Daniel Ayers

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Independent investigation into
the death of Mr Daniel Ayers,
a prisoner at HMP Winchester,
on 25 July 2021
A report by the Prisons and Probation Ombudsman
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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 Daniel Ayers was found hanged in his cell at HMP Winchester on 25 July 2021. He was
43 years old. I offer my condolences to Mr Ayers’ family and friends.
Mr Ayers arrived at Winchester on 30 June 2021. He had schizophrenia and a history of
suicide attempts and substance misuse. I am concerned that Mr Ayers’ risk of suicide and
self-harm was not properly assessed by reception staff when he arrived at Winchester. I
am also concerned that no one considered starting suicide and self-harm monitoring
(known as ACCT) when Mr Ayers’ presentation deteriorated a week or so after he arrived.
The clinical reviewer found that the clinical care Mr Ayers received at Winchester was not
equivalent to that he could have expected to receive in the community. Despite Mr Ayers’
diagnosis of a severe and enduring mental illness, and staff referring him for a mental
health assessment four times, he was never assessed while at Winchester.
The clinical reviewer was also concerned about the management of Mr Ayers’ medication.
He did not receive any antipsychotic or antidepressant medication at Winchester, despite
being on this medication in the community. Also, his benzodiazepine dose was reduced
during his time at Winchester, without proper discussion with Mr Ayers or knowledge of the
potential impact this may have based on his history in the community.
The night before Mr Ayers died, an officer signed to say that the evening roll check had
been completed when CCTV footage shows it was not. Subsequent roll checks were
completed as scheduled but I am nevertheless concerned that staff falsified the roll check
record.
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 May 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 30 June 2021, Mr Daniel Ayers was remanded in prison custody, charged with
threatening a police officer with an imitation firearm, and sent to HMP Winchester.
2. Mr Ayers had schizophrenia and a history of substance misuse. He had also
attempted suicide in 2003 and 2018. The reception nurse referred Mr Ayers for a
mental health assessment and to the prison’s substance misuse team.
3. Mr Ayers was prescribed multiple medications in the community, including
methadone (a heroin substitute), antidepressants, antipsychotics, diazepam (a
sedative) and pain relief. Staff recognised that the combination of drugs was risky
alongside methadone, so they only prescribed that and the diazepam, which they
reduced each week.
4. From 9 July, staff noted a deterioration in Mr Ayers’ behaviour. He became more
withdrawn and dishevelled and wore only a blanket. On 11 July, a substance
misuse nurse became concerned about Mr Ayers and asked a mental health nurse
to see him, but this did not happen.
5. On 22 July, members of the healthcare team met and recorded that they would
expedite a mental health review for Mr Ayers. He was subsequently sent an
appointment for 27 July.
6. On the evening of 24 July, an officer signed to say that she had completed a roll
check at 8.30pm but CCTV shows that neither she, nor any of her colleagues,
completed the check. A roll check was carried out later that evening and there were
no concerns.
7. Shortly after 6.00am on 25 July, during the early morning roll check, an operational
support grade (OSG) found Mr Ayers hanging from the light fitting in his cell. She
called a medical emergency code blue at 6.02am, and nearby staff arrived at the
scene within seconds. The control room called an ambulance at 6.05am.
8. Staff carried out CPR until ambulance paramedics arrived. When the paramedics
arrived, they assessed that Mr Ayers had rigor mortis (stiffening of the body after
death) and instructed staff to stop CPR. They declared Mr Ayers dead at 6.18am.
Findings
9. We are concerned that reception staff did not properly assess Mr Ayers’ risk of
suicide and self-harm when he arrived at Winchester. Paperwork was not
completed properly and, crucially, staff did not consider the digital PER which
flagged Mr Ayers’ risk of suicide and self-harm. We are also concerned that no one
considered starting suicide and self-harm monitoring (known as ACCT) when Mr
Ayers’ presentation started deteriorating a week or so after he arrived.
