Dale Samm

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Dale Samm,
a prisoner at HMP The Mount,
on 25 September 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
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 Dale Samm was found hanged in his cell on 25 September 2022 at HMP The Mount.
He was 28 years old. I offer my condolences to Mr Samm’s family and friends.
Mr Samm had been at The Mount for less than four weeks when he died. I am satisfied
that he gave staff no indication that he was at risk of suicide and self-harm during that time
and that staff could not have foreseen his death.
My investigation found some delays with the emergency response when Mr Samm was
found unresponsive. There was a delay in staff calling the medical emergency code and in
entering the cell. Although it made no difference to the outcome for Mr Samm as he was
dead when found, it is important that staff respond quickly to future medical emergencies
as any delays could be critical.
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 June 2023
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 23 August 2022, Mr Dale Samm was sentenced to two months and 23 days in
prison for property damage and carrying a bladed weapon. He was moved to HMP
The Mount on 30 August.
2. Mr Samm had a history of depression and substance misuse. He was referred to
the mental health team and to the substance misuse team.
3. On 12 September, a nurse conducted a mental health triage assessment for Mr
Samm. Mr Samm said he was fine and had no thoughts of suicide or self-harm. The
nurse noted that Mr Samm was stable in mood and had no concerns about him. He
concluded that Mr Samm did not need support from the mental health team.
4. At around 5.30am on 25 September, during a routine check, an Operational
Support Grade (OSG) saw that Mr Samm was slumped between his bed and his
cell window. She knocked on the cell door, but Mr Samm did not respond. She
thought he might be intoxicated, so she radioed for staff assistance. Then she
noticed that Mr Samm was not breathing. Another OSG joined her and saw that Mr
Samm had a ligature around his neck. She shouted to the first OSG to call a
medical emergency code, which she did. Control room staff called for an
ambulance. The two OSGs remained outside the cell until other staff arrived.
5. Around 90 seconds later, several officers arrived at Mr Samm’s cell and entered.
They assessed that Mr Samm was dead as he was cold and stiff. They did not start
CPR.
6. The control room updated the ambulance service that Mr Samm had rigor mortis
(stiffening of the body after death), which changed the urgency of the call. At around
7.00am, paramedics arrived at Mr Samm’s cell, and at 7.15am, pronounced that he
was dead.
Findings
7. Mr Samm did not give any indication to staff that he was at risk of suicide and self-
harm during his few weeks at The Mount. We are satisfied that staff could not have
foreseen his death.
8. There were delays with the emergency response when Mr Samm was found
unresponsive. The OSG should have called a medical emergency code when she
realised that Mr Samm was not breathing and once the second OSG joined her,
they should have entered the cell rather than waiting for officers to arrive.
9. We found that despite Mr Samm having been at The Mount for almost four weeks,
he had not been allocated a key worker. Key work sessions might have identified
that Mr Samm was struggling.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Recommendations
• The Governor should ensure that all prison staff understand their responsibilities
during medical emergencies, including that they:
• use the appropriate emergency code when they discover a medical
emergency; and
• enter cells as quickly as possible when it is safe to do so.
• The Governor should ensure that the key worker scheme provides meaningful and
ongoing support to all prisoners in line with national policy.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP The Mount informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Samm’s prison and
medical records.
12. The investigator interviewed seven members of staff between 18 October and 4
November 2022. These were carried out by video conferencing.
13. NHS England commissioned an independent clinical reviewer to review Mr Samm’s
clinical care at the prison. He jointly interviewed all staff with the investigator.
14. We informed HM Coroner for Hertfordshire of the investigation. The coroner gave
us the results of the post-mortem examination. We have sent the coroner a copy of
this report.
15. The Ombudsman’s family liaison officer contacted Mr Samm’s brother to explain the
investigation and to ask if he had any matters he wanted us to consider. Mr Samm’s
brother asked:
• Whether a fight in the days leading up to his death contributed to Mr Samm’s
decision to end his life.
• Whether there was any contact with an ex-girlfriend which might have
contributed to his decision.
These issues have been addressed in the report.
16. We shared our initial report with HM Prison and Probation Service (HMPPS). They
found no factual inaccuracies.
17. We sent a copy of our initial report to Mr Samm’s brother. He did not notify us of
any factual inaccuracies.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP The Mount
18. HMP The Mount is a medium security prison holding approximately 1,000 men.
Hertfordshire Community NHS Trust provides primary healthcare and GP services.
Hertfordshire Partnership University NHS Foundation Trust provides mental health
services.
HM Inspectorate of Prisons
19. The most recent full inspection of HMP The Mount was in March 2022. Inspectors
found that the prison was dealing with significant weaknesses identified in previous
inspections, but prisoners were more positive about many aspects of their care.
Recorded levels of self-harm had slightly increased, with too little support for
prisoners in crisis. Staff had struggled to implement the new case management
support process, which sometimes ended without having addressed the prisoner’s
risks and needs. Not enough support was given to new arrivals.
Independent Monitoring Board
20. 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 28 February 2022, the IMB
reported that on the whole, the prison was a clean and tidy environment. The new
healthcare provider gave a satisfactory service.
