Blake Wallis

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Blake Wallis,
a prisoner at HMP Lincoln,
on 3 January 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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 Blake Wallis died in hospital on 3 January 2022 after being found hanging in his cell at
HMP Lincoln on 30 December 2021. He was 26 years old. I offer my condolences to Mr
Wallis’ family and friends.
Mr Wallis was the fourth prisoner to apparently take their life at Lincoln since January 2019.
He was monitored under suicide and self-harm prevention procedures four times at Lincoln.
He received good support from staff across the disciplines, who worked hard to identify his
specific needs, risks and triggers. Both HM Chief Inspector of Prisons and the IMB at Lincoln
also reported that the prison’s approach to supporting those in crisis was good.
We make only one recommendation: that the national policy relating to clearing cells after a
prisoner leaves should make specific mention of medication.
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 October 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 13
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Summary
Events
1. On 24 December 2020, Mr Blake Wallis was remanded to HMP Lincoln for robbery.
2. In April 2021, Mr Wallis was placed on suicide and self-harm prevention measures
(known as ACCT) after telling staff that he was suicidal. Staff stopped ACCT
procedures the following day.
3. In July, Mr Wallis’ cell mate was released from prison and had left his prescription
medication in their shared cell. Mr Wallis took an overdose of this medication. He
pressed his cell bell and told staff what he had done but refused to go to hospital.
Staff started ACCT procedures.
4. On the night of 15 July, while still being monitored under ACCT procedures, Mr
Wallis attempted to hang himself. Staff attended and called a medical emergency
code. Mr Wallis was conscious and breathing and staff sent him to hospital by
emergency ambulance. He remained in hospital until 20 July, when he returned to
Lincoln. Staff placed Mr Wallis under constant supervision. On 20 August, prison
staff stopped ACCT procedures when they were satisfied he no longer posed a risk
to himself.
5. On 27 December, Mr Wallis told a member of staff he was struggling with his
feelings and staff started ACCT procedures. They closed them the following day.
Two days later on 29 December, staff re-opened the ACCT after Mr Wallis asked a
member of staff when he would be unlocked overnight and they were concerned
about his previous suicide attempts and presentation at the time.
6. On 30 December, Mr Wallis was locked in his cell at around 5.00pm. He was
checked and seen alive at approximately 8.00pm. Around an hour and a half later,
staff found him hanging in his cell. Other staff responded immediately and
administered first aid. Ambulance staff attended and took over Mr Wallis’ care. Mr
Wallis was taken to hospital where he remained on life support.
7. On 3 January 2022, Mr Wallis died in hospital.
Findings
8. Mr Wallis received good, personalised support from staff at Lincoln. ACCT plans
were opened appropriately, were well-managed and contained identified actions to
support Mr Wallis and reduce his risk. There is some learning for the Governor and
Head of Healthcare to ensure that the views of healthcare staff carry as much
weight as that of prison staff.
9. The clinical reviewer concluded that the care Mr Wallis received was of a
reasonable standard and was equivalent to that which he could have expected to
receive in the community.
10. The clinical reviewer also noted several areas of good practice in Mr Wallis’ clinical
care.
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Recommendations
• The Director General of HMPPS should amend the Prisoners’ Property Policy
Framework to make specific reference to prisoners’ medication in the cell clearance
section.
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The Investigation Process
11. HMPPS notified us of Mr Wallis’ death on 3 January 2023.
12. The investigator issued notices to staff and prisoners at HMP Lincoln informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Wallis’ prison and
medical records.
14. The investigator interviewed 15 members of staff by video calls in February 2022.
15. NHS England commissioned an independent clinical reviewer to review Mr Wallis’
clinical care at the prison. The clinical reviewer attended the majority of the
interviews.
16. We informed HM Coroner for Lincolnshire of the investigation. The coroner gave us
the results of the post-mortem examination. We have sent the coroner a copy of this
report.