10. The clinical reviewer found that the care Mr Ayers received at Winchester was not
equivalent to that he could have expected to receive in the community. He was not
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assessed by mental health staff despite several referrals, which were closed by the
same nurse without any action having been taken.
11. Staff identified that the combination of medications Mr Ayers was prescribed in the
community was risky. However, they stopped various medications without ever
trying to establish why he had been prescribed them. As a result, Mr Ayers was not
given any antipsychotic or antidepressant medication during his time at Winchester.
His diazepam dose was reduced without any discussion with him or consideration
of the potential impact this would have, given that he had told the community mental
health team that he would ‘end up under a train’ if they reduced it.
12. We are concerned that the night before Mr Ayers’ death, an officer signed for a roll
check she had not carried out, and that she routinely signed for checks that she
thought other people had completed.
13. There was a delay of three minutes between the code blue and calling an
ambulance. It made no difference in this case as Mr Ayers was dead when found,
but any delay could be critical in a future emergency.
14. Staff should not have started CPR, as Mr Ayers was clearly dead when found.
15. Not all staff thought they had received adequate support after Mr Ayers’ death.
Recommendations
• The Governor and Head of Healthcare should ensure that staff:
• consider all information that arrives with the prisoner, including both the
paper and digital version of the Person Escort Record.
• record the information they have considered that is relevant to the risk of
suicide and self-harm and their full reasoning if they decide not to start ACCT
monitoring; and
• are alert to any deterioration in the prisoner’s presentation, particularly those
who have a diagnosed mental health condition and/or are undergoing a drug
detoxification process and consider ACCT monitoring where appropriate.
• The Head of Healthcare should develop a reporting tool to identify mental health
referrals that are closed without action or explanation.
• The healthcare provider and the NHSE quality team should consider whether the
behaviour of the nurse who cancelled multiple mental health referrals requires
discussion with the appropriate regulator.
• The healthcare provider should ensure there is a GP onsite in line with the primary
care service specification for prisons in England.
• The Head of Healthcare should ensure that prescribers consider the full list of a
new prisoner’s medications and record their reasons for any they do not continue.
• The Head of Healthcare should ensure staff request prisoners’ community medical
records at the earliest opportunity.
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• The Head of Healthcare should ensure that a prisoner’s perspective on
detoxification is sought and recorded.
• The Head of Healthcare should share this report with the members of healthcare
staff who were involved in Mr Ayers’ care and discuss the Ombudsman’s findings
with them.
• The Governor should ensure that staff carry out roll checks at the required times
and only sign for them if they have completed them themselves.
• The Governor should ensure that control room staff call an ambulance immediately
when a medical emergency code is called.
• The Governor and the Head of Healthcare should ensure that staff are given clear
guidance about the circumstances in which resuscitation is inappropriate in line with
European Resuscitation Council Guidelines.
• The Governor and Head of Healthcare should ensure that staff are offered
appropriate support following a death in custody.
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The Investigation Process
16. The investigator issued notices to staff and prisoners at HMP Winchester informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
17. The investigator interviewed eight members of staff at HMP Winchester between
February and June 2022.
18. NHS England commissioned a clinical reviewer to review Mr Ayers’ clinical care at
the prison. The investigator and clinical reviewer jointly interviewed clinical staff and
some custodial staff.
19. We informed HM Coroner for Portsmouth and Southeast Hampshire of the
investigation. He gave us the results of the post-mortem examination. We have sent
the coroner a copy of this report.
20. The Ombudsman’s family liaison officer contacted Mr Ayers’ next of kin to explain
the investigation and to ask if she had any matters, she wanted us to consider. She
did not raise any issues but asked for a copy of our report.
21. Mr Ayers’ family received a copy of the initial report. They did not raise any further
issues but commented on the spelling of Mr Ayers’ name which we have amended
throughout this final report (from Ayres to Ayers). Interview transcripts and the
prison’s action plan remain as ‘Ayres’, as this is how the former were originally sent
to staff and the latter is a HMPPS document.
22. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Winchester
23. HMP Winchester is a local men’s prison, and holds up to 492 prisoners, including
some young adults. Practice Plus Group (PPG) provides physical and mental health
services.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Winchester was in January and February 2022.
