mental illness are transferred to Manchester and
that the outcome is fully documented in the prisoner’s medical records.
• All prisoners identified as requiring an urgent mental health
assessment are assessed promptly and within 48 hours.
• All prisoners with a significant and current mental illness are discussed
at the weekly mental health multidisciplinary meeting to ensure
continuity of care.
Learning lessons
214. We have identified a significant number of concerns in this report. We consider that
it is important for staff to learn from our findings. We make the following
recommendation:
The Governor and Head of Healthcare at HMP Manchester should ensure that
a copy of this report is shared with all staff named in this report and that a
senior manager discusses the Ombudsman’s findings with them.
Inquest verdict
215. The inquest hearing into the death of Mr Hussain was held on 1 December 2023. It
confirmed the medical cause of Mr Hussain’s death as pneumonia and
hypoxic/ischaemic brain damage as a consequence of hanging. The inquest
concluded that Mr Hussain died by suicide and that the failure to answer his
emergency cell bell on 5 July 2021, possibly contributed to his death.
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