17. The Ombudsman’s family liaison officer contacted Mr Wallis’ mother to explain the
investigation and to ask if she had any matters she wanted the investigation to
consider. She did not raise any concerns but asked for a copy of our report.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS identified some minor factual inaccuracies and we have amended our
report accordingly. The action plan has been annexed to this report.
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Background Information
HMP Lincoln
19. HMP Lincoln holds up to 729 remanded and convicted men. It serves the courts of
Lincolnshire, Nottinghamshire and Humberside. It has four residential wings,
including a Vulnerable Prisoners Unit. Nottingham Healthcare NHS Trust provides
health services and there is 24-hour nursing cover.
HM Inspectorate of Prisons
20. The most recent inspection of Lincoln was in 2020. Inspectors reported an overall
improvement since 2017. Inspectors found that despite the numbers of self-harm
incidents remaining high, the prison’s approach to supporting those in crisis was
good. In addition, case management of those prisoners on Assessment, Care in
Custody and Teamwork (ACCT) procedures was generally good and ACCT reviews
were often multidisciplinary.
21. Inspectors reported that the prison faced significant challenges regarding
rehabilitation and release planning, due to the varied sentences being served and
the often complex needs of those prisoners at Lincoln.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 January 2022, the IMB
reported that Lincoln had seen a significant reduction in the number of deaths
compared to the previous year. The report also found that while ACCT processes
were embedded, there were efforts to improve the management of them and there
had been a reduction in the volume of on-going ACCTs in the reporting year.
Previous deaths at HMP Lincoln
23. Mr Wallis was the eighth prisoner to die at Lincoln since January 2019. Of the
previous deaths, four were from natural causes and three were self-inflicted. There
are no similarities between our findings in the investigation into Mr Wallis’ death and
our investigation findings for the previous deaths.
Assessment, Care in Custody and Teamwork
24. ACCT is the Prison Service case management approach used to support those at
risk of suicide or self-harm. The purpose of the ACCT is to identify risk, how to
monitor and supervise the prisoner, and how to reduce risk. The prisoner is
assessed when the ACCT is opened, and the level of checks and supervision are
set according to the perceived risk. Regular multidisciplinary review meetings with
the prisoner should be held.
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Key Events
25. On 24 December 2020, Mr Blake Wallis was remanded to HMP Lincoln, charged
with robbery. This was his first time in prison.
26. Mr Wallis had pre-existing diagnoses of Asperger’s syndrome and autism
(neurodevelopmental disorders). On his arrival at Lincoln, staff conducted a
reception screen. A nurse noted that Mr Wallis could share a cell but was a high risk
due to his previous acts of arson. An officer recorded on Mr Wallis’ NOMIS
electronic record that, due to his Asperger’s diagnosis, he explained the prison
regime in detail and asked whether Mr Wallis would like to apply for vulnerable
prisoner status. Mr Wallis declined.
27. On 22 April, a Supervising Officer (SO) started suicide and self-harm prevention
procedures, known as ACCT. Mr Wallis said that his sister had told him that details
of his offence were now on social media, that he found this distressing and was
thinking about hanging himself. Staff recorded in the ACCT document that Mr Wallis
was having suicidal thoughts and had discussed ligaturing with staff. Staff checked
Mr Wallis once an hour.
28. On 23 April, an SO conducted an ACCT review. He recorded that Mr Wallis
engaged with the ACCT review saying that he was feeling better than the previous
day. The SO noted that Mr Wallis maintained good eye contact and when asked
about thoughts of suicide or self-harm, he said he had none. The SO stopped
ACCT procedures following the review, but it was agreed that Mr Wallis would have
weekly support from a key worker, which was an action set out in the care plan.