Inspectors reported that levels of self-harm had reduced but remained among the
highest of all local prisons. They found that improvements had been made to
reception screening to identify prisoners’ risk of suicide and self-harm.
25. Inspectors noted that there was one full-time GP in post, who ran five face-to-face
clinics and five remote clinics for patient review and administration. There was only
a remote GP service available to cover the onsite GP’s leave or sickness, which
meant that patients were at risk of not being seen.
26. The number of referrals to the mental health team was high, with a quarter of the
population being referred each month. At the time of the inspection, there were 33
patients waiting for an initial triage assessment, the longest wait being three weeks
and two days, which was too long.
Independent Monitoring Board
27. 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 May 2022, the IMB noted that
the number of ACCT documents at Winchester had decreased, as management of
‘at risk’ prisoners had received attention. They noted, however, that this had not
prevented the self-inflicted deaths of two prisoners.
28. The arrival of an interim Head of Healthcare in March and the continuity of other
senior post-holders had ensured that stability and cohesion had been maintained.
Vacancy levels and recruitment continued to require attention, however, with
ongoing reliance on bank and agency staff.
Previous deaths at HMP Winchester
29. Mr Ayers was the eleventh prisoner to die at Winchester since July 2019. Nine of
the previous deaths were from natural causes and one was self-inflicted. In two of
those investigations, we found that the clinical care the prisoner received at
Winchester was not equivalent to that they could have expected to receive in the
community.
30. There have been two self-inflicted deaths since Mr Ayers’ death. In one of those
investigations, we found that staff did not properly assess the prisoner’s risk of
suicide and self-harm when they arrived at Winchester. We are still investigating the
other death.
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Key Events
31. On 30 June 2021, Mr Daniel Ayers was remanded in prison custody, charged with
threatening police officers with an imitation firearm. He was sent to HMP
Winchester. It was not his first time in prison, though he had not been in prison for
20 years.
32. The paper version of Mr Ayers’ Person Escort Record (PER – a form that
accompanies prisoners between police custody, courts and prisons which sets out
the risks they pose) noted that Mr Ayers had attempted suicide on railway tracks in
2003 and 2018, but neither police nor court staff had completed the suicide and
self-harm warning form which sets out the current perceived risk of suicide and self-
harm. The digital version of the PER said that Mr Ayers was at risk of suicide and
self-harm.
33. An officer carried out Mr Ayers’ reception screen and noted that he presented well,
was prescribed methadone (a heroin substitute) and that he was schizophrenic. The
reception check sheet was signed by the officer, but none of the screening
questions had been answered on the form. We do not know if the officer considered
either versions of the PER as he has left the Prison Service and did not respond to
attempts to contact him.
34. A nurse carried out Mr Ayers’ reception health screen. She noted that Mr Ayers had
a history of substance misuse and mental health issues including schizophrenia and
psychosis. He said he did not engage with community mental health services
because he did not get on with mental health workers. She noted that Mr Ayers had
attempted suicide in 2003 and 2018 but had no current thoughts of suicide or self-
harm. She made a referral to the mental health team and to substance misuse
services (SMS). She also made a referral to the dentist, as Mr Ayers said he had
problems with his teeth.
35. At interview, the nurse said she had seen the paper PER but could not remember if
she had seen the digital PER. She said that digital PERs were relatively new at the
time, and she thought she was more likely to have relied on the paper form. She
said that, although she had some concerns about Mr Ayers, she was not sufficiently
concerned to begin suicide and self-harm monitoring procedures (known as ACCT).
36. A nurse prescriber with SMS carried out a substance misuse assessment. He noted
that Mr Ayers was on a methadone maintenance programme and took a range of
prescribed medication for his mental health issues and arthritis.
