Ashley Wood

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Ashley Wood,
a prisoner at HMP Exeter, on 9
September 2021
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 Ashley Wood died on 9 September having been found hanging in his cell two days
earlier at HMP Exeter. Mr Wood was 26 years old. I offer my condolences to Mr Wood’s
family and friends.
Mr Wood was subject to Prison Service suicide and self-harm support measures (known
as ACCT) when he died. However, I have concerns that these measures were not
managed appropriately, Mr Wood’s escalating risk was not adequately assessed and there
were severe failings in the recording and communication of information relevant to Mr
Wood’s risk. I am also concerned that the risk Mr Wood perceived from others was not
appropriately managed, nor were sufficient wellbeing checks carried out in line with
Exeter’s policy.
The clinical reviewer concluded that Mr Wood’s clinical care was not equivalent to that he
could have expected to receive in the community and identified several shortcomings in
his care. These included a lack of mental health support, clinical observations not being
done, referrals to the mental health team not being completed properly and Mr Wood’s
learning disability not being appropriately assessed and managed.
I have expressed concerns to the Governor of HMP Exeter and to the Prison Group
Director for Devon and North Dorset about deficiencies in ACCT procedures in previous
investigations at Exeter and it is troubling that I have had to raise these issues again in this
report.
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 March 2023
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 9
Findings ......................................................................................................................... 23
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 21 October 2020, Mr Wood was sentenced to 18 months imprisonment for
offences including assault. He was taken to HMP Exeter. It was his first time in
prison. A GP continued Mr Wood’s prescription of antidepressants. On 11
December, Mr Wood transferred to HMP Channings Wood.
2. On 16 July 2021, Mr Wood appeared at court for further assault charges and was
remanded in custody. He was taken to Exeter. During his time at Exeter, Mr Wood
felt threatened by other prisoners and wanted to transfer back to Channings Wood.
On 29 July, Mr Wood cut his face and staff started ACCT measures. On 2 August,
a GP stopped Mr Wood’s antidepressant medication and prescribed him
propranolol to try to lessen his feelings of paranoia and anxiety. On three separate
occasions, Mr Wood said that he had symptoms of Covid-19 and self-isolated. All
tests were negative, and staff thought that he may have been isolating due to
feeling threatened by other prisoners.
3. Staff continued to review his ACCT regularly and noted that he should be referred
for a Challenge Support and Intervention Plan (CSIP – to manage those at risk from
or a risk to others). On 6 August, Mr Wood tied a ligature round his neck. On 7
August, Mr Wood moved to B wing which was for vulnerable prisoners. He
continued to worry about leaving his cell although staff said that over time he began
to settle. On 13 August, Mr Wood was sentenced to a further three years’
imprisonment.
4. On 25 August, staff closed Mr Wood’s ACCT. This was reopened on 28 August
when Mr Wood self-harmed by cutting his arm. Towards the end of August, staff
informed Mr Wood that all B wing prisoners were moving to A wing while B wing
was refurbished. Mr Wood was very anxious about this and on 30 August tied a
ligature around his neck.
5. On 3 September, all B wing prisoners moved to the fourth landing of A wing (A4).
That evening, Mr Wood superficially cut his throat. On 4 September, he told a
chaplain that he had tied a ligature the night before. That evening, he told staff that
he had swallowed four vials of vape solution. Healthcare staff observed him for
signs of toxicity. Mr Wood was due to transfer to Channings Wood on 9
September.
6. On 6 September, Mr Wood tied a ligature around his neck in the evening. Staff
responded, radioed an emergency code, removed the ligature and spoke to him. A
supervising officer (SO) increased his observations to hourly. The next morning a
nurse assessed Mr Wood as he said he was having chest pain. He told her that he
was hearing voices and had been banging his head. During the morning, he told
staff that he was scared for his life.
7. At 11.13am, an officer found Mr Wood tying a ligature to his bed. Staff responded
and removed the ligature. A nurse spoke to Mr Wood as he had chest pains but
said she was unaware he had tied a ligature. In the afternoon, a mental health
nurse assessed Mr Wood, but she was also not aware of the recent ligatures Mr
Wood had tied. He told her he felt under threat from other prisoners. At 4.46pm,
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
staff found Mr Wood collapsed and unresponsive in his cell. Staff went into his cell,
and he started to respond. A nurse assessed him and had no concerns that he was
a risk to himself.
8. That evening, Mr Wood complained of chest pains on two separate occasions.
Officers said they would alert healthcare staff but there is no evidence that they did
so. At 7.33pm, an officer found Mr Wood hanging in his cell. They cut him down
and began chest compressions. Paramedics took him to hospital and Mr Wood
was placed on life support. On 9 September, hospital staff withdrew this life support
and he died at 1.11pm.
Findings
9. Mr Wood was subject to ACCT measures from 29 July until he died, apart from a
period of three days. We have concerns that consistent case managers did not
chair ACCT reviews, immediate ACCT reviews did not take place after Mr Wood
self-harmed or tied a ligature, his family were not involved in the ACCT and the
ACCT review scheduled for 7 September did not take place. It is also concerning
that staff did not adequately record, communicate and assess Mr Wood’s increasing
risk on 6 September and 7 September. We recommend that staff need further
ACCT training.
10. Mr Wood felt at risk from other prisoners after he returned to Exeter. Despite staff
indicating they would do so, he was never referred for a CSIP. It seems likely that
Mr Wood’s fear increased when the vulnerable prisoners’ wing was temporarily
relocated to the top floor of a standard wing, and we are not convinced that his
feelings of being threatened were adequately explored or dealt with.
11. The clinical reviewer concluded that Mr Wood’s clinical care was not equivalent to
that he could have expected to receive in the community. He should have had
access to mental health support, mental health referrals sometimes did not follow
the correct process, clinical observations were not carried out as directed and his
learning disability was not adequately assessed or planned for.
12. Mr Wood should have had daily wellbeing checks during the Covid-19 pandemic as
he was considered a risk to himself. These took place on less than half of the days
that they should have.
Recommendations
• The Governor and Head of Healthcare should ensure that all staff have a clear
understanding of their responsibilities to manage prisoners at risk of suicide and
self-harm in line with national guidelines, including that:
• a named consistent case manager chairs ACCT reviews;
• staff hold an urgent case review when a prisoner’s risk increases;
• a prisoner’s family and friends are included in the ACCT process where
appropriate;
• staff hold ACCT reviews as scheduled;
• staff appropriately question prisoners following an incident of self-harm or
attempted suicide; and
• staff record and share all information that affects risk.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• The Governor should ensure that prison staff inform healthcare staff when a
prisoner asks to see them.
• The Governor and Head of Healthcare should ensure that all staff have received
full (two day) ACCT training and that they are satisfied that staff can appropriately
assess a prisoner’s risk to themselves.
• The Governor should ensure that incidents of violence, bullying or intimidation are
investigated and dealt with in line with local and national policies.
• The Head of Healthcare should ensure that those who are on a waiting list for
therapy have access to mental health support in the interim if there is a risk of
suicide and self-harm.
• The Head of Healthcare should ensure that:
• when a prisoner needs clinical observations these are completed; and
• staff refer prisoners appropriately to the mental health team.
• The Head of Healthcare should ensure that all prisoners with learning disabilities
are clearly recorded, staff receive relevant learning disability training and follow
NHSE/I guidance for prisoners with learning disabilities.
• The Governor should ensure that the key worker scheme is properly embedded
and that key workers are allocated sufficient time for an average of 45 minutes per
prisoner per week for delivery of the key worker role.
• The Governor and Head of Healthcare should ensure that this report is shared with
all staff named in it and that they are given the opportunity to reflect on the
learning involved.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Exeter informing them
of the investigation and asking anyone with relevant information to contact her.
One prisoner responded.
14. Due to the COVID-19 pandemic, the investigator was unable to visit the prison.
She obtained copies of relevant extracts from Mr Wood’s prison and medical
records via email.
15. NHS England commissioned a clinical reviewer to review Mr Wood’s clinical care at
the prison. The investigator and clinical reviewer interviewed 17 members of staff
and three prisoners via telephone and video conference.
16. We informed HM Coroner for Exeter and Greater Devon of the investigation who
gave us the results of the post-mortem examination. We have sent the coroner a
copy of this report.
17. One of the Ombudsman’s family liaison officers contacted Mr Wood’s stepmother
and daughter, to explain the investigation and to ask if they had any matters they
wanted the investigation to consider. Mr Wood’s stepmother asked the following
questions:
• Why had Mr Wood’s co-defendant been allowed to make false allegations
about the nature of Mr Wood’s offence?
• Why was Mr Wood’s co-defendant transferred before him?
• Why were Mr Wood’s suicidal thoughts not taken seriously? Was he on an
ACCT? If he was on an ACCT, how could he take his own life? How often
was he being checked?