29. On 28 April, staff identified that Mr Wallis was possibly a victim of bullying. Staff
monitored him in line with the violence reduction policy and they planned to review it
in May. A safer custody administrator told us that Mr Wallis was open about it, and
said that the bullying was linked to vaping. She also said that Mr Wallis had
disclosed that he had used spice (synthetic cannabinoids) in the past, and that he
was worried this would have implications for him. The administrator passed this
information to his offender manager but said that Mr Wallis was not tested for drugs
because he said that it was in the past.
30. On 30 April, an officer conducted an ACCT post-closure interview with Mr Wallis.
He recorded that Mr Wallis had said that he had no thoughts of suicide or self-harm
and that he was interested in working. During the review, they discussed sources of
support and the officer recorded that he advised Mr Wallis of the support available
to him.
31. On 5 May, the safer custody administrator conducted a mid-point victim monitoring
review in line with the violence reduction process and recorded that no further
information had been received, but that Mr Wallis would remain on victim monitoring
for a further seven days.
32. On 12 May, an officer removed Mr Wallis from victim monitoring as there had been
no further evidence or intelligence to suggest he was a victim of violence or
bullying. Staff spoke to Mr Wallis in the weeks leading up to this, and he said that
he was no longer being bullied.
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33. A mental health nurse saw Mr Wallis regularly during his time in prison. She told us
that as an autistic person, Mr Wallis had developed the ability to mimic neurotypical
behaviours and use a learned persona (presenting as a different person).
34. On 9 July, Mr Wallis pressed his cell bell and an officer responded. Mr Wallis said
that he had taken an overdose of 11 tablets and said he had done this on impulse
because of low mood. Prison staff started ACCT procedures. Staff tried to persuade
him to go to hospital but he refused.
35. An officer conducted an ACCT assessment. She noted that Mr Wallis’ cell mate had
left prison the previous day and left behind his prescription medication, and Mr
Wallis had seen this as an opportunity to attempt suicide. Mr Wallis told her that he
had no further thoughts of suicide, but the officer recorded that this could change
easily.
36. On 10 July, staff held the first ACCT review, which was attended by an SO, an
officer and a mental health worker. Observations were set at two per hour and two
discussions per day, with the next review set for 13 July. The care plan contained
meaningful actions, including providing Mr Wallis with a chess board which he had
identified as a useful distraction method.
37. On 13 July, Mr Wallis attended another ACCT review. An SO led the review and
recorded that Mr Wallis had been reflecting on his family and his crime, and said
that he felt anxious. Mr Wallis had also said that he would benefit from seeing
someone from the mental health team, and staff arranged for a nurse to see him.
Mr Wallis said that he had no thoughts of suicide or self-harm at that time. Mr Wallis
was not in regular contact with his family at this time and they were not listed as a
source of support on his ACCT.
38. During the night of 15 July, the night patrol officer was walking past Mr Wallis’ cell
and saw him hanging. He radioed a medical emergency code blue (indicating a
prisoner is unconscious or is having breathing difficulties). Staff attended, and Mr
Wallis was breathing. He was sent to hospital where he received further treatment.
The prison appointed a family liaison officer who visited Mr Wallis’ next of kin and
explained what had happened. Mr Wallis’ next of kin informed them that Mr Wallis
had previously overdosed on medication and was known to make impulsive
decisions.
39. On 20 July, an SO held an ACCT review when Mr Wallis returned from hospital.
The SO noted that they had a frank and open conversation about Mr Wallis’ suicide
attempt and how close he was to killing himself. A mental health nurse was present
and said that a doctor would visit him the following day. Staff agreed that Mr Wallis
would remain under constant supervision (in a gated cell with a member of staff
positioned at the gate to monitor the prisoner at all times). Staff also provided Mr
Wallis with a chess board in line with the earlier action plan.
40. On 21 July, an SO held an ACCT review. Mr Wallis said that he was more relaxed
than the previous day, but staff agreed that he should remain under constant
supervision. Staff continued to support Mr Wallis and he agreed to have
counselling.