37. The nurse considered that Mr Ayers’ community prescription for dihydrocodeine (an
opioid painkiller) and zopiclone (sleeping tablet) was inappropriate given his high
methadone dose and prescription for diazepam (a benzodiazepine, a sedative), as
it carried a risk of respiratory depression. He continued the methadone dose and
prescribed diazepam at 30mg for seven days, to be reduced by 5mg each week. He
noted that Mr Ayers’ community prescription should be discussed with the prison
GP. (There was no GP on site as she was on leave and another doctor was
covering remotely.) He advised that Mr Ayers should be monitored daily for
withdrawal symptoms. He noted that Mr Ayers had no thoughts of suicide or self-
harm.
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38. On 1 July, the remote prescribing GP reviewed Mr Ayers’ medical records and
noted that his combination of medication was high risk and that the SMS team were
managing him appropriately with methadone and diazepam. He made a referral to
the mental health team to consider Mr Ayers’ need for quetiapine (an antipsychotic)
and mirtazapine (an antidepressant), both of which he was prescribed in the
community. He did not specify why the rest of Mr Ayers’ community medications,
omeprazole (used to treat heartburn), meloxicam (used to treat arthritis) and
zolmitriptan (used to treat migraines), were not prescribed.
39. On 2 July, a member of the psychosocial support team noted that Mr Ayers had
completed a full assessment with the substance misuse team and would be working
directly with him. He noted that Mr Ayers did not seem too low in mood and was
talking about the future. He recorded that he had mild concerns about Mr Ayers’ risk
of deliberate self-harm.
40. He made a referral to the mental health team and said that Mr Ayers had
schizophrenia, struggled to engage with the community mental health team and
was prescribed quetiapine and mirtazapine.
41. On 2 July, a nurse carried out observations on Mr Ayers. She noted that he had a
swollen cheek and he said he had recently been taking antibiotics for a dental
abscess. She sent a task asking a nurse to review Mr Ayers.
42. On 2 July, a nurse carried out the secondary health screen. He gave Mr Ayers two
doses of ibuprofen but did not record why (probably for dental pain).
43. On 3 July, a mental health nurse closed the remote prescribing GP’s mental health
referral task noting the status as ‘completed’. She also closed the referral made by
the member of the psychosocial support team. Neither task had been completed
and Mr Ayers had not had a mental health assessment.
44. On 3 July, a prison paramedic saw Mr Ayers, as he had told staff his jaw was tender
and swollen and he thought he had an abscess. He said he had already applied to
see the dentist. The paramedic sent a task asking for the dentist to see Mr Ayers at
the next available slot. He also asked the nurse prescriber if he could prescribe
antibiotics, but the nurse could only prescribe for SMS purposes. The paramedic
also called HMP Bullingdon and left messages asking if they could provide
antibiotics, as it would be a week before Winchester could get any.
45. On 4 July, a nurse noted she had not asked Mr Ayers if he would like his COVID-19
vaccination, as he was suffering from a nasty tooth infection.
46. On 4 July, a nurse saw Mr Ayers and noted considerable swelling on one side of his
face. She gave him pain relief.
47. On 5 July, a dental nurse saw Mr Ayers by looking through the hatch in his cell
door. She noted that she saw no evidence of infection and discussed a plan for
prescribing painkillers with him, which he seemed happy with. She noted that he
appeared ‘distressed mentally’ and was ‘holding his head and ears’. She also
recorded that she could not see any swelling and noted his dental referral as for no
further action. She did not record whether she considered raising his mental
distress with the mental health team.
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48. On 7 July, Mr Ayers asked a nurse for quetiapine. The nurse told him to complete a
request to see the mental health team.
49. On 8 July, the prison GP recorded that Mr Ayers’ inappropriate prescribing in the
community had been discussed at a multi-disciplinary team meeting (MDT).
However, there was no record of any plan as a result.
50. On 9 July, a nurse noted Mr Ayers had demonstrated ‘weird behaviour’ when she
gave him his medication. He came to the cell door to collect his medication and
then returned to bed without saying anything and covered himself in a blanket. She
checked the records and saw a mental health referral was made on 2 July. She
sent a follow-up task setting out what she had observed and drawing attention to
the previous task.