Previous deaths at HMP The Mount
21. Mr Samm was the seventh prisoner to die at The Mount since September 2020. Of
the previous deaths, one was self-inflicted, two were drug related and three were
from natural causes.
22. We have previously made recommendations to The Mount about the use of medical
emergency codes.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
23. On 23 August 2022, Mr Dale Samm was convicted of property damage and carrying
a bladed weapon. He was sentenced to two months and 23 days in prison and was
sent to HMP Bedford. Mr Samm had previously been in prison in 2021.
24. Mr Samm had no history of suicide attempts or self-harm in prison. Mr Samm’s
medical records show he had a period of treatment for low mood and anxiety from
2015 to 2018 and had a history of substance misuse.
25. On 23 August, a nurse conducted Mr Samm’s reception health screen. He noted
that Mr Samm was engaging well and did not have any thoughts or history of
suicide attempts or self-harm. He referred Mr Samm to the mental health team for
triage due to his past prescription for antidepressants.
26. On 24 August, a nurse conducted the secondary health screen and noted that Mr
Samm told him that he previously suffered from depression and anxiety. However,
he said he had no thoughts of suicide or self-harm. Another nurse then conducted a
mental health triage assessment. She recorded that Mr Samm was not currently on
medication for his mental health and appeared to be in a stable mood. She told Mr
Samm to contact the prison GP if anything changed.
27. On 30 August, Mr Samm was moved to HMP The Mount. At his reception
screening, he said he had no thoughts of suicide or self-harm.
28. A nurse conducted Mr Samm’s health screen. He noted that Mr Samm was
prescribed methadone (a heroin substitute) and referred him to the substance
misuse team. He made a referral to the mental health team as Mr Samm had
previously been prescribed antidepressants. Mr Samm said he had no thoughts of
suicide and self-harm.
29. On 1 September, a nurse from the substance misuse team saw Mr Samm about his
methadone treatment. Mr Samm asked for his dose of methadone to be reduced,
so it was reduced by 5ml a week. Mr Samm did not express any problems or
concerns during this appointment.
30. On 10 September, Mr Samm was moved off the induction wing. Mr Samm also
engaged with the education team about enrolling in a course.
31. On 12 September, Mr Samm received a mental health triage assessment following
the referral by the nurse. A nurse conducted the review. The nurse said Mr Samm
engaged well in the assessment and talked about his previous treatments. Mr
Samm told the nurse that he was having flashbacks to a past incident where he was
stabbed but said he had no thoughts of suicide or self-harm. The nurse advised Mr
Samm to self-refer to the Improving Access to Psychological Therapies (IAPT) team
for support with his flashbacks and said he could contact the mental health team for
any further support. He told Mr Samm he would not be on the mental health team
caseload.
32. On 14 September, a nurse saw Mr Samm to discuss his substance misuse
treatment, and he did not report any issues.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
33. On 20 September, Mr Samm’s probation practitioner completed a resettlement plan
for Mr Samm as his sentence was due to end in October.
34. On 23 September, Mr Samm was moved to another cell on the same wing. Staff
said this was due to Mr Samm and his cellmate not wanting to share together after
moving from the induction wing. Mr Samm was allocated a single cell.
35. At around 8.00pm on 24 September, Operational Support Grade (OSG) A
conducted a routine check of all prisoners on the wing, including Mr Samm. She
said there was nothing out of the ordinary and she did not have any concerns about
him at that time.
36. Mr Samm had one number on his prison phone account, which was his mother’s.
He did not make any calls while at The Mount.
Events of 25 September
37. At 5.32am on 25 September, during a roll check, OSG A saw that Mr Samm’s light
was on, and Mr Samm was at the far wall between the bed and the window,
slumped over. She did not realise straightaway that he was hanging, so she
knocked a few times to try and rouse him. When she got no response, she then
requested assistance over the radio. She said at this point she thought Mr Samm
could have been intoxicated.
38. A Custodial Manager (CM) said that he became aware of the situation when OSG A
called for ‘an assist’. The CM said he asked for clarification, and she responded that
she wanted staff assistance. He went to the cell and was joined on the way by three
members of staff.
39. OSG A said she knocked a few more times after calling for help and noticed that Mr
Samm’s chest was not moving, and she realised he was not breathing.
40. OSG B was the first member of staff to respond to the request for assistance. As
she approached Mr Samm’s cell, OSG A told her she saw Mr Samm slumped and
he was not responding. OSG B said she went to the door, looked in and saw that
Mr Samm had a ligature around his neck. She then shouted to OSG A to radio a
code blue which she did.
41. OSG A said she considered the risk of entering Mr Samm’s cell, but as she did not
see him hanging initially, she did not believe it was safe. OSG B said that she did
not enter the cell straightaway as other officers were at the cell very quickly and
took over. CCTV shows there was around 90 seconds between OSG B getting to
the cell and other officers arriving.
42. The CM said that while he was on the way to the cell the code blue was called. One
of the OSGs met him at the gate and told him Mr Samm had a ligature around his
neck. He went to the cell, looked through the flap and immediately went into the
cell. He was followed in by an officer. Two other officers remained outside the cell.