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41. From 21 to 29 July, Mr Wallis remained under constant supervision, which was
reviewed every two days at scheduled ACCT reviews. In the ACCT review on the
29 July, an SO noted that those present at the meeting all agreed that Mr Wallis
should remain on a high level of observations subject to review. A nurse raised the
issue of Mr Wallis not taking his antipsychotic and ADHD (Attention Deficit
Hyperactivity Disorder) medication which she said could lead to impulsive
behaviour. Mr Wallis agreed to begin taking his medication again.
42. On 29 July, Mr Wallis told a nurse that he thought he would be admitted to hospital
under the Mental Health Act. The nurse told us that Mr Wallis had assumed he
would be ‘sectioned’ as a result of his suicide attempt, and told us she made it clear
to him that she would tell him if his circumstances changed.
43. On 31 July, staff agreed that Mr Wallis’ observations would be lowered to two
observations and one conversation per hour, as he appeared to be coping with his
moods.
44. On 1 August, an officer retrospectively recorded that he had spoken to Mr Wallis
while he was under constant supervision, and he remained hopeful. He explained
he would be on leave until the end of August and noted that they had scheduled a
chess game together. The officer also told us he made efforts to find Mr Wallis
people to play chess with, and that he had regular casual conversations with him.
45. On 6 August, an SO chaired an ACCT review, with a nurse and the prison’s
neurodiversity lead. Mr Wallis said that he had engaged in education, but wanted
more of a challenge. He said that he had no thoughts of suicide or self-harm.
46. On 10 and 13 August, further multidisciplinary ACCT reviews were held. On 13
August, staff addressed rumours that Mr Wallis was in debt. He admitted that he
had smoked spice and suggested that when he received his purchases from the
prison shop, his issues would be solved. Mr Wallis said that his old cell mate had
accused him of stealing, but he denied it. Mr Wallis said that he did not feel very
‘streetwise’ and that he did not feel like he fitted in. Staff offered him vulnerable
prisoner status but he declined. Due to Mr Wallis appearing agitated, staff kept the
ACCT procedures ongoing. Staff did not start victim monitoring again. Mr Wallis
was referred to the substance misuse service.
47. On 20 August, an SO conducted an ACCT review. The neurodiversity lead was also
present. Mr Wallis said that he wanted to have a single cell, but staff explained to
him that he did not meet the criteria. The SO recorded that due to his attempted
suicide in July, staff thought Mr Wallis was safer in a shared cell. During the review,
Mr Wallis said that he felt frustrated that the ACCT was being kept open and that he
was not being listened to when he said he had no thoughts of suicide or self-harm.
Mr Wallis also said that he would press the cell bell if he felt anything changed. The
SO agreed to end ACCT procedures following the review, and started the seven
day post-closure process. The neurodiversity lead told us that those present agreed
that the ACCT should be closed as Mr Wallis had been taking his medication and
was displaying more normal behaviour.
48. On 27 August, an SO completed a post-closure interview. He noted that Mr Wallis
was feeling positive but expressed difficultly in communicating emotions because of
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his Asperger’s. The SO noted that Mr Wallis would benefit from the post-closure
period being extended for a further week.
49. On 3 September, an SO conducted a post-closure review. The SO noted that Mr
Wallis was in a far better place than when the ACCT was opened as he was taking
his medication and working as a wing cleaner. The SO ended the post-closure
phase of ACCT monitoring.
50. A safer custody administrator recorded that Mr Wallis had appealed his cell sharing
risk assessment. Mr Wallis said that he felt he should be in a single cell for medical
reasons. Staff explained that his request would be forwarded to the healthcare
team, but from a safer custody perspective he would remain able to share (apart
from with known arsonists).
51. From 3 September, Mr Wallis had key worker sessions every one to two weeks.
Initially, his key worker changed several times, but after a few weeks, the sessions
were consistent with the same member of staff.
52. A nurse told us that Mr Wallis frequently requested a single cell. She did not think it
was appropriate because of his recent suicide attempt. The nurse told us that she
refused his request on a number of occasions, until she saw proof that he was safe.