51. A nurse responded to the task the same day, saying she would see Mr Ayers either
that day or the next day. She closed the task, but there is nothing in the medical
record to suggest she saw Mr Ayers.
52. On 11 July, an officer noted that Mr Ayers’ behaviour was bizarre. His presentation
was ‘flat’ and even though he had been given fresh clothes, he was only wearing
his blanket wrapped around him. He was not collecting food left at his door and the
officer considered that he needed to be monitored to check he was eating. He
initially refused to take his medication, but a SMS nurse eventually persuaded him
to.
53. A nurse noted that Mr Ayers was sitting on the floor covered in a blanket, facing
away from the door. He responded the third time the nurse called him and declined
his medication but did not seem able to give a reason and just stared blankly. When
the nurse explained it was diazepam, he took it and asked to see a chaplain.
54. The nurse noted the cell was dirty and messy and Mr Ayers looked dishevelled. He
passed Mr Ayers’ request to a wing officer and recorded that he had noted his
presentation in the wing’s observation book. The nurse also noted that he verbally
asked the duty mental health nurse (unnamed) to review Mr Ayers and added him
to the detox nurse’s overnight checklist. The wing officer told the investigator he
would have contacted the chaplain.
55. On 13 July, a nurse noted that Mr Ayers appeared mentally unwell, covering his
face and grunting when she gave him his medication. She asked him if he was in
pain, but he shook his head and went back to his cell. There is no record of whether
she took any further action.
56. On 14 July, an unknown member of the mental health team noted: ‘No access visit
for Mental Health appointment with Mental Health A. Home visit – no reply’. We
were not able to establish what this entry really meant but considered it most likely
that it related to the COVID-19 restrictions in place at Winchester at the time.
57. On 16 July, Mr Ayers was moved from C Wing to B Wing.
58. On 20 July, the clinical lead for mental health reviewed Mr Ayers’ record because
he had been flagged as being under the Care Programme Approach (CPA – a
package of care for people with mental health problems). She had access to the
discharge letter from the community mental health team dated 10 May which said
that Mr Ayers’ mood was better when he was taking antipsychotic medication. A
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nurse recorded that antipsychotic medication had been decreased and stopped in
the community. This was not correct. Olanzapine had been stopped but not
quetiapine (although it was suggested this could be reduced). Nurse Hopkin
recorded there was a plan to triage Mr Ayers, but she did not take any further
action.
59. The same day, an entry by the mental health team noted: ‘No access visit for
Mental Health appointment with Mental Health A. Home visit - no reply’.
60. On 21 July, a member of the mental health team noted, ‘Due to increase in covid
positive people on the wing, access to the wing is limited so unable to be seen in
person for triage. Attempted to complete a telephone triage to in cell phone
however no answer/line unobtainable. Will remain on triage list and be reviewed at
earliest opportunity.’
61. On 22 July, the prison GP noted that an MDT meeting had taken place. The Head
of Healthcare, a member of the substance misuse team, the mental health lead and
the primary care lead attended. The GP noted that the SMS cover said Mr Ayers
was tolerating his detox well, but they were concerned about his mental health.
They planned to slow the diazepam withdrawal when he got down to 10mgs. They
found him very vacant and distracted but there was no evidence he was using other
substances. The GP noted that a nurse would ‘expedite’ a mental health review. (It
is not clear that the discharge letter from the community mental health team formed
part of discussions, particularly Mr Ayers’ statement that he would harm himself if
diazepam was stopped or the improvement in his mood when he was taking
antipsychotic medication.)
62. On the same day, the mental health team sent Mr Ayers an appointment letter for
27 July for a mental health review. The nurse told the clinical reviewer that the term
‘expedite’ had been discussed after Mr Ayers’ death and considered vague. In
future, the team had agreed it would be better to be specific about time frames.
Events of 24 and 25 July
63. On 24 July, an officer signed the roll check (when a member of staff checks and
counts each prisoner) record to say that a roll check had been completed at
8.30pm. However, CCTV shows that neither she nor any of her colleagues had
carried out a roll check at that time.
