Ashley Ferrie

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Independent investigation into
the death of Mr Ashley Ferrie,
a prisoner at HMP Fosse Way,
on 13 February 2024
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Ashley Ferrie died on 13 February 2024, after he was found hanging in his cell at HMP
Fosse Way. Staff and paramedics tried to resuscitate him but were unsuccessful. He was
35 years old. I offer my condolences to Mr Ferrie’s family and friends.
Mr Ferrie was the first prisoner to die at Fosse Way, a new prison that opened in May
2023. During his five months there, Mr Ferrie gave no indication to staff that he was at risk
of suicide or self-harm. I am satisfied that staff could not have foreseen his actions.
Although Mr Ferrie had weekly key worker sessions at Fosse Way, they were delivered by
ten different officers and Mr Ferrie himself commented that he saw a different key worker
each week. I cannot see how meaningful, supportive relationships can be built with such a
model and I have asked the Director to review how key work is delivered at Fosse Way.
Mr Ferrie was found hanging from his cell door, despite the doors having been designed to
be anti-ligature. I recommend that those involved in prison design should review whether
any changes to cell door design are needed and review the frequency of cell door
maintenance checks to ensure their safety features remain effective.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On 29 September 2022, Mr Ashley Ferrie was remanded in prison charged with
drug offences. On 2 June 2023, he was sentenced to eight years in prison and
moved to HMP Onley.
2. In July 2023, after an alleged split from his partner, Mr Ferrie swallowed some
batteries. Staff monitored him under suicide and self-harm prevention procedures
(known as ACCT) from 30 July to 8 August. By then, he had received a visit from
his partner and children and seemed much better.
3. On 14 September, Mr Ferrie was moved to HMP Fosse Way. Staff had no concerns
about him over the next five months.
4. Shortly after 5.15pm on 13 February, an officer carried out a routine check on all
prisoners while they were locked in their cells. In his statement, the officer said that
he saw Mr Ferrie on his bed. CCTV shows that he looked in briefly.
5. Around 15 minutes later, another officer unlocked all the cells on Mr Ferrie’s unit.
CCTV shows that the officer who unlocked Mr Ferrie did not look into the cell. A few
minutes later, a prisoner went into Mr Ferrie’s cell and found him hanging from the
door. He alerted staff who responded quickly. They cut the ligature and immediately
started CPR. Other officers and healthcare staff arrived quickly and assisted with
the resuscitation attempt.
6. Paramedics arrived and continued with the resuscitation attempts. However, they
were unsuccessful and at 6.39pm, the ambulance doctor pronounced Mr Ferrie’s
death.
7. Mr Ferrie left two notes in his cell which indicated that he intended to take his life.
He said he was lonely and depressed.
Findings
8. Mr Ferrie did not show any signs that he was at risk of suicide or self-harm during
his time at Fosse Way. We are satisfied that staff could not have foreseen his
actions.
9. Local instructions say that staff should carry out welfare checks on prisoners four
times a day, at 7.15am, 1.15pm, 5.00pm and 10.00pm, and that they should get a
response from the prisoner. CCTV shows that although an officer looked into Mr
Ferrie’s cell briefly during the routine check at 5.15pm, he did not try to get a
response from Mr Ferrie. Also, no one signed to say they had completed the
5.00pm welfare checks that day. The officer who unlocked Mr Ferrie’s cell at
5.32pm did not look in so no one identified that Mr Ferrie was hanging until a
prisoner found him. Evidence suggests that welfare checks are not being carried
out correctly or at the appropriate times.
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10. Mr Ferrie had weekly key worker sessions at Fosse Way but they were held by ten
different officers during his five months there. The purpose of key worker sessions
is to build a supportive relationship that can help the prisoner to progress through
their sentence. We consider that this cannot be achieved if a prisoner’s key worker
changes frequently.
11. Despite the cell doors at Fosse Way having been designed to be anti-ligature (so
that a ligature would be very difficult to attach), Mr Ferrie was found hanging from
his cell door. We were told that the anti-ligature strip around the door frame needed
maintenance to ensure that it remained effective. An annual check was scheduled
so the door was not due to be checked until May 2024. The cell door design and
frequency of maintenance checks should be reviewed.