43. The officer used his anti-ligature knife and cut the ligature. The CM said Mr Samm
was cold and stiff, and he said to staff that CPR was probably not appropriate. The
officer also said it was obvious that Mr Samm was deceased when they entered the
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
cell. He attached a defibrillator, which did not shock and advised CPR. He did one
compression and stopped as it was clear Mr Samm was dead. He said he felt it
would have been disrespectful to continue CPR.
44. The second officer said that she was communicating with the control room,
providing information for the ambulance. She updated the control room that Mr
Samm was deceased, and they passed this to the ambulance service. The control
room noted that they told paramedics rigor mortis had set in. The ambulance
service told the control room it could be up to six hours before someone attended.
The third officer said it was approximately 5.46am when officers decided there was
no more they could do.
45. At 7.03am paramedics arrived at Mr Samm’s cell. They pronounced him dead at
7.16am.
Contact with Mr Samm’s family
46. The prison’s family liaison officer and a prison chaplain visited the home of Mr
Samm’s parents and told them that he had died and offered condolences. The
prison paid toward to the cost of the funeral in line with national policy.
Support for prisoners and staff
47. After Mr Samm’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
48. The prison posted notices informing other prisoners of Mr Samm’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 Samm’s death.
Post-mortem report
49. The post-mortem report established that Mr Samm died from hanging. Toxicology
analysis found that Mr Samm had only methadone, which he was prescribed, in his
system.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Assessment of risk
50. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), lists a number of risk factors and
potential triggers for suicide and self-harm. It says all staff should be aware of the
risk factors and should start suicide and self-harm procedures (known as ACCT)
when they identify that a prisoner might be at risk.
51. Mr Samm did not have a history of suicide attempts or self-harm but did have some
risk factors. He had substance misuse issues and a history of low mood and
anxiety, all of which had been identified and recorded. However, we consider that
these risk factors did not warrant ACCT monitoring.
52. Mr Samm gave no indication to staff that he was at risk of suicide and self-harm
during his few weeks at The Mount. We are satisfied that staff could not have
foreseen his death.
53. There is no record that Mr Samm was involved in any fights while at The Mount.
The prison confirmed that he did not report anything to staff.
Emergency response
54. PSI 24/2011 on the management and security of nights says that under normal
circumstances authority to unlock a cell at night must be given by the night orderly
officer and no cell will be opened unless two/three (subject to local risk assessment
procedures) members of staff are present one of whom should be the night orderly
officer. However, it says that the preservation of life must take precedence over
usual arrangements for opening cells and where there is, or appears to be,
immediate danger to life, cells may be unlocked without the authority of the night
orderly officer and an individual member of staff can enter the cell on their own.
Staff should do a dynamic risk assessment to decide whether it is safe to enter a
cell.
55. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
requires prisons to have a two-code medical emergency response system: code
blue for prisoners who are unconscious or having breathing difficulties; and code
red for severe blood loss. Calling a medical emergency code should trigger the
control room to call an ambulance immediately and for healthcare staff to attend
with the appropriate medical equipment.
56. OSG A, who saw Mr Samm slumped by his window, did not notice that he was
hanging and thought initially that he might be intoxicated. She called for assistance,
which was justified in the circumstances. However, when she noticed that Mr Samm
was not breathing, she should have called a code blue in line with national policy
expectations.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
57. We accept that the situation was unclear initially and that it was reasonable for OSG
A to assess that it was not safe for her to enter Mr Samm’s cell alone. However,
once OSG B arrived and saw that Mr Samm was hanging, they should have
entered the cell. It was another 90 seconds before other staff arrived and entered
the cell. It made no difference to the outcome in this case as Mr Samm was dead
when found, but a delay could be critical in a future medical emergency. We
recommend.
The Governor should ensure that all prison staff understand their
responsibilities during medical emergencies, including that they
• use the appropriate emergency code when they discover a medical
emergency; and
• enter cells as quickly as possible in life-threatening situations when it
is safe to do so.
Key worker support
58. The Prison Service’s Manage the Custodial Sentence Policy Framework 2018
states that all prisoners within the male closed estate must be allocated to a prison
officer who will have a key worker role. It also says that Governors must ensure that
time is made available for an average of 45 minutes per prisoner per week for the
delivery of key work, which should include time with each prisoner.
59. During the time Mr Samm was at The Mount he was not allocated a key worker and
did not receive any sessions. While it is not possible to say whether staff would
have picked up on anything in this case, key work sessions are a useful way to
monitor the wellbeing of prisoners. We recommend:
The Governor should ensure that the key worker scheme provides meaningful
and ongoing support to all prisoners in line with national policy.
Clinical care
60. The clinical reviewer found that the care Mr Samm received was of a good standard
and was equivalent to that which he could have expected to receive in the
community.
61. The clinical reviewer did not identify any issues with the mental or physical
healthcare provided to Mr Samm while he was in prison.
Inquest
62. The inquest, held from 3 to 6 September 2024, concluded that Mr Samm died by
suicide.
Prisons and Probation Ombudsman 9
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