64. At approximately 9.00pm, an Operational Support Grade (OSG) carried out the last
evening roll check. Mr Ayers was in his cell, and she had no concerns. Mr Ayers did
not press his cell bell during the night.
65. At around 6.00am on 25 July, the OSG started the morning roll checks. When she
got to Mr Ayers’ cell, she saw that he was hanging from the light fitting using a
ligature made from ripped bedding. She called a code blue (a medical emergency
code used when a prisoner is unconscious or having breathing difficulties). Several
colleagues who were nearby arrived within 14 seconds and went into the cell.
66. An officer was one of the officers who responded. He went into the cell, cut down
Mr Ayers and started CPR. More staff assisted. According to a Custodial Manager’s
statement, he and an officer thought Mr Ayers was dead, but they continued with
CPR.
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67. A nurse attended within four minutes of the OSG calling the code. Another nurse
followed shortly afterwards, after she had finished locking medication away. A nurse
attached the defibrillator and, at interview, said on two occasions it advised a shock,
although no one else remembers this and he did not put this in the medical record.
His medical record entry described Mr Ayers as pale and stiff. He did not discuss Mr
Ayers’ presentation with his colleague, who went to get the clinical record.
68. The control room log shows that the code blue was called at 6.02am and an officer
called an ambulance three minutes later at 6.05am. The emergency service’s log
shows they received the call at 6.06am.
69. At 6.12am, the ambulance arrived at the prison and paramedics were at Mr Ayers’
cell by 6.16am. They concluded that Mr Ayers’ body showed signs of rigor mortis
and advised staff to stop CPR. At 6.18am, they pronounced Mr Ayers dead.
Contact with Mr Ayers’ family.
70. On 25 July, the prison appointed a family liaison officer. He telephoned Mr Ayers’
named nest of kin that day to break the news.
71. Mr Ayers’ funeral was on 1 September 2021. The prison contributed to the costs in
line with national policy.
Support for prisoners and staff
72. After Mr Ayers’ death, a senior 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. The OSG
said that she felt officers had received better aftercare than her, and that while they
were offered the opportunity to be relieved of their duties, she was not.
73. The prison posted notices informing other prisoners of Mr Ayers’ 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 Ayers’ death.
Post-mortem report
74. The post-mortem report concluded that the cause of Mr Ayers’ death was hanging
by ligature. The toxicology tests found evidence of benzodiazepine and methadone
in his system, in line with his prescribed medications.
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Findings
Assessing Mr Ayers’ risk of suicide and self-harm
Reception
75. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk from self,
from others and to others (Safer Custody) requires that all staff who have contact
with prisoners are aware of the risk factors and triggers that might increase the risk
of suicide and self-harm. Any prisoner identified as at risk of suicide and self-harm
must be managed under ACCT procedures. PSI 64/2011 lists potential risk factors
and triggers.
76. PSI 07/2015, Early Days in Custody, states that reception staff must examine the
PER and any other available information and assess prisoners’ risk of suicide and
self-harm.
77. We are concerned that Mr Ayers’ risk of suicide and self-harm was not properly
assessed when he arrived at Winchester. An officer did not complete the reception
checklist, and his NOMIS entry made no mention of Mr Ayers’ history of suicide
attempts or of the suicide and self-harm risk marker on the digital PER. The officer
has since left the Prison Service, so we were unable to interview him.
78. The reception nurse was unable to recall if she had seen the digital PER but said
she had seen the paper PER so was aware of Mr Ayers’ previous suicide attempts.
Neither the officer nor the nurse recorded that they had considered ACCT
monitoring.