53. An SO told us that Mr Wallis raised issues with him about debt, particularly
regarding his cell mate. As a result, the SO moved Mr Wallis out of the cell. He said
that he checked in with Mr Wallis about these issues, and it appeared to be
resolved. Mr Wallis was allocated a single cell, but there is no evidence the debt
issue was investigated further.
54. On 11 November, a nurse saw Mr Wallis and reported no concerns about his
mental wellbeing, however she did record that he was worried about his upcoming
release on 22 February 2022.
55. On 17 November, a nurse saw Mr Wallis again. He told her that he did not want to
engage with his planned release and he was going to spend his discharge money
on drugs and alcohol to kill himself. The nurse was concerned by what Mr Wallis
had said and his body language, so informed healthcare and prison staff and
arranged a mental capacity assessment for him.
56. On 22 November, Mr Wallis was designated as requiring a single cell for medical
reasons. A nurse told us that, while Mr Wallis did not have a cell mate prior to being
assessed as requiring a single cell, his presentation completely changed for the
better once he received this news; he was more positive and he was working on the
wing. She also said that Mr Wallis had not been monitored under ACCT procedures
for some time (since September) and he seemed to flourish in a single cell.
57. Several members of staff told us that Mr Wallis had anxiety around his release. An
SO said that key worker sessions around November and December were focused
on his release, and whether he could cope outside of prison. The SO told us that he
spoke to Shelter (the housing charity) about housing for Mr Wallis’ release, and
liaised with the neurodiversity lead and the Chaplain to offer him support pre-
release.
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58. On 18 December, an officer recorded that he was told during a staff handover that
Mr Wallis had been behaving strangely and that he was in his cell staring at the
wall. Healthcare staff attended his cell and assessed that there was no cause for
concern.
59. On 21 December, a nurse met with Mr Wallis, who discussed hypothetical drug use
on the wing, but did not say he had used any. The following day, the neurodiversity
lead passed on a message to the nurse from Mr Wallis, apologising and saying he
had been using illicit drugs. The nurse referred Mr Wallis to the prison’s substance
misuse team. Mr Wallis’ urine was tested a few days later and the result was
negative. He was not seen by anyone from the substance misuse team.
60. On 22 December, an officer conducted a key worker session with Mr Wallis. He
noted that Mr Wallis appeared very distracted and unsure and said he felt lost. The
officer got Mr Wallis to expand on his feelings and explain what he meant by this.
He asked Mr Wallis whether there was anyone he wanted to talk to or needed, and
Mr Wallis said that there was not. The officer emailed the neurodiversity lead who
worked closely with Mr Wallis and said he had just seen him and he had spoken
about death a lot during their session. He responded that he had just seen Mr
Wallis and he did not mention death.
61. On 27 December, an SO started ACCT procedures for Mr Wallis because he told
staff that he was considering suicide. Mr Wallis asked for help and support to deal
with his suicidal feelings and anxiety. The SO had a detailed conversation with Mr
Wallis and set half hourly observations at irregular intervals. Mr Wallis told the SO
that he had no intention of taking his own life. During interview, the officer told us
that Mr Wallis appeared flustered and said during their conversation that he was
struggling, so an ACCT offered him appropriate help.
62. An officer conducted the ACCT assessment. He recorded that Mr Wallis said that
he felt lost and unsure and was struggling with his mental health, which was partly
intensified by his upcoming release. Mr Wallis told the officer that he was not feeling
suicidal at the time and said he was feeling better. The officer noted that Mr Wallis
could not explain why he was feeling better. Mr Wallis was in contact with several
members of his family, who were listed on the ACCT as a source of support for him.
63. On 28 December, an SO held an ACCT review, which was also attended by an
officer and nurse. The SO recorded that Mr Wallis said that he had no intention of
taking his own life. He added that Mr Wallis said he would seek help if he was
struggling and knew he could speak to staff. The officer then closed the ACCT.