Recommendations
• The Director should review the prison’s local instructions on roll checks, unlocking
and welfare checks to ensure that there are sufficient quality assurance processes
in place to establish that:
• staff are clear about the type of check required, when they should
do it, and how the check should be carried out;
• a welfare check is carried out on all prisoners at or before
unlocking; and
• staff carry out checks in accordance with the prison’s local
instructions and relevant national guidance.
• The Director should review the key working model in place at Fosse Way to ensure
that it is delivering the desired outcomes.
• The Head of Custodial Contracts, in conjunction with the MoJ Prison Infrastructure
Team and MoJ Property Directorate Technical Standards, should review:
• Whether any changes to cell door design are needed.
• The frequency of cell door maintenance checks needed to ensure
that the anti-ligature features remain effective.
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The Investigation Process
12. HMPPS notified us of Mr Ferrie’s death on 13 February 2024.
13. The investigator issued notices to staff and prisoners at HMP Fosse Way informing
them of the investigation and asking anyone with relevant information to contact
her. Two prisoners responded. Neither provided information specific to Mr Ferrie’s
death.
14. The investigator and the Deputy Ombudsman visited Fosse Way on 22 February
2024. They had informal discussions with the Director, Deputy Director, the Deputy
Controller and the Independent Monitoring Board. They also spoke to two prisoners
who were on the same wing as Mr Ferrie. The investigator obtained copies of
relevant extracts from Mr Ferrie’s prison and medical records, CCTV and body worn
video camera (BWVC) footage, the recordings of telephone calls and radio
transmissions.
15. The investigator interviewed five members of staff and one prisoner at Fosse Way
in February, April and July 2024.
16. NHS England commissioned an independent clinical reviewer to review Mr Ferrie’s
clinical care at the prison. She jointly interviewed staff and the prisoner with the
investigator.
17. We informed HM Coroner for Leicester City & South Leicestershire of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
18. The Ombudsman’s office contacted Mr Ferrie’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. She asked if Mr Ferrie
had been in a fight the night before he died which may have affected his state of
mind. This has been addressed in this report.
19. Mr Ferrie’s mother received a copy of the initial report. She did not raise any further
issues, or comment on the factual accuracy of the report.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy in the clinical review and two factual
inaccuracies in relation to staff names in one of the transcripts and these have been
amended accordingly.
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Background Information
HMP Fosse Way
21. HMP Fosse Way opened in May 2023 and is managed by Serco. It is a local
category C prison that holds adult men. Nottinghamshire Healthcare NHS
Foundation Trust provides healthcare services.
HM Inspectorate of Prisons
22. There has not yet been an inspection of Fosse Way.
Independent Monitoring Board
23. 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.
24. The IMB has not yet issued an annual report for Fosse Way. The IMB chair told the
investigator that as the prison was newly opened, there were only two members of
the Board. The majority of the complaints the IMB received were in relation to
property.
Previous deaths at HMP Fosse Way
25. Mr Ferrie was the first prisoner to die at Fosse Way.
Assessment, Care in Custody and Teamwork
26. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and 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. Guidance on ACCT procedures is set out in Prison Service Instruction
(PSI) 64/2011. After an initial assessment of the prisoner’s main concerns, levels of
supervision and interactions are set according to the perceived risk of harm. All
decisions made as part of the ACCT process about the prisoner should be written in
the ACCT booklet, which accompanies the prisoner as they move.
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Key Events
27. On 29 September 2022, Mr Ashley Ferrie was remanded in prison, charged with
drug offences. It was his first time in prison.
28. On 2 June 2023, Mr Ferrie was sentenced to eight years imprisonment. He was
moved to HMP Onley on 6 July.
29. Mr Ferrie had a history of alcohol and drug misuse. He also had a history of mental
health issues including possible schizophrenia, borderline personality disorder,
PTSD, depression and self-harm by cutting. He was admitted to mental health units
on several occasions due to drug-induced psychosis.