Post-reception
79. On 11 July, Mr Ayers initially refused to take his diazepam until a nurse persuaded
him to take it. The nurse noted that Mr Ayers’ engagement and eye contact was
poor, he was dishevelled and was withdrawn. He recorded that he had asked the
duty mental health nurse to see Mr Ayers, but he did not record the name of the
nurse he spoke to. He also recorded that he had asked SMS staff to review Mr
Ayers overnight (there is no record that they did). While the clinical reviewer noted
that the nurse had apparently tried to escalate his concerns, there was no record
that he had considered starting ACCT monitoring. The clinical reviewer considered
that as Mr Ayers had an enduring mental illness, was not receiving his antipsychotic
and antidepressant medication and was in a neglected and withdrawn state, the
nurse should have considered ACCT monitoring.
80. On 13 July, a nurse noted that Mr Ayers seemed mentally unwell as he was
grunting and covering his face. She had already chased up a mental health referral
four days previously and may have thought this had already been organised, but
this incident on 13 July was another missed opportunity to consider mental health
intervention and ACCT monitoring. We recommend:
The Governor and Head of Healthcare should ensure that staff:
• consider all information that arrives with the prisoner, including both
the paper and digital version of the Person Escort Record;
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• record the information they have considered that is relevant to the risk
of suicide and self-harm and their full reasoning if they decide not to
start ACCT monitoring; and
• are alert to any deterioration in the prisoner’s presentation, particularly
those who have a diagnosed mental health condition and/or are
undergoing a drug detoxification process and consider ACCT
monitoring where appropriate.
Clinical care
81. The clinical reviewer found that the care provided to Mr Ayers at HMP Winchester
was not equivalent to that he could have expected to receive in the community.
There were multiple failings.
Mental health care
82. Despite staff referring Mr Ayers (who had a known diagnosis of schizophrenia) for a
mental health assessment on four occasions between 30 June and 9 July, he was
never assessed at Winchester. A nurse closed the referrals despite no action
having been taken. The investigator and clinical reviewer were unable to speak to
the nurse as she was no longer employed by the prison.
83. We are concerned that there was no safety net in place to provide oversight of the
circumstances in which referrals were closed. We recommend:
The Head of Healthcare should develop a reporting tool to identify mental
health referrals that are closed without action or explanation.
The healthcare provider and the NHSE quality team should consider whether
the behaviour of the nurse who cancelled multiple mental health referrals
requires discussion with the appropriate regulator.
84. Attempts to see Mr Ayers on 14, 20 and 21 July were unsuccessful, apparently due
to COVID restrictions. And, despite staff agreeing on 22 July that they would
expedite a mental health review, Mr Ayers was given an appointment for 27 July.
The mental health team have accepted that ‘expedite’ was too vague and a more
specific timescale should have been agreed.
Medication
85. Staff recognised quickly that Mr Ayers was prescribed a dangerous combination of
drugs in the community. However, there was no onsite GP available at the prison
when Mr Ayers arrived who could have spoken to Mr Ayers and his community GP
and made a decision about continuing his current medication regime. At interview,
the prison GP said that whenever she was on leave, getting GP cover was
extremely difficult however much notice she provided.
86. The offsite regional medical lead was covering for the prison GP, and he requested
the mental health team and the complex care team carry out a review before any
more medication was prescribed. However, his message was not sufficiently
detailed, and was not followed up with a specific task to the prison GP, or a face-to
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face review or discussion with other members of the team. There is no written
record of any detailed discussion with Mr Ayers about his medication. There is also
no record to suggest his full GP record was requested before 17 July. As a result,
Mr Ayers did not receive any antipsychotic or antidepressant medication at all while
he was at Winchester, despite being used to significant doses in the community.
87. The clinical reviewer also noted that in the past, Mr Ayers had been very sensitive
to benzodiazepine (diazepam) withdrawal. He had refused to engage with the
community mental health team for fear they would reduce it and told them he would
‘end up under a train’ if they did. While reducing his benzodiazepine dose was good
practice, it was done without talking to him in detail about it and without any
knowledge of his past concerns about it. We make the following recommendations:
The healthcare provider should ensure there is a GP onsite in line with the
primary care service specification for prisons in England.
The Head of Healthcare should ensure that prescribers consider the full list of
a new prisoner’s medications and record their reasons for any they do not
continue.
The Head of Healthcare should ensure staff request prisoners’ community
medical records at the earliest opportunity.