64. The nurse did not agree that ACCT monitoring should end. She told the meeting
that because she did not know Mr Wallis well, he had attempted suicide in July and
had been monitored under ACCT procedures before. She felt that, as the ACCT
had only just been opened, it should remain open to manage his risk. The nurse
added that while she had concerns, nothing stood out as an immediate risk to her
as he was talking about the future and acknowledged anxiety around his release
and seeking support.
65. The SO told us that Mr Wallis seemed more settled and appeared to be more
content in himself. When asked directly about his rationale for ending ACCT
monitoring, the SO said the ACCT process placed pressure on SOs and ACCT
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reviewers to interpret mental health issues and needs without any training or
expertise, but he did not explain why he did not listen more closely to the nurse.
66. The officer told us that Mr Wallis presented with some direct risks, including his
mental health and ability to cope. He said that Mr Wallis did not raise any issues
around bullying or debt, but his body language was poor. Mr Wallis was open about
his willingness to approach staff as he had done this the previous day.
67. On 29 December, an officer re-started the ACCT procedures after Mr Wallis had
asked when his cell would be opened between final lock up in the evening and the
following morning. He also said that he was in debt to another prisoner. The officer
recorded that he re-opened the ACCT document as a precaution as Mr Wallis had
previously attempted suicide overnight.
68. The officer carried out an immediate action plan meeting and noted that Mr Wallis
was engaging and was aware of the support available to him. Mr Wallis said that he
felt better having spoken to staff and needed support getting through this period.
The officer recorded that Mr Wallis said that he had no intention of self-harming or
taking his own life.
69. At 8.30pm, during an ACCT check on Mr Wallis, an officer noted that Mr Wallis had
handed over several lengths of cable under the door. This was recorded on the
ACCT paperwork.
70. An officer spoke to Mr Wallis and signposted him to places of support and reminded
him that he would come and speak to him whenever he needed. There is no written
evidence in the ACCT document that there was any further discussion about the
significance of Mr Wallis handing over lengths of cable.
Events of 30 December
71. On 30 December, an officer conducted a Challenge, Support and Intervention
(CSIP, the Prison Service process to manage violence in prisons)/ Self-harm triage,
following what Mr Wallis had said the previous day. He noted that they discussed
how Mr Wallis was feeling and whether he was being bullied. Mr Wallis told the
officer he had been prescribed antidepressants to help him cope with negative
feelings. Mr Wallis said that he did not know why he was on an ACCT or why he
was getting so much unwanted attention, but after further discussion, the officer
noted he accepted it. The officer also said that they discussed that, while Mr Wallis
said he had no intention of taking his life, he had a history of not coping, which
caused staff concern. Mr Wallis said that he was not being bullied, he was paying
off a debt the following day and there was no threat. The officer said he reminded
Mr Wallis of the support available to him, and that he was part of a community
which would support him. He fed this information into the ACCT process, but said
Mr Wallis was often very direct with him so felt he was being honest in what he had
told him.
72. An SO conducted an ACCT case review, with the neurodiversity lead and a nurse.
The SO recorded that Mr Wallis was feeling better, and said he was not self-
harming at present and had no strong suicidal thoughts. He also recorded that
those present had concerns about Mr Wallis due to his erratic behaviour over the
previous days and it was agreed he should remain on an ACCT to monitor him. The
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next review was set for 2 January 2022. In interview, the SO told us that Mr Wallis
was very hard to gauge on this occasion, and he supported the ACCT remaining
open. The review increased observations from one per hour to two at irregular
intervals.
73. A nurse told us she had attended several of Mr Wallis’ ACCT reviews previously
and that there was nothing about Mr Wallis’ presentation or what he said that stood
out to her as suggesting his risk had significantly increased, but Mr Wallis appeared
more agitated than on other occasions. The neurodiversity lead confirmed this and
added that while Mr Wallis wanted the ACCT closed, those present agreed to keep
it open.