30. On 20 July, Onley’s safer custody department received a telephone call to say that
Mr Ferrie had split from his partner and he was going to kill himself. Staff checked
on Mr Ferrie who said he was okay. Staff provided information to him about the
support that was available if needed. They assessed that Mr Ferrie did not require
suicide and self-harm monitoring (known as ACCT) at that time but that they would
keep checking on him.
31. On 30 July, Onley received a call to say that Mr Ferrie had swallowed some
batteries. Prison staff took him to hospital and started ACCT procedures. Mr Ferrie
was discharged from hospital the next day. Staff continued ACCT monitoring until 8
August. By then he had received a visit from his partner and children, had been
working with the mental health team and was feeling much better. There were no
further incidents of self-harm at Onley.
HMP Fosse Way
32. On 14 September, Mr Ferrie was moved to HMP Fosse Way. His ACCT document
should have travelled with him along with the rest of his prison paperwork but it did
not. Onley said that they posted Mr Ferrie’s ACCT document to Fosse Way, but it
never arrived (they had proof of posting but Royal Mail was unable to confirm
delivery). This was discovered only after Mr Ferrie’s death. Onley provided us with a
recreated ACCT document using notes that the case coordinator had kept.
33. A nurse completed Mr Ferrie’s reception health screen when he arrived at Fosse
Way. She recorded that Mr Ferrie said that he did not have any drug issues and no
thoughts of suicide or self-harm. She noted that Mr Ferrie had been on an ACCT up
until August but that he felt fine now. He said that he had a history of mental health
problems and that he had been prescribed sertraline (an antidepressant) the day
before. After consulting with a mental health nurse who had no concerns, she
recorded that Mr Ferrie did not need a referral to the mental health team at that time
and advised him how to self-refer if necessary. Healthcare staff prescribed
sertraline a few days later.
34. On 18 September, a nurse completed a secondary health screen. She noted that
Mr Ferrie said he had no concerns and was aware how to access healthcare if
needed.
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35. Mr Ferrie had regular key worker sessions. During those sessions, he told staff that
he felt safe and settled on Houseblock C and had no thoughts of suicide or self-
harm. Staff noted that he was an enhanced prisoner, enjoyed keeping busy with his
job (as a servery worker and then as a wing cleaner) and had mainly positive
entries in his prison record. He socialised with several prisoners and had regular
contact with his family.
36. Mr Ferrie had an allocated key worker. However, he only had six sessions with her
and from 27 October, he saw nine different officers for his key worker sessions. Mr
Ferrie commented that he was seeing a different staff member every week. The
prison told us that at that time, even though each prisoner had an allocated key
worker, the prisoner would be seen by whoever was on duty on that wing/landing at
the time, so not necessarily their designated key worker.
2024
37. On 5 February, an officer held a key worker session with Mr Ferrie. He noted that
Mr Ferrie had no physical or mental health concerns and no thoughts of suicide or
self-harm. He said he felt safe on the houseblock and got along with everyone. The
officer noted that Mr Ferrie did not have a job or attend education. (Mr Ferrie had
given up his job of wing cleaner in January for unknown reasons.) This was the last
entry in his prison record.
38. On 9 February, a mental health nurse assessed Mr Ferrie after he told staff at the
medications hatch that he was not sleeping and wanted to review his medication.
He told her that, “I just want to feel a bit better” and asked to restart his
antipsychotic medication (which he had previously been prescribed before he was
sent to prison but was stopped when he told a prison psychiatrist that he was not
sure if it had helped him). She told him that he would need to see a psychiatrist and
made a referral. (The average waiting time was up to six weeks but as Mr Ferrie’s
referral was not urgent, it was expected to be up to two months.) At interview she
said that Mr Ferrie told her that he had symptoms of attention deficit hyperactivity
disorder (ADHD) and was feeling restless and fidgety. She therefore made a
referral for review by the speech and language therapist who managed the
neurodiversity caseload. She noted that Mr Ferrie appeared well-kempt and that he
said he had no thoughts of suicide or self-harm.