The Head of Healthcare should ensure that a prisoner’s perspective on
detoxification is sought and recorded.
Dental care
88. Mr Ayers was clearly experiencing dental pain and facial swelling while he was at
Winchester. The clinical reviewer is not satisfied that staff followed this up in line
with good practice or the requirements of the dental contract.
89. It is unlikely that the dental nurse who assessed Mr Ayers through the hatch in his
cell door could have carried out a proper examination in this way and while the
regime at the time may have prevented anything more thorough, she should not
have closed down the referral, particularly in the light of facial swelling that staff
themselves had noted. While we do not make a specific recommendation, this is
another incident which staff should reflect on.
Learning from this investigation
90. We consider it is important for staff to learn the lessons from this investigation. We
recommend:
The Head of Healthcare should share this report with the members of
healthcare staff who were involved in Mr Ayers’ care and discuss the
Ombudsman’s findings with them.
Roll checks
91. On 24 July, the night before Mr Ayers hanged himself, an officer recorded that she
carried out a roll check at 8.30pm. The investigator watched the CCTV and could
see no evidence of anyone doing a check at this time.
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92. At interview, the officer said she would not sign for a check that had not been
completed, and that although the roll check sheet had a pre-typed time of 8.30pm,
in practice, staff carried out the checks at around 7.30pm to ensure there was
enough time to get them done before night staff came on duty.
93. The officer said that sometimes whoever she was on duty with would do the checks
instead of her, but she would sign for it. She could not remember who she was on
duty with that night. The investigator re-checked the CCTV footage and there was
no sign of anyone completing the check that she had signed for.
94. It is unacceptable that the officer regarded it normal practice to sign for a check that
she herself had not done. The issue of the missed check alone was picked up by
the prison’s Early Learning Review, so the investigator contacted the Governor to
find out how he had responded to the review’s findings. He did not reply.
95. Two further roll checks were carried out properly by the OSG after the missed
check, so the officer’s error did not affect the outcome for Mr Ayers. However, we
are concerned that a roll check was missed, and the record was falsified to show it
had been done when it had not. We recommend:
The Governor should ensure that staff carry out roll checks at the required
times and only sign for them if they have completed them themselves.
Emergency Response
96. PSI 3/2013, Medical Emergency Codes, says that the control room must call an
ambulance immediately when a medical emergency code is called.
97. An officer was on duty in the control room on the morning of 25 July when staff
called the code blue after finding Mr Ayers hanging. The control room log shows
that he waited three minutes before calling an ambulance. We were unable to
interview him, as he had left the Prison Service. We recommend:
The Governor should ensure that control room staff call an ambulance
immediately when a medical emergency code is called.
98. Resuscitation Council Guidelines say that resuscitation should not be attempted
when there is clear evidence that it would be futile. Trying to resuscitate someone
who is clearly dead is distressing for the people involved and undignified for the
deceased.
99. Mr Ayers had rigor mortis when he was found, so had clearly been dead for some
time. When interviewed, a nurse maintained that it might have been possible to
resuscitate Mr Ayers. He said that the defibrillator had advised ‘shock’ on two
occasions, but he did not note this in his record at the time and no one else at the
scene recalled this. He was interviewed many months after the event, and it is likely
he has misremembered this. We recommend:
The Governor and the Head of Healthcare should ensure that staff are given
clear guidance about the circumstances in which resuscitation is
inappropriate in line with European Resuscitation Council Guidelines.
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Staff Support
100. Not all staff considered they were offered appropriate support after Mr Ayers’ death.
We recommend:
The Governor and Head of Healthcare should ensure that staff are offered
appropriate support following a death in custody.
Inquest
101. The inquest, held on 27 January 2025, concluded that Mr Ayers died by suicide.
However, the jury found that the cessation of his long-term medication and
antipsychotic and antidepressant drugs, along with his inability to receive any
quality of mental health care in prison, contributed to his death. This was
exacerbated by the infection control measures and the reduced staffing levels
imposed by COVID.
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