74. The neurodiversity lead told us that he went to see Mr Wallis after the ACCT review
to complete the ‘safe and well’ plan, which contains coping mechanisms for
prisoners. He said that Mr Wallis discussed the review with him, but they agreed to
meet again to complete the plan the following Monday.
75. At 4.41pm, Mr Wallis left his cell and returned three minutes later. Between 4.59pm
and 7.56 pm officers conducted several checks on Mr Wallis, in line with the
required two checks an hour under the ACCT process. CCTV shows the final check
was conducted at 7:56 pm.
76. An officer told us that he remembered checking on Mr Wallis a few times that
evening, from 6.00pm onwards. He told us that Mr Wallis was on the phone and he
did not want to disturb him, and he appeared to go to bed early at around 7.40pm.
The officer said that his behaviour was consistent with his previous experience of
Mr Wallis, and he did not seem to be upset.
77. At approximately 9.36pm, an OSG went to conduct an ACCT check on Mr Wallis.
She found Mr Wallis hanging from the top bunk by a green sheet. She told us she
stepped back from the cell and radioed that Mr Wallis had ligatured in his cell. She
did not radio a medical emergency code blue (which indicates that a prisoner is
unconscious or not breathing and triggers the calling of an ambulance), but officers
responded immediately in any case.
78. A Custodial Manager (CM) attended and looked through the cell door observation
panel. She entered the cell and cut the ligature. She said that while in the cell, she
noticed a nurse was present and asked him to confirm a code blue had been called
and an ambulance requested. She conducted CPR with the nurse and an officer. At
9:43pm, control room staff called an ambulance.
79. At 9:51pm, the first ambulance arrived at the prison. Paramedics provided first aid
to Mr Wallis and he was taken to hospital and arrived there at 10.53pm.
80. On 3 January 2022, Mr Wallis died in hospital.
Contact with Mr Wallis’ family
81. On 31 December 2021, the prison appointed a family liaison officer. At 8.30am, she
spoke with Mr Wallis’ grandfather and told him that Mr Wallis was in intensive care
following a serious suicide attempt. Mr Wallis’ family were present in hospital when
he died.
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82. The prison contributed to Mr Wallis’ funeral costs in line with national policy.
Support for prisoners and staff
83. After Mr Wallis’ death, a senior prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
84. The prison posted notices informing other prisoners of Mr Wallis’ 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 Wallis’ death.
Post-mortem report
85. A post-mortem report gave Mr Wallis’ cause of death as hanging. The report
estimated that Mr Wallis had only been hanging for 15 minutes when found, but had
suffered irreversible brain damage as a result of lack of oxygen. The toxicology
report showed that a number of medications were present in Mr Wallis’ blood, some
of which were prescribed to him in prison and some of which were not. However,
we do not know whether any of those not prescribed at Lincoln formed part of his
hospital treatment.
12 Prisons and Probation Ombudsman
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Findings
Assessment of risk
86. Mr Wallis was monitored under ACCT procedures four times at Lincoln. The
reviews were multi-disciplinary, care plan actions were appropriate and staff
involved knew Mr Wallis and used their relationships with him to manage his risk.
87. In July, an officer opened an ACCT after Mr Wallis revealed he had taken an
overdose of his ex-cell mate’s medication which was left in the cell after his cell
mate left Lincoln. When a prisoner vacates their cell, national guidance sets out the
actions prison staff must take to ensure all of the prisoner’s property has been
removed from the cell, including when prisoners share a cell. However, the
guidance does not make reference to prisoners’ medication. We do not know if the
medication was loose in the cell when the cell mate left, in a box with the cell mate’s
name on it or indeed whether the cell mate gave Mr Wallis his medication when he
left. While amending the national guidance would not prevent medication misuse, it
would provide extra protection. We make the following recommendation:
The Director General of HMPPS should amend the Prisoners’ Property Policy
Framework to make specific reference to prisoners’ medication in the cell
clearance section.