• If the prison knew Mr Wood had suicidal thoughts, why was he allowed
razors?
• Did Mr Wood have a safeguarding plan and, if so, what was on it?
• Why was Mr Wood not transferred to HMP Channings Wood on 17 August
when his family had been informed he would be?
• Why was Mr Wood’s family not told when Mr Wood cut his arms and neck or
had suicidal thoughts?
• Was Mr Wood “spiked”, bullied or exploited for sexual activity?
• Can Mr Wood’s cellmate when he first went to Exeter be interviewed?
18. Our investigation found no evidence that Mr Wood took illicit drugs or drank alcohol
with or without his own consent or that he was exploited for sexual activity. We
have not interviewed Mr Wood’s previous cellmate since he was in a single cell for
around the last month of his life. Staff confirmed that Mr Wood was allowed to have
razors and that such items would only be restricted if he was assessed as being a
very high risk to himself, which he was not. Prison Service policy indicates that
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
unnecessary removal of such items can have a detrimental effect by increasing a
prisoner’s distress and risk.
19. We interviewed Mr Wood’s co-defendant and he denied making any false
allegations about the nature of Mr Wood’s offences. During a telephone call to his
family, Mr Wood also said that this was the case. All of Mr Wood’s family’s other
questions have been addressed in the report.
20. Mr Wood’s daughter received a copy of the draft report and indicated that they were
satisfied with the findings.
21. Mr Wood’s stepmother family received a copy of the initial report. They raised a
number of questions that do not impact on the factual accuracy of this report and
have been addressed through separate correspondence.
22. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Exeter
23. HMP Exeter holds up to 431 adult men and young offenders, and serves the courts
of Devon, Cornwall and Somerset. GP and primary care health services are
delivered by Practice Plus Group (PPG), formerly known as Care UK. Devon
Partnership NHS Trust provide mental health services and substance misuse
services are provided by PPG and EDP Drug and Alcohol Services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Exeter was in March 2021. Inspectors reported
that there was a high turnover of staff at all levels and one-third of frontline staff had
been in post for less than a year. They found that more progress was needed to
create a safer, more decent and secure prison. Inspectors noted that relationships
between prisoners and staff were not good enough.
25. Inspectors found that there had been little progress in addressing long-standing
deficiencies in the care of prisoners at risk of suicide and self-harm. Levels of self-
harm had increased during the pandemic and were very high. Inspectors found that
the quality of many ACCT documents was poor. They noted that most caremaps
contained basic actions but few of these had been completed. Inspectors found
that there were also limited opportunities for prisoners at risk of self-harm to have
meaningful interaction with staff. Conversations with prisoners on ACCT took place
each day but most were conducted through doors and lacked privacy and depth.
They found that case reviews were timely, but healthcare staff often were not
present. Inspectors found that there was a well supervised safer custody telephone
line for people to call if they had concerns about a prisoner.
26. Inspectors concluded that healthcare provision was reasonable and access to
clinics was improving. Inspectors found that the provision of medicines was
managed well.
27. HMIP found that prisoners’ perceptions of safety were poor with 29% feeling unsafe
at the time of the inspection, 24% said that they had experienced bullying or
victimisation from other prisoners and 41% said they had experienced bullying or
victimisation from staff.
28. Inspectors reported that for most prisoners, time out of their cell was limited to
around 90 minutes per day and less at the weekends.
Independent Monitoring Board
29. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to December 2021, the IMB
reported that the prison’s response to Covid-19 had been generally well managed.
However, they noted that several prison processes and programmes had suffered.
They noted the high proportion of newly appointed officers, the difficulty of retraining
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
staff and staff doing extra hours to cover shifts resulting in some staff fatigue. The
IMB noted levels of self-harm and violence remained high. They noted that there
was clear evidence that the prison was committed to reducing violence and self-
harm but there was still scope for improvement.
30. The IMB concluded that staffing problems in healthcare had coincided with the need
to manage the pandemic. Some healthcare appointments had been restricted to
urgent care and medications only, although GP appointments continued via the
telephone.
31. The IMB noted that the refurbishment of B wing (which housed vulnerable
prisoners) and their temporary relocation to A wing had created a number of
practical challenges for prisoners some of which had impacted on their perceptions
of safety and opportunities. They noted that when the B wing prisoners moved, a
secure gate had not been fitted to prevent access to A4 landing by other A wing
prisoners. (Although the prison clarified that an officer was stationed at the
entrance to A4 landing to prevent other prisoners accessing the landing.) Mr Wood
was located on A4 landing when he died.
Previous deaths at HMP Exeter
32. Mr Wood was the ninth prisoner to die at Exeter since September 2019. Three of
these previous deaths were self-inflicted and five were due to natural causes. In all
three self-inflicted investigations, we have identified the need for improvements in
risk assessment and ACCT management (although one of these is still subject to
investigation). We also requested a meeting with the Prison Group Director for
Devon and North Dorset so that they could outline what they were doing to improve
the management of prisoners at risk of suicide and self-harm. Two previous
investigations also found that improvements were needed in investigating and
dealing with incidents of violence, bullying or intimidation. There has been one self-
inflicted death at the prison since that of Mr Wood which we are currently
investigating.
Assessment, Care in Custody and Teamwork
33. 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. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
34. As part of the process, a care plan is put in place. The ACCT plan should not be
closed until all the actions of the care plan have been completed. All decisions
made as part of the ACCT process and any relevant observations about the
prisoner should be written in the ACCT booklet, which accompanies the prisoner as
they move around the prison. Guidance on ACCT procedures is set out in Prison
Service Instruction (PSI) 64/2011, Safer Custody.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
COVID-19 restrictions
35. On 24 March 2020, in response to the COVID-19 pandemic and in line with
Government advice, HMPPS issued an instruction to all prisons to introduce social
distancing and a restricted regime for staff and prisoners, wherever possible. On 27
March, HMPPS issued operational guidance to prisons on exceptional regime and
service delivery, which reflected Government restrictions following the national
lockdown of 23 March. This guidance resulted in significantly restricted prisoner
activities. Prison visits were suspended, education and non-essential work was
cancelled, and healthcare delivery was also affected. This meant that prisoners
spent much of their day locked behind their cell doors.
Keyworker scheme
36. The keyworker scheme aims to improve safer custody by engaging with prisoners,
building better relationships between staff and prisoners and helping prisoners
settle into life in prison. It provides that all adult male prisoners will be allocated a
key worker who will spend an average of 45 minutes a week on key worker
activities, including having meaningful conversation which each of their allocated
prisoners.
The keyworker scheme was suspended across the estate on 24 March 2020 due to
the COVID-19 pandemic. To ensure that meaningful interaction continued for
priority prisoners, such as those who were at risk of suicide or self-harm, the Prison
Service introduced the Exceptional Delivery Model for keywork in May 2020. This
provides that an officer will have a weekly conversation with prisoners identified as
vulnerable.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
HMP Exeter, 21 October 2020 – 11 December 2020
37. On 21 October 2020, Mr Wood was sentenced to 18 months imprisonment for
assault, causing animal suffering and possession of an offensive weapon and taken
to HMP Exeter. It was his first time in prison. Mr Wood told a nurse that he had
previously self-harmed by cutting himself in March but had no current thoughts of
suicide or self-harm. He said he suffered from anxiety and depression and was
referred to the mental health team. Mr Wood said he misused alcohol, his
withdrawal symptoms were assessed, and he was prescribed medication to try to
lessen these.
38. On 24 October, a nurse from the mental health team assessed Mr Wood. He said
that he wanted to be transferred to HMP Channings Wood as he had heard positive
reports about it. He said he had previously been prescribed citalopram (an
antidepressant). A GP later prescribed him citalopram and planned to review his
mood in three weeks. Mr Wood declined psychological support as he did not feel it
was the right time for him.
39. On 10 November, a GP reviewed Mr Wood’s mood and doubled his prescription of
citalopram. On 1 December, a GP noted that Mr Wood had a possible diagnosis of
a learning disability and that this had not been addressed in his recent mental
health assessment. They sent a referral to the learning disabilities team.
40. On 7 December, Mr Wood told staff that he had chest pain. Healthcare staff
assessed him and had no concerns. Mr Wood then said he needed paracetamol
for toothache. Nurses told him they could not give him the medication. Mr Wood
cut himself with a razor. Staff started Prison Service suicide and self-harm support
measures, known as ACCT. Healthcare staff assessed Mr Wood, and he was
given paracetamol and ibuprofen.
41. During the ACCT review later that day, Mr Wood told staff that his toothache had
been so acute that he had felt like he had no other option but to self-harm. He said
he had no current thoughts of suicide or self-harm. Staff closed Mr Wood’s ACCT
and a senior prison manager investigated why Mr Wood had not originally been
given his pain medication.