39. There was no record of Mr Ferrie being involved in an argument or fight.
Events of 13 February
40. The investigator watched CCTV footage, body worn video camera (BWVC) footage
and listened to the telephone calls and prison radio transmissions from 13
February. She also obtained information from the East Midlands Ambulance
Service.
41. Mr Ferrie was on Houseblock C. The daily regime for prisoners on Houseblock C
was that they were unlocked at around 7.45am and could access the wing; they
were locked back in over the lunch period, between 12.15pm and 1.15pm; then
unlocked for the afternoon until around 5.00pm; then locked back into their cells for
a roll check (a routine count of all prisoners) at around 5.15pm before being
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unlocked again until around 7.00pm when they were locked into their cells for the
night.
42. After being unlocked on the morning of 13 February, Mr Ferrie remained in and by
his cell for most of the morning. CCTV shows that for short periods he sat on
seating outside his cell, speaking to other prisoners by his cell door. At one point, a
prisoner hugged Mr Ferrie as they were speaking.
43. Mr Ferrie rang his partner four times that morning. It was his son’s birthday, and he
spoke to him during one of the calls. When Mr Ferrie spoke to his partner, he
became aggressive and asked her repeatedly if she wanted or had a new partner.
At one point he threatened to kill her if she got a new partner. Mr Ferrie made the
last call at 11.54am and said he would call back later. He did not mention any
thoughts of suicide or self-harm.
44. CCTV shows that before the lunchtime roll check, Mr Ferrie went back into his cell
and closed the door.
45. The lunchtime roll check was completed at approximately 12.07pm by Prison
Custody Officer (PCO) A. In his statement, he said that he saw Mr Ferrie lying on
his bed as he locked his cell door. CCTV shows that at approximately 1.19pm, he
unlocked the cell door and briefly looked in. Mr Ferrie did not leave his cell and no
one entered his cell over the next three hours.
46. At around 4.45pm PCO B was checking that prisoners were in their cells so he
could lock them in for the 5.00pm roll count. CCTV shows that when he got to Mr
Ferrie’s cell, he pushed the cell door slightly open. He did not appear to look into
the cell. In his statement, he said that he could not see Mr Ferrie in the cell, so he
left it unlocked as he thought he was still out on the wing.
47. At 5.00pm, prison staff began conducting a roll count. In his written statement, PCO
A said that at approximately 5.15pm when he looked into the cell he saw Mr Ferrie
lying on his bed. CCTV shows he briefly looked into the cell and locked the cell
door.
48. CCTV shows that at 5.32pm, PCO B unlocked the cell door and slightly pushed it
open. He did not look through the observation panel.
49. A few minutes later, a prisoner who lived next door to Mr Ferrie slightly opened Mr
Ferrie’s cell door and then left it. He did not enter the cell. At around 5.35pm
another prisoner went into Mr Ferrie’s cell and found him suspended from a ligature
made from a bedsheet attached to the top corner of the cell door. He shouted for
help.
50. CCTV shows several prisoners crowded around the cell door. PCO B pushed
through the prisoners and entered the cell. He saw Mr Ferrie hanging from the cell
door. He shouted to a colleague and pressed the general alarm. PCO A was the
first to respond. PCO B shouted for his ligature knife and on the recorded radio
transmission, PCO A used his radio to call an emergency radio code blue. Staff in
the control room immediately called for an ambulance at 5.37pm.
51. In the cell, PCO B cut the ligature and with help from some prisoners, laid Mr Ferrie
on the cell floor and he immediately began chest compressions. At approximately
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5.40pm, other officers and healthcare staff responded to the radio message.
Officers cleared prisoners from the immediate vicinity and assisted PCO B with
resuscitation.
52. In order to have more room, staff moved Mr Ferrie from the cell to the landing
outside and continued with resuscitation attempts.
53. Ambulance paramedics arrived at 6.10pm and continued with resuscitation
attempts. At 6.39pm, the ambulance doctor pronounced Mr Ferrie’s death.