88. On 27 December, an officer began ACCT monitoring after Mr Wallis reported that
he was distressed. Evidence from various members of staff and documentation
suggests it was widely known that Mr Wallis was anxious about his upcoming
release. The officer considered the support of an ACCT was appropriate due to the
previous serious suicide attempt months prior and Mr Wallis’ state of mind at the
time.
89. The following day, an SO chaired an ACCT review and concluded that the ACCT
should close, which was against the advice of the mental health nurse present. The
nurse told us that while each case was different, mental health staff were not
always listened to and sometimes they found it hard to get their point across.
Ultimately, if there is no consensus among the review group, the ACCT review chair
(in this case the SO) makes the final decision. The Governor and Head of
Healthcare will wish to consider how they can ensure that healthcare staff’s input in
ACCT reviews is given equal weight to that of prison staff.
90. On 29 December, the ACCT was re-opened after staff became concerned about Mr
Wallis. That evening, he pushed lengths of cable under his cell door.
91. The multidisciplinary review occurred on 30 December with the SO chairing again.
Although Mr Wallis wanted ACCT monitoring to end, those in attendance agreed it
should remain in place and the SO noted Mr Wallis was acting strangely. The
review did not discuss the significance of the cable with Mr Wallis and it was not
considered when evaluating the level of risk he posed. The review increased
observations from one per hour to two at irregular intervals and three conversations
per day. We are satisfied that that staff appropriately began ACCT monitoring, and
took into account what they knew about Mr Wallis when making decisions about the
frequency of checks, but consider that they missed an opportunity to question Mr
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Wallis about the cables, which might have led them to a different decision. Again,
this is something that the Governor will want to consider and address.
Good practice
92. Throughout his time at Lincoln, staff were aware of Mr Wallis’ neurodiverse needs
and took more time to engage with him as a result. Of particular note is the support
offered by the neurodiversity lead and the identification of chess as an activity to
improve Mr Wallis’ wellbeing, and staff scheduling times to play with him and
organise games with other prisoners.
93. It is clear that Mr Wallis received good, consistent and appropriate support from
many staff at Lincoln, who worked hard to understand his needs and had a
reasonable understanding of his risks and triggers.
94. After discovering Mr Wallis, a CM, nurse and officer conducted CPR on him until
relieved by the paramedics. CPR is a difficult, distressing and occasionally
unpleasant procedure to perform. It seems clear that their combined actions were a
significant factor in Mr Wallis making it to hospital alive. Although he died just a few
days later, he did so with his family at his bedside. This would not have been the
case had he died whilst in his prison cell.
Clinical care
95. The clinical reviewer concluded that the care Mr Wallis received at Lincoln was of a
good standard and was equivalent to that which he could have expected to receive
in the community.
Emergency Response
96. PSI 03/2013 requires staff to use recognised emergency response codes when
there is a medical emergency. The policy requires local protocols for using code red
for incidents involving bleeding and code blue for unconscious prisoners or those
struggling to breathe. An ambulance must be called immediately, even if there is
any doubt as to the specifics or severity of the incident.
97. The OSG who found Mr Wallis ligatured did not call a code blue and instead
radioed that Mr Wallis had ligatured in his cell. Although staff responded to her radio
call immediately, there was an eight minute delay in control room staff calling an
ambulance. While it does not appear that the delay was caused by not calling a
code blue, policy requires staff to use codes so an ambulance is called quickly.
98. The Governor addressed this with a staff information notice issued on 4 January
2022, reminding staff of the requirement to always use emergency codes, and
include as much relevant information as possible on the condition of the prisoner.
We do not therefore make a recommendation.
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Inquest
99. The inquest, held from 12 to 16 May 2025, concluded that Mr Wallis died by suicide.
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