42. On 8 December, Mr Wood’s cellmate assaulted him, and he sustained facial
injuries. Healthcare staff assessed him and observed him regularly. Mr Wood was
also assessed by staff from the learning disabilities team. He said that he was
dyslexic but was unaware of any diagnosis of a learning disability. Staff noted that
they did not assess he had a learning disability but noted that he was somewhat
naïve and could be potentially vulnerable to exploitation and bullying.
HMP Channings Wood, 11 December 2020 – 16 July 2021
43. On 11 December, Mr Wood transferred to Channings Wood. He progressed well at
the prison, engaged with substance misuse services, enrolled in education and
worked intermittently. In January 2021, it was documented that Mr Wood had a
diagnosis of second-degree heart block (a condition which causes the heart to skip
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
beats). The clinical reviewer noted that this has a range of clinical consequences
but was not a concern for Mr Wood and did not require any ongoing treatment.
Symptoms can include chest pain, fainting and dizziness.
44. In February and April, Mr Wood said he had chest pain. Healthcare staff and
paramedics assessed him and concluded that it was anxiety related. Mr Wood had
been working towards his release on 21 July. However, he became concerned that
he might be facing further charges.
45. On 13 June, a nurse from the mental health team assessed Mr Wood after he had
referred himself. He told them that he was expecting further charges and thought
he would be remanded to HMP Exeter. He said he had suffered from anxiety for
years, had heart palpitations, struggled with his breathing and his body ached. He
said he struggled to get out of bed some days and had low motivation. Mr Wood
said that he had taken an overdose two years ago. Due to Mr Wood’s planned
release the following month, he was not added to their caseload.
46. On 25 June, Mr Wood was due to appear at court on new charges. He refused to
attend. On 8 July, staff from the mental health team saw Mr Wood at his request.
He said he had felt increasingly anxious over the previous month, felt low in mood
but had no thoughts of suicide or self-harm. The nurse said that she would speak
to the team and noted that he might benefit from attending the anxiety group. She
also advised him to speak to the GP about his medication.
47. On 12 July, a nurse assessed Mr Wood who said he felt anxious about his court
hearing that week. He said he had chest pains which healthcare staff assessed.
On 14 July, staff did an ECG which showed abnormalities and Mr Wood was taken
to hospital for further investigation. There is no discharge summary in Mr Wood’s
record to detail the conclusion of this assessment.
48. On 16 July, Mr Wood attended court and was remanded to custody on further
assault charges. Mr Wood’s co-defendant was also remanded to custody that day.
He told the investigator that Mr Wood seemed anxious in court. He said that they
had regularly spoken on the telephone before the court date and that Mr Wood had
seemed “bright”. He never had any concerns that he was a risk to himself.
HMP Exeter, 16 July 2021 onwards
C wing
49. Mr Wood was taken to Exeter and located on C wing, a standard residential wing.
On 20 July, a GP prescribed him citalopram after staff realised he had not brought
this medication with him from Channings Wood. The GP also referred him for an
ECG which was due to take place on 25 July. This did not go ahead, and it is not
clear why. On 28 July, Mr Wood met with his key worker. He said he wanted to be
sentenced and return to Channings Wood.
50. On 29 July, around 7.00am, Mr Wood gave a note to staff to say that he felt his life
was in danger due to rumours about him and he would like to be moved to B wing,
where the vulnerable prisoners (those that are considered to be at risk from other
prisoners) were located. He said other prisoners were calling him a “nonce” and
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
threatening to stab him. At 1.20pm, Mr Wood made superficial cuts to his face with
a razor blade. Staff opened an ACCT. Healthcare staff assessed him, and he was
referred to the mental health team
51. On 30 July, an officer completed Mr Wood’s ACCT assessment. Mr Wood said that
he felt anxious, and his antidepressants were not working. He said that he had
been too scared to leave his cell due to being threatened by other prisoners (but
would not give any names) and had not been eating. During the subsequent case
review chaired by a Supervising Officer (SO), staff present reduced Mr Wood’s
observations. The SO told the investigator that those present thought opening a
Challenge Support Intervention Plan (CSIP – used to support prisoners at risk from
or a risk towards others) might be more appropriate than an ACCT and noted that
they would refer him.
52. A nurse noted that Mr Wood had his medication in his own possession, but he had
not collected this since arriving at Exeter. The nurse sent a task to the pharmacy
team to review him and check his cell for medication. She also changed Mr Wood’s
medication to not in his possession since he was on an ACCT.
53. A nurse from the mental health team had been present in the ACCT review and
assessed Mr Wood afterwards. He said he wanted to try different medication as he
thought the citalopram was not working and felt anxious. There is no record that
she discussed this may have been because Mr Wood had not been taking his
citalopram.
A wing
54. On 1 August, Mr Wood moved to A wing. There is also a note in his record that a
SO was going to do a CSIP referral. There is no record that this was done.
55. On 2 August, Mr Wood’s sister rang the prison. She said she was concerned about
Mr Wood who said that he was going to hang himself. Staff carried out a welfare
check and a SO increased Mr Wood’s ACCT observations to hourly.
56. During a multidisciplinary meeting that day, healthcare staff agreed Mr Wood would
start psychological therapy once transferred to Channings Wood. A prison GP
subsequently assessed Mr Wood and noted he showed no signs of depression but
was anxious. She stopped Mr Wood’s prescription of citalopram and prescribed
him propranolol to try to lessen his feelings of paranoia and anxiety. Mr Wood told
staff that he had a sore throat and had lost his sense of taste and smell. He self-
isolated and was tested for COVID-19 (which was negative a couple of days later).
57. On 3 August, during an ACCT case review chaired by a SO, Mr Wood told staff that
he still felt threatened on A wing and was waiting for a response to his application to
be a vulnerable prisoner.
58. On 6 August, during a case review, Mr Wood again said that he had Covid-19
symptoms and he self-isolated. Staff noted that they had not witnessed anyone
threatening him nor had his cellmate, but Mr Wood said that he was “absolutely
terrified” of leaving his cell. He still wanted to move to B wing. The SO noted that
he was being considered for a CSIP which they considered would have been more
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
appropriate than an ACCT. Mr Wood said that he had no thoughts of suicide or
self-harm.
59. At 11.40pm, Mr Wood’s family telephoned the prison to say that he had just called
them and told them he was going to tie a ligature. Staff went to Mr Wood’s cell,
who started to put his head through a ligature he had made. Staff went into his cell
and removed the ligature and healthcare staff assessed Mr Wood. They noted faint
marks on his neck but no other injuries. They referred him to the mental health
team. He told staff that he wanted to move to B wing as prisoners were calling him
names. Staff explained this was not possible as he did not meet the criteria and
discussed other options. Mr Wood said he would self-isolate until he was
sentenced after which he would apply for a transfer to Channings Wood. Mr
Wood’s ACCT observations were increased to three per hour.
60. Mr Wood’s stepmother told police that the calls from Mr Wood became more
worrying. He said he was under threat from prisoners and staff who he thought
would stab him. She said that she telephoned the prison and asked them to put
him under constant observation. They replied that they would assess and support
him. She said that a few weeks before Mr Wood was sentenced, a SO called her
and told her that Mr Wood would be transferred to Channings Wood on 17 August.
She said that the SO had told her that he was going on leave, but Mr Wood would
be transferred while he was away.
61. On 7 August, during an ACCT case review chaired by a SO, staff and Mr Wood
discussed his plan to isolate until his court appearance on 13 August. They
decreased Mr Wood’s observations to hourly. A nurse from the mental health team
spoke to Mr Wood after his ACCT review. Mr Wood said he was paranoid and
anxious on A wing. He said he had no thoughts of suicide or self-harm and would
speak to her the next day.
B wing
62. Mr Wood was not assessed as a vulnerable prisoner but at his request he moved to
B wing (for vulnerable prisoners) in the afternoon of 7 August. A SO said that Mr
Wood was unlocked with a small number of prisoners who were also on the
vulnerable prisoners’ wing but were not vulnerable prisoners themselves.
63. On 9 August, the mental health nurse assessed Mr Wood. He remained fearful of
other prisoners and had been refusing to leave his cell. The nurse also noted that
Mr Wood had not had the ECG which had been requested and this took place later
that day. She referred him to a GP who later prescribed him sertraline (an
antidepressant). Mr Wood was compliant with both his sertraline and propranolol
medication.