54. Mr Ferrie left two notes in his cell that clearly indicated his intention to take his life.
One said that it was “Saturday 20th” (presumed to be 20 January) and he was about
to hang himself. He said that he was lonely as no one talked to him and he was
very depressed.
55. Friends on Mr Ferrie’s houseblock said they interacted with him daily. They said on
occasions he appeared down as he spoke about possible charges, family issues
and relationship struggles but never said anything specific.
56. A prisoner said that Mr Ferrie told him that he was having relationship problems and
thought that his mental health was not being treated correctly.
Contact with Mr Ferrie’s family
57. The prison appointed a PCO as the family liaison officer and a prison manager as
the deputy. They visited Mr Ferrie’s family at approximately 8.15pm on 13 February
to tell them he had died and offer support. (In fact, they had already learnt of his
death via the son of a friend who was also at Fosse Way.)
58. The prison contributed to the cost of Mr Ferrie’s funeral, in line with national
guidelines.
Support for prisoners and staff
59. After Mr Ferrie’s death, the Deputy Director 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.
60. The prison posted notices informing other prisoners of Mr Ferrie’s death, and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Ferrie’s death. Managers
said that safety staff stayed on the wing throughout the night and opened ACCT
documents for five prisoners who were distressed. The next day, staff completed
ACCT assessments and first case reviews.
Post-mortem report
61. A post-mortem examination found that Mr Ferrie died from hanging. The pathologist
found no injuries to indicate that he had been assaulted or forcibly restrained prior
to his death. Toxicology results showed evidence of previous mirtazapine use but
there were no other significant findings.
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Findings
Assessment of risk
62. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures (known
as ACCT) that staff must follow if they identify that a prisoner is at risk of suicide or
self-harm.
63. Mr Ferrie was supported using ACCT procedures from 30 July to 8 August 2023 at
Onley, after he swallowed some batteries. He had no more self-harm incidents at
Onley and by the time he moved to Fosse Way on 14 September, he seemed more
settled. He had a thorough reception screening at Fosse Way and showed no signs
that he was at risk of suicide or self-harm.
64. During the next five months at Fosse Way, Mr Ferrie did not give any indication that
he was at risk of suicide or self-harm. When asked by staff at various different
times, he always said he had no thoughts of suicide or self-harm. He did not display
any behaviour or present with any new risk factors to indicate to prison or
healthcare staff that he was at an increased risk of suicide or self-harm.
65. In the days leading to his death, Mr Ferrie told his partner in telephone
conversations that he was concerned about their relationship, his family and
sentencing. However, he never shared his feelings with staff and did not raise any
specific concerns with them. We are satisfied that staff could not have foreseen Mr
Ferrie’s actions.
Welfare checks
66. According to the Residential House Block Diary form in use at Fosse Way, welfare
checks must be conducted four times a day at 7.15am,1.15pm, 5.00pm and
10.00pm (during roll checks) and says, “Response required from a prisoner during
the welfare checks conducted to assure staff that there are no issues of concern.”
67. CCTV shows that when officers checked on Mr Ferrie at 1.19pm and 5.15pm, they
did not try to get a response from him. Also, no one signed the Residential House
Block Diary form to show that they had carried out the 5.00pm welfare checks. The
evidence we have seen in this case indicates that welfare checks are not being
carried out properly. We also consider that there is a high likelihood that Mr Ferrie
was hanging from his cell door when staff unlocked him at 5.32pm, but they did not
notice. We recommend:
The Director should review the prison’s local instructions on roll checks,
unlocking and welfare checks to ensure that:
• staff are clear about the type of check required, when they should do it,
and how the check should be carried out;
• a welfare check is carried out on all prisoners at or before unlocking;
and
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• staff carry out checks in accordance with the prison’s local instructions
and relevant national guidance.
Key worker scheme
68. HMPPS’s Manage the Custodial Sentence Policy Framework requires that all
prisoners should be allocated a prison officer key worker to engage, motivate and
support them throughout their time in custody. Key workers should spend an
average of 45 minutes each week per prisoner on key work duties, including
individual time with each prisoner.