64. On 10 August, during an ACCT case review chaired by a SO, Mr Wood said he felt
safer on B wing and asked if he was going to be moved back to A wing. He was
told this was not the plan. Staff noted that the mental health team had indicated
that he was unlikely to be allocated to their caseload as he was only due to be at
Exeter for a short time. On 12 August, a healthcare assistant from the mental
health team went to see Mr Wood. They noted that Mr Wood was paranoid and
dishevelled. Mr Wood later said that he had a sore throat and therefore self-
isolated.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
65. On 13 August, Mr Wood was sentenced to three years imprisonment for assault
offences. He did not attend court as he was self-isolating. There is no evidence
that staff informed him of the outcome despite it being listed in the triggers section
of his ACCT document and him having mentioned this during ACCT reviews. Mr
Wood told a nurse that prisoners from A wing were threatening him. The nurse
noted that he had not yet been discussed at the weekly Multi-Disciplinary Team
(MDT) allocation meeting.
66. Mr Wood’s stepmother said that Mr Wood continued to call her daily with his mood
fluctuating between paranoid and rational. However, between 13 August and 2
September Mr Wood was unable to call anyone due to an issue with the prison’s
telephone lines.
67. On 16 August, Mr Wood asked staff during an ACCT review what sentence he had
received at court. There is no record that staff knew the outcome or that they
informed him. A nurse discussed Mr Wood at the MDT meeting later that day. She
told the investigator that because Mr Wood’s transfer to Channings Wood had not
happened as quickly as they had been expecting the MDT had agreed to refer him
to a psychologist. A GP also reviewed Mr Wood’s recent ECG and noted they had
no concerns.
68. Prisoner A was on B wing at the same time as Mr Wood and shared a cell with his
cousin. He had known Mr Wood since childhood. They were not unlocked for
association at the same time, but he said that Mr Wood used to come to their cell to
speak to them through the observation panel. He said that Mr Wood seemed
depressed and was not himself. He said that Mr Wood was quite “feisty” in the
community but in prison he seemed “deflated”, “low” and lethargic. Mr Wood told
the prisoner that he was worried that other prisoners thought he was a sex offender
and were shouting abuse at him.
69. Staff told the investigator that Mr Wood was generally anxious while he was on B
wing and often had to be encouraged to leave his cell. Staff said that over time staff
built up trust with Mr Wood, so that he seemed more settled and less paranoid
about other prisoners. At some point, Mr Wood was informed about the sentence
he had received although this is not documented. A SO told the investigator that Mr
Wood seemed fairly happy about the sentence and had been expecting three years.
70. On 18 August, Mr Wood had a key worker session. This took place at Mr Wood’s
cell door as he was self-isolating. Mr Wood said that when he stopped isolating, he
would like to enrol in education and spoke about his release.
71. On 20 August, Mr Wood’s most recent Covid-19 test came back as negative.
Around 5.00pm, he said that he had chest pain. A nurse assessed him, his
observations were normal, and they did an ECG which they sent to a GP for review.
The nurse questioned whether the pains were anxiety related.
72. On 25 August, during an ACCT review, Mr Wood said that his medication had
helped his anxiety, he was no longer isolating and was associating with other
prisoners. He said he had no thoughts of suicide and self-harm, and staff closed
his ACCT.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
73. On 27 August, Mr Wood asked an officer if he could see the mental health team. A
GP reviewed Mr Wood’s recent ECG results. The GP concluded that the chest pain
was probably musculoskeletal and prescribed codeine (a painkiller), requested
blood tests, a repeat ECG, daily clinical observations and a follow-up review in a
week. On 28 August, at 6.45pm, Mr Wood self-harmed by making superficial cuts
to his arm. He said he did so as he felt unsafe on the wing. Staff reopened his
ACCT.
74. During an ACCT review on 29 August, Mr Wood said that he had no intention of
dying but was having suicidal thoughts and used self-harm as a coping mechanism.
He said he did not want his medication increased. Staff noted that he had poor
personal hygiene and still felt under threat on the wing.
75. On 30 August, staff found Mr Wood with part of a bed sheet wrapped around his
neck and the other end tied to the pinboard holder. Mr Wood did not respond to
staff, so they radioed a code blue (an emergency code indicating that a prisoner is
not breathing or is having difficulty breathing) and went into the cell. Mr Wood got
up and removed the sheet from his neck. Mr Wood said that if he was moved to a
standard residential wing he would be killed. (Although it is not documented, it
seems likely that staff had spoken to him about moving back to A wing while B wing
was being refurbished). A nurse checked Mr Wood and mental health staff spoke
to him. Staff increased his observations to hourly until he had an ACCT review the
following day.
76. A nurse later reviewed Mr Wood and he said that he had tied the ligature over
anxiety about moving back to the main wing where he would be under threat. He
said he wanted to transfer to Channings Wood. On 31 August, healthcare staff did
an ECG and took observations and blood for testing as previously requested by the
GP. A GP reviewed the ECG results and concluded that there was evidence of
possible heart block and tasked a nurse to complete further examinations. There is
no evidence that further examinations took place.
77. During an ACCT review, staff confirmed that all prisoners on B wing had to move to
A wing at the end of the week as B wing was closing for refurbishment. Mr Wood
said that he might self-isolate until his transfer to Channings Wood but could not
provide any names of prisoners from whom he was under threat. A SO spoke to
the transfer clerk who confirmed that Mr Wood was prioritised for transfer the
following week.
78. On 1 September, healthcare staff discussed Mr Wood at the MDT and arranged him
an appointment with a psychologist on 7 September. On 3 September, Mr Wood
told staff that he was worried about moving to A wing, he would not be able to cope
and was having thoughts of self-harm. Staff told the orderly officer in charge of the
prison. A SO told the investigator that Mr Wood had been worried that he would not
be kept with the vulnerable prisoners, but staff reassured him that he would be.
A wing
79. Later that day, Mr Wood moved to the fourth landing of A wing (A4). A wing is a
standard residential wing, but the fourth landing had been designated for vulnerable
prisoners while B wing was being refurbished.
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
80. Around 8.00pm, Mr Wood made superficial cuts to his throat as he was not happy
on A wing. Healthcare staff cleaned and glued his wounds. His observations were
increased to two per hour. A SO said that staff tried to reassure him and talk to him
about his imminent transfer.
81. On 4 September, during an ACCT review at 8.50am, Mr Wood said that he was
terrified about collecting his medication with other prisoners. Staff arranged for Mr
Wood to be able to collect his medication on his own. He told staff he felt unsafe on
A wing and other prisoners would be able to harm him. Staff tried to reassure him
that this was not the case and he and the vulnerable prisoners would remain
separated from the rest of the prisoners. Staff reflected that he would be
transferring to Channings Wood early the following week and encouraged Mr Wood
to focus on this. They noted that he was likely to isolate until he moved. His
observations were set at five overnight and one conversation in the morning and
afternoon.
82. A member of chaplaincy staff went to see Mr Wood around 10.00am. He said he
felt unsafe, and two prisoners had banged on his door the day before, told him he
owed them money and he should pay, or they would “do him in”. Mr Wood told the
chaplain that that he had tried to tie a ligature last night. The chaplain noted that
they told staff about their conversation, but did not note it in Mr Wood’s ACCT.
83. Prisoner B was also a prisoner who was on B wing and then moved to A4 when it
shut. He said that when they moved prisoners from other landings shouted towards
the vulnerable prisoners, calling them derogatory names and saying things like “you
all need to kill yourself”. He said it did not happen all of the time but as soon as one
prisoner started, others joined in. He said that this lessened after a short time,
although it still happened sporadically. He never heard any threats or insults being
directed specifically at Mr Wood.
84. At 11.50pm, healthcare staff assessed Mr Wood as he said that he had swallowed
four vials of vape solution and had vomited blood. The GP advised staff that Mr
Wood needed to go to hospital. However, the manager in charge of the prison at
the time said that if Mr Wood went out to hospital it meant that they would not have
sufficient staff if anyone needed emergency treatment. Healthcare staff decided to
regularly observe Mr Wood overnight and the next day instead. Mr Wood’s clinical
observations remained stable that evening and there were no obvious toxicity
symptoms. There is no evidence that these observations continued for the rest of
the next day as planned.
85. On 5 September, Mr Wood worked with a group of prisoners on B wing to prepare it
for the refurbishment. A SO deliberately included Mr Wood to get him out of his cell
and socialising with other prisoners. The SO noted that he was happy working on B
wing but was still anxious when he returned to A wing. The SO said that Mr Wood
knew he was due to transfer to Channings Wood on 9 September and was looking
forward to it.
6 September 2021
86. On 6 September, Mr Wood asked a member of staff if they could check if he was
definitely moving to Channings Wood on 9 September. They said they would look
into it for him. Mr Wood followed the regime and collected his food.
Prisons and Probation Ombudsman 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
87. In the afternoon, Mr Wood asked to make a telephone call to request a GP
appointment as his cell wall plug was not working. He spoke to a GP in the office
on the telephone. He told her that he thought his new antidepressants were
working better. He told the GP that he felt at risk from other prisoners and was
looking forward to being transferred to Channings Wood. Mr Wood said that he had
a heart issue and the GP noted that they needed to follow up the hospital for
discharge information from the last time he Had been admitted.
88. A nurse administered the medication to prisoners on A4 landing at around 6.00pm.
She said that when Mr Wood came to collect his medication, he asked if he could
see her later that day. She said that she would try and see him once she had
finished giving prisoners medication.
89. During the evening, Mr Wood told staff that he was scared of being on A wing. At
7.05pm, Mr Wood rang his cell bell and, when an officer attended, he was standing
by his window with a ligature around his neck tied to the outer bars. The officer
radioed for staff assistance and recorded that they cut the ligature. They noted in
the ACCT document that Mr Wood’s feet had remained on the floor throughout. Mr
Wood said that other prisoners on A4 landing were calling him names. The officer
no longer works for the Prison Service, so it was not possible to interview her.
90. Two nurses were both in the wing office when they heard the radio request for staff
assistance. They went straight to Mr Wood’s cell. Mr Wood was alert and
conscious but had a red mark around his neck. Nurse A noted that there was a
ligature made of torn bed sheet tied to the window bar which appeared frayed and
another piece on the floor. The nurse told the investigator that she assumed that
Mr Wood had put some pressure on it, and it had broken. She asked Mr Wood
what had happened. Mr Wood said he was worried about being located on A4
landing and being at risk from other prisoners. The nurse tried to reassure him that
prisoners from other landings could not gain access to A4. (At that time there was
no gate separating the landings, but an officer guarded the stairs.) He also told the
nurse that he was due to transfer to Channings Wood in a few days, but he could
not wait to go there. Again, Nurse A tried to reassure him that it was only around
two days until he would be there. Mr Wood then spoke to Nurse B, who also tried
to reassure him and spoke to him about relaxation techniques.
91. A Custodial Manager (CM) was in charge of the prison that evening. When he
heard that Mr Wood had tied a ligature, he went to his cell. He told the investigator
that when he got there, the two nurses were talking to Mr Wood. Nurse B said that
Mr Wood asked the CM if he could go onto constant watch or be in a safe cell. She
said that the CM said that this was not necessary. The CM said that this
conversation did not occur, and Mr Wood made no such request. The CM said that
he tried to reassure Mr Wood that he was safe.
92. Nurse B asked Mr Wood if he was happy if a mental health nurse came to talk to
him as she had to go and finish giving other prisoners their medication. He
confirmed that he was happy with this. She said she left the cell when other staff
were still in there to ring the mental health team. She tried to locate them, but they
had left the prison earlier than scheduled (there should have been cover until
8.30pm). She did not refer Mr Wood to the mental health team. Neither nurse
recorded the incident on Mr Wood’s medical record or ACCT. Nurse A recorded the
incident on the healthcare handover sheet by writing, “ligature, not suspended”.
16 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
93. The CM asked a SO to review Mr Wood’s ACCT observations. The SO said that
when he went to see Mr Wood he was pacing in his cell. He was alone and the SO
was aware that he had just tied a ligature in his cell. He did not notice any mark on
his neck. The SO spoke to him about his anxieties and tried to reassure him that he
was safe and prisoners from the landing below could not access A4. They spoke
about Channings Wood and what it was like there. The SO scheduled an ACCT
review for the next day and increased Mr Wood’s observations to hourly.
94. The SO said that he did not think constant observation was necessary, since Mr
Wood was a lot calmer by the end of their conversation and was focussed on the
future. The SO spoke to the CM, and they were both satisfied that the increase in
observations was appropriate. The CM recorded the information in Mr Wood’s
record and on a handover sheet for all staff to access the next morning. The SO
returned later that evening to see Mr Wood who seemed calm and was in his bed.
Events of 7 September
95. On 7 September around 3.30am, Mr Wood told an officer that he had chest pain. A
nurse assessed him and noted that Mr Wood was sitting on his bed and had no
obvious symptoms of chest pain. He told her that he was hearing voices and had
been banging his head. The nurse tried to reassure him that if he was anxious, it
might help if he got some sleep. She noted that he appeared low in mood and
“would try by all means to get to hospital”. She told him to take some deep breaths
and to keep himself occupied. She did not take any clinical observations. The
nurse sent an email directly to a mental health nurse.
96. Wing staff spoke to Mr Wood during the morning. He told them that he felt dizzy
and unwell, and he was scared for his life. He said that prisoners were saying they
would “get him” and Mr Wood said, “I might as well do it myself before they get to
me.” Officers explained that they would keep him safe. Officer A told the
investigator that Mr Wood often put himself down and questioned the point of him
being alive. He tried to speak to Mr Wood about his family and plans for the future.
97. At 11.13am, Officer B found Mr Wood tying a ligature from a ripped piece of sheet
that was tied to the top bunk of his bed with a loop the other end, but he had not put
it round his neck. He informed another officer who was passing and stood outside
his cell, and also told Officer A, who went to Mr Wood’s cell within a minute. Officer
B radioed Hotel 1 (the healthcare emergency responder) to come to Mr Wood’s cell.
98. Officer A and Officer B gave the investigator conflicting accounts of what happened
next. Officer B said that she went into the cell with Officer A and tried to talk to Mr
Wood, but he did not really engage with them and seemed to be in a “daze”. She
said that the ligature was tied onto his bed, and they took it out of the cell.
99. Officer A told the investigator that Mr Wood denied that he had been making a
ligature and that he had hidden it by the time she went into the cell. She said that
another officer then came to the cell and she and Officer B told him that she had
seen him make a ligature but that they did not know where it was. Officer A said
that the other officer found the ligature and Officer B took it away. It has not been
possible to identify the other officer.
Prisons and Probation Ombudsman 17
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
100. Officer A said that Mr Wood was upset and paranoid that other prisoners were
shouting at him and thought he was a sex offender. He said he felt threatened and
unsafe. She said that she tried to reassure Mr Wood and tell him that he was safe.
He also asked about his transfer to Channings Wood. She spoke to the chaplain
and mental health team and asked them to see him. Both Officer A and Officer B
knew that Mr Wood had tied a ligature the night before.
101. A nurse responded five minutes after Officer B had radioed for healthcare staff.
Officer B said that she spoke to her and told her about the ligature. The nurse said
that she was told that Mr Wood had chest pain and was short of breath. She said
she was not told about the ligature.
102. The nurse assessed Mr Wood in his cell for around ten minutes. She said she
could not take him to the clinic room as there was another prisoner in there being
treated. He said that he was short of breath and had a tight chest and pain down
his left arm. She checked his blood pressure and oxygen saturation which were
both normal. The nurse told Mr Wood that she thought his symptoms were anxiety
related but Mr Wood said this was not the case and that he had had heart problems
in the past. She noted that staff should complete an ECG and the GP would be in
the prison that afternoon and should review it. She told Mr Wood to use his cell bell
if his symptoms got worse. She spoke to officers on the wing who were concerned
and said that the mental health team would also try to assess him that day. She
told the investigator that she did not have any concerns that Mr Wood was a risk to
himself.
103. A SO said he went to Mr Wood’s cell, and he was being spoken to by staff. He was
unaware that Mr Wood had tied a ligature but was told he was anxious and having
chest pains. He spoke to him briefly and said he was “very quiet”.
104. At 12.00pm, Officer A moved Mr Wood to another cell across the landing because
the telephone and water supply were not working in his current cell. Mr Wood had
not had a telephone in his cell since moving to A wing but used the ones on the
landing. She said that he seemed happy to be moving cells so that there was a
telephone he could use. She locked him in his cell at 12.03pm.
105. The nurse later returned to the wing twice to do Mr Wood’s ECG, but he was not in
his cell. However, she was unaware at the time that Mr Wood had moved cells so
was looking in the wrong cell. At 1.15pm, she spoke to another nurse to ask if she
could go and see him as she felt that Mr Wood was anxious.
106. Officer A and Officer B did Mr Wood’s ACCT checks that afternoon at 1.30pm,
2.15pm, 3.10pm and 4.15pm. Officer A said that during the afternoon Mr Wood
said he had chest pains but did not seem to be in pain and she was concerned he
may have been trying to get to hospital. Officer B said that throughout the day, Mr
Wood remained paranoid and distant, and she tried to reassure him that he was
safe. She said that she heard prisoners from the landing below shouting towards
prisoners on A4, but that this was not directed specifically at Mr Wood. She said
that when she answered his cell bell, he was concerned about what the prisoners
were saying and that they were coming after him.
107. A healthcare assistant (HCA) went to collect Mr Wood for his ECG at 2.15pm, but
he was outside having his exercise so she noted that she would return later.