69. Although Mr Ferrie had weekly key worker sessions, he had them with nine different
officers from September 2023 until his last session on 5 February 2024. On 16
December 2023, Mr Ferrie commented that he was seeing a different person each
week.
70. The prison told us that when the prison was newly opened, they were struggling to
provide key worker sessions with a consistent member of staff due to staffing levels.
They allocated a nominal key worker but then whoever was on duty on the
wing/landing at the time would carry out the key worker sessions. When
interviewed, an officer told us that the prison had for a time changed the model so
that officers saw their allocated prisoners for key working sessions but recently it
had reverted back to the original model of whoever was on duty would carry out the
sessions.
71. The purpose of the key worker relationship is to build trust and rapport. In our view,
this cannot be achieved by prisoners seeing multiple different officers, especially
when many prisoners find it difficult to build trusting relationships and share how
they are feeling. We recommend:
The Director should review the key working model in place at Fosse Way to
ensure that it is delivering the desired outcomes.
Cell door design
72. We understand that when the cells at Fosse Way were designed, there was a focus
on minimising ligature points in the cell. This included the design of the cell doors,
which have a metal strip (known as an anti-ligature strip) around the door frame to
reduce any gap through which a ligature could be attached.
73. Despite this safety feature, Mr Ferrie hanged himself from his cell door. The
investigator spoke to senior HMPPS safety policy staff, staff responsible for new
build prison design and MOJ prison infrastructure technical specialists in the
property directorate about the cell door design. They said that anti-ligature strips
around door frames in new build prisons such as Fosse Way should be checked
and adjusted as part of a regular asset and maintenance check. At Fosse Way, the
maintenance check was scheduled to take place annually, so a check had not taken
place by the time Mr Ferrie died, around nine months after the prison opened.
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74. We recommend:
The Head of Custodial Contracts, in conjunction with the MoJ Prison
Infrastructure Team and MoJ Property Directorate Technical Standards,
should review:
• Whether any changes to cell door design are needed.
• The frequency of cell door maintenance checks needed to ensure that
the anti-ligature features remain effective.
Clinical care
75. The clinical reviewer concluded that the healthcare Mr Ferrie received at Fosse
Way was of a good standard which was at least equivalent to that which he could
have expected to receive in the community.
76. The clinical reviewer noted that Mr Ferrie received assessments from the
mental health services for both his mental health needs and his capacity to
make his own decisions. His request for a medication review was being
processed, along with a referral to the Neurodevelopmental Disorder Services
to assess his possible ADHD condition. His risk of self-harm was assessed to
have been low, based on his presentation and behaviour. The clinical reviewer
identified no concerns with the mental health care provided to Mr Ferrie.
Governor to note – HMP Onley
Missing ACCT document and lack of NOMIS entries
77. Mr Ferrie’s ACCT document went missing after Onley posted it to Fosse Way.
While Mr Ferrie’s prison record (known as NOMIS) showed that an ACCT had been
opened for him from 30 July to 8 August 2023, there were no entries in NOMIS
about the reasons for the ACCT, or details of what was discussed at the ACCT
case reviews. The ACCT case coordinator at Onley had kept some notes which
enabled some ACCT documentation to be recreated after Mr Ferrie’s death, but
none of these notes were on NOMIS and therefore were not available to staff at
Fosse Way.
78. As Mr Ferrie did not give any indication to staff at Fosse Way that he was at risk of
suicide or self-harm, the fact that they did not have access to his ACCT document
or any NOMIS entries about the ACCT is unlikely to have made any difference.
However, the previous ACCT and details of Mr Ferrie’s risk factors and triggers
could have been highly relevant if Mr Ferrie had shown signs of being at risk. All
significant interactions with prisoners should be recorded on NOMIS. We consider
that at the very least, the reasons for opening an ACCT and basic contents of
ACCT reviews should be recorded on NOMIS.
79. We bring this issue to the attention of the Governor at Onley.
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Inquest
80. At the inquest, held from 4 to 10 March 2025, the jury concluded that Mr Ferrie died
by suicide.
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