18 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
108. Between 2.40pm and 3.40pm Mr Wood was let out of his cell for association.
During this time, a nurse assessed Mr Wood. She told the investigator that she was
not aware that Mr Wood had tied a ligature the night before or that morning. She
noted that Mr Wood was stood just outside his door when she got there. They
spoke in his cell. Mr Wood said that he felt under threat from other prisoners and
thought that officers would unlock his door so that prisoners could assault him. The
nurse tried to reassure Mr Wood and spoke about his transfer to Channings Wood.
She told the investigator that Mr Wood was due to be assessed by a psychologist
the following week and told him this.
109. Prisoner A also saw Mr Wood during this association time. He said that he seemed
“quiet” but “alright”.
110. Around 3.00pm, a probation officer spoke to Mr Wood on the landing to confirm that
he would be transferred to Channings Wood on 9 September. Mr Wood said that
he wished it could happen more quickly as he felt under threat from prisoners, and
he was hearing voices telling him to kill himself. The probation officer thought that
these were ongoing concerns which had been shared with staff before. He
recorded the information in Mr Wood’s ACCT. He said that he would contact the
mental health team. However, he spoke to healthcare staff before he left the
landing.
111. CCTV shows that during the afternoon, Mr Wood left this cell to use the kiosk on the
landing, took part in exercise along with other prisoners and spoke to staff and
prisoners on the landing.
112. The Head of Safety said that in the late afternoon, the TV boosters broke so that
there was no TV in any of the cells on A wing. He said that this led to an increase
in the noise on the wing, including prisoners shouting general abuse and kicking
their doors.
113. At 3.39pm, Mr Wood rang his mother and spoke to her for 10 minutes. They spoke
about his transfer the following week and plans for release. Mr Wood then spoke to
his brother and said he had tried to hang himself the night before but would not do it
again. Mr Wood said that other prisoners were threatening him and asking staff to
get him out of his cell. Mr Wood’s brother reassured him that this would not
happen. They spoke about his transfer in two days, but Mr Wood said that he was
scared he would not survive until then as other prisoners would harm him before
that. Mr Wood said he would call him tomorrow.
114. At 4.18pm, Mr Wood rang his grandparents and spoke to them for 21 minutes.
They discussed Mr Wood’s medication. Mr Wood said his television was not
working so he would find it difficult to sleep. Mr Wood said that he used to feel safe
in his cell but did not anymore. His grandparents tried to encourage him about his
imminent transfer.
115. At 4.42pm, staff unlocked Mr Wood’s cell and he went to collect his evening meal,
returning to his cell two minutes later. At 4.46pm, Officer A was walking past the
cell, glanced in and then returned to Mr Wood’s cell. Mr Wood was on the floor and
appeared to be unresponsive. She shouted a code blue to Officer B, but neither
officer had a radio. Other staff then radioed the code blue. Officer A went into Mr
Wood’s cell and tried to rouse Mr Wood by shaking him and calling his name and
Prisons and Probation Ombudsman 19
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
put him in the recovery position. He then started to respond. She said Mr Wood
seemed confused and asked what had happened.
116. At 4.48pm, a nurse responded and went into Mr Wood’s cell with the emergency
bag. She assessed Mr Wood, who was sitting on his bed when she got to the cell,
alert and responsive. His observations were normal. She had no concerns that Mr
Wood was a risk to himself. She ensured that Mr Wood had his ECG done as soon
as possible. The nurse left the cell at 4.59pm, having spoken to a CM and Officer
A.
117. At 5.00pm, Mr Wood left his cell to attend healthcare for an ECG. By this time, no
GP was available at the prison to review it. A nurse (who had previously worked in
cardiac care and had also seen one of Mr Wood’s previous ECGs) reviewed the
ECG and stated that there had been an improvement in the ECG since the previous
reading two weeks ago and no urgent referral to the hospital was required. She
requested that a prison GP should review the ECG the next day.
118. Mr Wood returned to his cell at 5.18pm. He briefly spoke to Officer A, who locked
him in his cell.
119. At 5.18pm, Mr Wood rang his grandfather and spoke to him for 40 minutes. Mr
Wood said that he had collapsed after getting his food. He said that he could not
remember what had happened and had never fainted like that before. They
discussed his release. At 5.25pm, Officer A and Officer B did a roll check. Both
officers looked in through Mr Wood’s observation panel.
120. At 6.00pm, Mr Wood rang his stepmother and mother, but neither answered their
telephone. He then rang his brother, whom he spoke to for 31 minutes. Mr Wood
said he still had no television. They spoke about his transfer and Mr Wood said that
he still had to get through two nights at Exeter. He said that he still felt under threat
from other prisoners. There was increasingly loud banging in the background of the
telephone call.
121. Around 14 minutes into the call, Mr Wood rang his cell bell. An officer responded
and the conversation can be heard on Mr Wood’s telephone call. He told the officer
that he was in “agony” with chest and rib pains and had collapsed earlier but these
were new pains. He asked for aspirin or an ambulance. The officer asked Mr
Wood to sit down and said she would ask healthcare staff what they could do.
There is no evidence that the officer took further action to the request. The officer
told the investigator that she could not recall this conversation.
122. Mr Wood remained on the telephone to his brother, they spoke about his release
and transfer. Again, Mr Wood reiterated that other prisoners would harm him
before he could be transferred. At 6.35pm, Mr Wood rang his mother and
grandfather. Neither answered his call.
123. At 6.43pm, Mr Wood rang his grandfather and spoke to him and his other brother
for around 23 minutes. Mr Wood said he was in “agony” and still had 60 hours to
get through before being transferred as other prisoners wanted him dead. Towards
the end of the call, Mr Wood started whispering and told his grandfather that officers
had just let other prisoners out to kill him. His grandfather tried to reassure him.
The call then cut out as Mr Wood’s telephone credit had run out.
20 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
124. During the call, Mr Wood rang his cell bell. At 7.13pm, Officer B responded to this.
Mr Wood said he had chest pain and asked to see healthcare staff. She told Mr
Wood that she would speak to healthcare staff and see if they could provide some
pain relief. This request was not passed on to healthcare. She told the investigator
that she had planned to take Mr Wood to see healthcare once they had finished
unlocking prisoners for medication. She said that she did not have any concerns
that Mr Wood was a risk to himself as he was engaging with her and the person he
was on the telephone to.
125. At 7.33pm, Officer C looked through Mr Wood’s observation panel. He saw Mr
Wood hanging by a ligature at the back of the cell. He immediately unlocked the
door, while shouting to staff, and went into the cell with Officer A behind him.
Officer C radioed a code blue. Officer D got to the cell a few seconds later. Officer
C supported Mr Wood’s weight while Officer D cut Mr Wood down with his anti-
ligature knife. Mr Wood had used a bedsheet as a ligature tied to the window bars.
Officer D removed the ligature from Mr Wood’s neck and Officer C began chest
compressions. Several more prison staff got to the cell within a few seconds. The
officers took it in turns to do chest compressions.
126. At 7.34pm, a nurse arrived with the emergency equipment and defibrillator along
with another nurse. More healthcare staff got to the cell shortly afterwards.
Healthcare staff assessed Mr Wood, administered oxygen and attached a
defibrillator while staff continued chest compressions.
127. Four minutes after the code blue, an officer called an ambulance. At 7.57pm,
paramedics arrived and took over Mr Wood’s care. They noted that his blood
pressure rose to normal levels. At 8.40pm, they took Mr Wood to hospital, where
he was in a coma and placed on life support. No restraints were used.
128. The nurse told the investigator that during the emergency response, she could hear
prisoners shouting derogatory names to Mr Wood and making offensive remarks.
129. At 8.45pm, a governor telephoned Mr Wood’s stepmother (who Mr Wood had listed
as his next of kin), told her that Mr Wood had hanged himself and arranged to meet
her at the hospital. At 9.15pm, a SO was appointed as family liaison officer (FLO).
At 11.30pm, the FLO and the governor met Mr Wood’s stepmother and father at the
hospital.
130. On 9 September, hospital staff withdrew Mr Wood’s life support, and, at 1.11pm, a
hospital doctor pronounced that Mr Wood had died. His next of kin were present.
131. After Mr Wood died, the police recovered some undated notes from his cell. The
police told the investigator that initially Mr Wood was relatively positive writing about
his plans for release. However, after he was charged with further offences, his tone
was less positive.
132. The FLO remained in contact with Mr Wood’s next of kin. In line with Prison
Service policy, the prison offered a contribution to Mr Wood’s funeral expenses.
Prisons and Probation Ombudsman 21
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Support for prisoners and staff
133. After Mr Wood’s death, a CM 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.
134. The prison posted notices informing other prisoners of Mr Wood’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 Wood’s death.
Post-mortem report
135. The pathologist concluded that Mr Wood died of hypoxic-ischaemic encephalopathy
(brain damage due to a lack of blood circulating to the brain) caused by hanging.
The pathologist found several superficial cuts on Mr Wood’s arms and chin which
appeared to be self-inflicted.
22 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment and management of risk
136. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of self-harm or suicide posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under ACCT procedures. PSI 64/2011
also states that any information that becomes available which may affect a
prisoner’s risk of harm to self must be recorded and shared, to inform proper
decision making.
137. Mr Wood was subject to ACCT support from 29 July until he died, apart from a
period of three days from 25 to 28 August. We recognise that staff and prisoners
made considerable efforts to engage with Mr Wood. However, we have concerns
about the management of his risk of harm and lack of responsivity and information
sharing in relation to his increasing risk, particularly on 6 September and 7
September.
138. During Mr Wood’s time at Exeter, he had ten ACCT case reviews which were
chaired by six different SOs. A consistent case manager should have chaired these
reviews. We do, however, recognise that several of these case reviews were
unplanned and followed an incident of self-harm, making a consistent case
manager chairing all the reviews virtually impossible. However, there was no
named case coordinator on the front cover of the ACCT document.
139. Furthermore, following these incidents of self-harm or using a ligature, staff did not
hold immediate ACCT reviews. Staff typically increased Mr Wood’s observations
but the reviews always took place the following day, regardless of the time of day
the incident had taken place. PSI 64/2011 notes that an urgent case review needs
to take place as soon as possible if a prisoner’s risk is likely to have increased, as
was the case indicated by the increased observations.
140. Mr Wood told staff that his family were supportive of him. There is no evidence that
any of his family were included in the ACCT review process, or that Mr Wood’s
consent was sought to do this in line with PSI 64/2011. Mr Wood had significant
telephone contact with his family, and this was a missed opportunity to include them
in Mr Wood’s care.
141. Mr Wood was sentenced to a further period of imprisonment on 13 August. This
was noted as a trigger on his ACCT document. He did not attend court as he was
self-isolating. However, despite asking, Mr Wood did not find out what had
happened at court for several days. This was unacceptable and contrary to local
policy which indicates that prisoners must have a risk assessment when their status
changes – in this case Mr Wood had changed from being a remand to a sentenced
prisoner.
142. It is also concerning that the ACCT review scheduled for 7 September did not take
place. A SO had been scheduled to do the review and was working on C wing that
day. The SO had started preparing for this by reading Mr Wood’s documentation
and speaking to staff. However, he was then called to an incident at height as he
Prisons and Probation Ombudsman 23
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
was the only trained negotiator in the prison at the time. The SO told the
investigator that he was about to do the review when he heard the emergency code
in relation to Mr Wood on the radio.
143. The clinical reviewer noted that Mr Wood’s risk increased during the time he was at
Exeter. There were twelve incidents of self-harm and suicidal behaviour and these
increased in frequency and severity in September 2021. We are particularly
concerned about missed opportunities to adequately assess Mr Wood’s risk and
share relevant information on 6 September and 7 September. These are discussed
further below.
Events of 6 September
144. Mr Wood tied a ligature around his neck on the evening of 6 September. There are
conflicting accounts about what happened following this. Nurse A said that Mr
Wood asked to go on constant observation, but a CM said this was not necessary.
She said that, as she was fairly new to the prison, she did not feel able to challenge
a CM’s assessment of risk at the time. The CM denied that Mr Wood asked to go
on constant supervision. We are unable to determine whether this conversation
took place. However, the CM said that a SO informed him that he had increased Mr
Wood’s observations to hourly and he was satisfied that that was appropriate at the
time.
145. Nurse A also told the investigator that she saw a frayed ligature which she assumed
had snapped when Mr Wood applied pressure to it, whereas an officer recorded
that they had cut the ligature from Mr Wood and his feet had remained on the floor.
If the latter is correct, communication between staff in such a critical and risk related
situation was inadequate.
146. Neither Nurse A nor Nurse B recorded the incident on Mr Wood’s medical record or
wrote in his ACCT document. Both nurses recognised that this was unacceptable.
Since Mr Wood’s death, the temporary Head of Healthcare has reminded staff of
the importance of accurately recording interactions with prisoners and often spoke
about it in handover sessions. The clinical reviewer noted that she had been
assured by both nurses that they recognised the seriousness of their omission and
had reflected and learnt from this. We concur with this opinion.
147. None of the staff we spoke to said that they asked Mr Wood about what his
intentions had been in tying the ligature, whether he wanted to kill himself and
whether he would attempt to do so again. The clinical reviewer noted that research
shows that asking a person who presents with suicidal thoughts direct questions
about their intent, decreases the likelihood of a person acting on these thoughts.
Aside from this, these questions were necessary to make an informed risk
assessment of Mr Wood at that time.
Events of 7 September
148. A nurse said that when she assessed Mr Wood on 7 September, she was not told
that he had just tied a ligature but assessed his chest pains. The officer said that
they did inform the nurse. It has not been possible to determine if this was the
case. She said if she had known that Mr Wood had just tied a ligature, when she
saw him on 7 September, she would have discussed him with the team. She did
24 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
not see the ACCT document that day. The temporary Head of Healthcare said that
the nurse should have at least been aware of the ligature tied the night before from
the handover sheet.
149. A SO also said that he did not know about the ligature when he went to Mr Wood’s
cell. He said that if he had been told about the ligature, he would have considered
whether Mr Wood’s ACCT observations needed to be increased or he needed to
have an immediate review. He said he would also have informed Oscar 1, who was
in charge of the prison at the time.
150. There is no evidence that the three officers who removed the ligature from Mr Wood
considered holding an ACCT review or increasing Mr Wood’s observations. At least
two of these members of staff were also aware that he had tied a ligature the night
before. The increase in seriousness and frequency of Mr Wood’s behaviour should
have led staff to hold an immediate ACCT case review.
151. A nurse also assessed Mr Wood on 7 September. She said that she was unaware
of the ligatures he had tied that day and the day before. She said that she would
usually write in a prisoner’s ACCT but had omitted to do so on 7 September. Had
she looked at the ACCT, she would have at least been aware of the ligature Mr
Wood had tied that morning.
152. Overall, we are very concerned by the often-ineffective communication between
staff, whether written or verbal, such that crucial risk information about Mr Wood
was not shared effectively and therefore an informed risk assessment could not be
made. Mr Wood’s risk to himself was clearly increasing in the days before he died.
He was subject to hourly observations which were not enough to manage his
increasingly risky behaviour. We make the following recommendation:
The Governor and Head of Healthcare should ensure that all staff have a clear
understanding of their responsibilities to manage prisoners at risk of suicide
and self-harm in line with national guidelines, including that:
• a named consistent case manager chairs ACCT reviews;
• staff hold an urgent case review when a prisoner’s risk increases;
• a prisoner’s family and friends are included in the ACCT process where
appropriate;
• staff hold ACCT reviews as scheduled;
• staff appropriately question prisoners following an incident of self-
harm or attempted suicide; and
• staff record and share all information that affects risk.
153. Additionally, within the two hours before he was found hanging in the evening of 7
September, Mr Wood pressed his cell bell twice, complaining of chest pains and
asking to see healthcare staff. Prison staff did not ask healthcare staff to see him.
Given Mr Wood had already collapsed once that day and been found with a
ligature, staff should have prioritised this. We make the following recommendation:
The Governor should ensure that prison staff inform healthcare staff when a
prisoner asks to see them.
Prisons and Probation Ombudsman 25
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Training
154. All healthcare staff we interviewed said they had not received the full two-day ACCT
training, some said they had recently had an hour’s training on the new version of
ACCT. The temporary Head of Healthcare said that she was pursuing ACCT
training for all healthcare staff.
155. Officer B was on a shadowing week at the prison and was still doing her initial
officer training when she found Mr Wood with a ligature. She said that she was
fairly new to the ACCT process and was not completely sure how to handle the
situation when she found Mr Wood with a ligature. We are concerned that neither
she, nor those who should have been supporting her had been adequately trained
to appropriately assess the risks involved.
The Governor and Head of Healthcare should ensure that all staff have
received full (two day) ACCT training and that they are satisfied that staff can
appropriately assess a prisoner’s risk to themselves.
Risk from others
156. Mr Wood repeatedly stated that he was at risk from others and that this risk
followed him when he moved wings. The investigator did not find any evidence of
any threats or abuse being directed specifically towards Mr Wood. Nor did Mr
Wood name any prisoners who were targeting him. However, staff noted in July
and August that they intended to open a CSIP for Mr Wood. This never happened.
This could have run alongside the support he was receiving through the ACCT
process and allowed staff to assess the risk of a threat from other prisoners more
formally and support Mr Wood. Furthermore, since Mr Wood self-isolated due to
stating he had Covid-19 symptoms on three separate occasions (he never tested
positive), according to local policy this meant that he should have automatically
been referred for a CSIP.
157. While staff did not hear any comments directed specifically at Mr Wood, it is clear
that when the prisoners who had been located on B wing, moved to A4 landing,
they were subject to abuse and derogatory remarks from other prisoners on the
wing. This is documented in the wing observation book and was reported to us by
staff and prisoners. Some of this abuse allegedly encouraged prisoners on A4 to
kill themselves. Mr Wood moved to A4 on 4 September and after this time his risk
to himself and ligature attempts increased significantly. He repeatedly said he felt
unsafe, and, at the time, there was no gate separating A4 from the other landings,
but an officer prevented access to the landing. (This was rectified soon after Mr
Wood’s death.)
158. The Head of Safety acknowledged that at the time CSIP had not been working well
but that this had since been relaunched. He said that they had a lot of
inexperienced staff at Exeter who they were training and that staffing levels had
also improved since Mr Wood’s death. Both the IMB and HMIP have noted their
concerns about prisoners feeling unsafe and how well CSIP was operating at the
prison. It is also an issue we have identified following recent deaths at the prison.
We therefore make the following repeated recommendation:
26 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Governor should ensure that incidents of violence, bullying or
intimidation are investigated and dealt with in line with local and national
policies.
Clinical care
159. The clinical reviewer concluded that the clinical care Mr Wood received at Exeter
was not of a reasonable standard and not equivalent to that he could have received
in the community.
160. The clinical reviewer noted that at the time Mr Wood was at Exeter, there was a
significant shortage of healthcare staff, with staff working extended hours to cover
the service. Staff reflected that it was an extremely challenging time and they often
had to take on multiple healthcare roles during the day which was not sustainable.
The Head of Healthcare was also on long-term sick leave and leadership was
limited. At the time of interview, a temporary Head of Healthcare had been
appointed to fill the post. She said that said that since Mr Wood’s death all
healthcare vacancies had been temporarily filled with agency staff.
161. The clinical reviewer concluded that there was a lack of a single case manager
taking responsibility to coordinate and review Mr Wood’s care. He was not on a
mental health caseload as he had been referred to psychology and this was
assessed as being his primary need. However, the clinical reviewer concluded that,
given Mr Wood’s risk to himself and mental health needs, an interim care plan
should have been provided by the mental health team while he was waiting for
psychological support.
The Head of Healthcare should ensure that those who are on a waiting list for
therapy have access to mental health support in the interim if there is a risk of
suicide and self-harm.
162. The clinical reviewer also noted that Mr Wood should have been referred to the
multi-disciplinary complex case clinic (MPCCC) to be reviewed and discussed. He
would have had a case manager who was responsible for coordinating his care
which would have been particularly helpful as he did not have one from the primary
care mental health team. This issue was identified during an initial internal
investigation, the local operating policy reviewed and shared with all healthcare
staff. Therefore, we do not make a further recommendation here.
163. The clinical reviewer noted that Mr Wood did not receive his antidepressant
medication for the first two weeks he returned to Exeter. This was because he did
not transfer with any medication, the GP who prescribed it did not review his in-
possession medication status and the pharmacy did not realise he had not collected
his prescription. Following Mr Wood’s death, PPG identified this issue and
amended their policy so that prescribers review a prisoner’s medication possession
assessment when prescribing and tell them when to collect it. We do not make a
further recommendation here.
164. The clinical reviewer noted that prisoners starting antidepressants should be closely
monitored and reviewed every two weeks. Mr Wood was reviewed a month after
starting his prescription of sertraline, but this seemed to be in response to his
presentation at the time rather than a planned review of his response to
Prisons and Probation Ombudsman 27
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
antidepressant medication. The Head of Healthcare will want to note the clinical
reviewer’s recommendation in this regard.
165. After Mr Wood had allegedly swallowed vape solution, the plan was for clinical staff
to observe him overnight and the following day. Mr Wood had regular observations
overnight but there is no evidence that these took place the next day. Additionally,
after the nurse assessed Mr Wood for chest pains in the morning of 7 September,
she did not take any clinical observations which would have been appropriate given
his cardiology history. She also sent an email directly to a mental health nurse. It
was identified in an internal investigation that this should be avoided, and electronic
tasks should be sent to a team and where an urgent response is needed the team
should be telephoned. Furthermore, a nurse the previous night who had responded
to Mr Wood making a ligature had tried to contact the mental health team but had
failed to do so. She should have completed a written referral to the team.
The Head of Healthcare should ensure that:
• when a prisoner needs clinical observations, these are completed; and
• staff refer prisoners appropriately to the mental health team.
166. The clinical reviewer noted that Mr Wood had been diagnosed with a learning
disability in the community. On 8 December 2020, a nurse assessed this and
concluded that he did not have an obvious learning disability, but he was somewhat
naïve and may have been prone to bullying or exploitation. The clinical reviewer
noted that the assessment did not explore how Mr Wood processed information,
solved problems, socially interacted or what support he needed to access
healthcare. There is also no evidence that his vulnerability was further considered.
Mr Wood did sometimes mention his learning disability to healthcare staff, but this
was not sufficiently explored. The clinical reviewer notes that he should have had a
long-term care plan in relation to his learning disability which would have enabled
more support for his anxiety and vulnerability and increased staff awareness.
The Head of Healthcare should ensure that all prisoners with learning
disabilities are clearly recorded, staff receive relevant learning disability
training and follow NHSE/I guidance for prisoners with learning disabilities.
Transfer to Channings Wood
167. Mr Wood had transferred to Exeter from Channings Wood as he had pleaded guilty
to further charges and was on remand. Although he had been a category C
prisoner prior to this further remand, he needed to be reassessed following these
further charges. The Offender Management in Custody (OMiC) policy states that
initial categorisation and a move to an appropriate prison should take place within
ten working days of sentencing. Mr Wood was categorised as a category C
prisoner on 31 August, 11 working days after he had been sentenced. This was
late as his offender manager had been on annual leave. The HMPPS Early
Learning Review also noted that Exeter had a waiting list for Channings Wood and
that it was not always possible to transfer prisoners within the ten-day timescale
due to the lack of spaces which are allocated by HMPPS’ population management
department.
28 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
168. The first allocation of places at Channings Wood Exeter was given after Mr Wood
had been categorised was on 9 September and the probation officer ensured that
he was prioritised for transfer on that date.
169. The investigator spoke to a manager about Mr Wood’s transfer to Channings Wood.
The manager said that Mr Wood had been due to transfer but then said he had
Covid-19 symptoms so had been self-isolating when it was due to occur and could
not transfer. He denied that the recategorisation of Mr Wood being a day late had
delayed his transfer.
170. A SO told the investigator that he had spoken to Mr Wood’s stepmother and said
that while he was on leave Mr Wood would be sentenced and then they would try
and get him transferred as soon as possible after that. He acknowledged that there
were several factors which could affect how quickly a prisoner could transfer and
said he never told Mr Wood’s family a specific date when he would transfer.
171. We recognise that whatever the reasons that Mr Wood had not transferred before
he died, Exeter was making significant efforts to get him transferred to Channings
Wood and had prioritised this move for 9 September.
Meaningful contact
172. The HMPPS Early Learning Review noted that Covid-19 restrictions at the time that
Mr Wood was at Exeter meant that vulnerable prisoners should have had a daily
wellbeing check which was noted in their record. Out of the 38 days that Mr Wood
should have been checked, there were two keyworking sessions and 13 wellbeing
entries in his record meaning there were 23 days where there is no evidence that
these checks were completed.
173. The Head of Safety told the investigator that he had been trying to improve
completion of these wellbeing checks. He also acknowledged that it had been
difficult to continue with key working sessions through the pandemic and staff
shortages. At the time of writing, Covid-19 restrictions were lessening, and we
therefore make the following recommendation:
The Governor should ensure that the key worker scheme is properly
embedded and that key workers are allocated sufficient time for an average of
45 minutes per prisoner per week for delivery of the key worker role.
Emergency response
174. When staff found Mr Wood hanging, they acted quickly and competently. An officer
radioed a code blue and an officer documented that he telephoned an ambulance
four minutes later. A code blue emergency indicates that the control room should
telephone an ambulance immediately.
175. The officer said that he did telephone the ambulance immediately, but he was on
hold to the 999 operator for a couple of minutes before he got through. During this
time on hold, he said that he obtained some information from staff dealing with the
emergency and there was some confusion regarding the cell location of Mr Wood.
In these circumstances, we accept that there was no delay in requesting an
ambulance but note that records should reflect timings accurately.
Prisons and Probation Ombudsman 29
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Sharing Learning
176. Finally, given the learning outlined in this report, we make the following
recommendation:
The Governor and Head of Healthcare should ensure that this report is shared
with all staff named in it and that they are given the opportunity to reflect on
the learning involved.
Inquest
177. The inquest into Mr Wood’s death concluded in February 2025. It found that Mr
Wood died as a result of suicide.
30 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE