David Bassett

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Independent investigation into
the death of Mr David Bassett,
a prisoner at HMP Swansea,
on 1 December 2019
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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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 David Bassett died on 1 December 2019, after he was found hanging in his cell at HMP
Swansea. He was 52 years old. I offer my condolences to Mr Bassett’s family and
friends.
Mr Bassett had been at Swansea for only 36 hours when he was found hanging. He
arrived with warnings that he was at risk of suicide and self-harm and yet staff failed to
start suicide and self-harm prevention procedures.
I am concerned that reception staff appeared to place too much weight on Mr Bassett’s
presentation, rather than looking objectively at his risk factors for suicide and self-harm.
This was a missed opportunity to put support in place.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman September 2020
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
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Summary
Events
1. On 29 November 2019, Mr David Bassett was remanded in prison custody, charged
with arson of his own home, and sent to HMP Swansea. This was his first time in
prison for ten years.
2. Mr Bassett arrived at Swansea with suicide and self-harm warnings, which were
recorded on his Person Escort Record (PER) and on a suicide/self-harm (SASH)
warning form. The PER said that Mr Bassett was at risk of suicide and self-harm
because he had tried to burn himself on 27 November. The SASH warning form
said that Mr Bassett had tried to burn himself, was very depressed, that he had
attempted hanging or self-strangulation in the last six months and that he was being
checked six times an hour.
3. Neither the reception nurse nor the reception officer considered that suicide and
self-harm prevention procedures (known as ACCT) were needed. Nor did the Duty
Governor who also saw Mr Bassett. Mr Bassett was placed in a shared cell, in line
with local procedures for prisoners’ first night in custody.
4. On 30 November, Mr Bassett’s cellmate was moved to a different cell and Mr
Bassett remained in the cell on his own.
5. Mr Bassett was checked several times during the night during for his first few days,
in line with standard practice at Swansea. When a nurse checked on Mr Bassett at
5.43am on 1 December, she saw him hanging from a ligature tied to the bed frame.
The nurse radioed a medical emergency code and then went to collect an
emergency medical bag. Three officers responded to the emergency code and
went into the cell and cut the ligature from Mr Bassett’s neck. As they laid Mr
Bassett on his back, the nurse returned and ordered the officers to start
cardiopulmonary resuscitation (CPR).
6. Paramedics arrived at 5.57am and assisted with resuscitation. Their efforts were
unsuccessful and at 6.20am, the paramedics pronounced that Mr Bassett had died.
Findings
7. The reception nurse did not see the SASH warning form, only the PER. We were
told that she took only one of his files before she carried out her assessment, and
the SASH form was on the other file. The reception officer saw both documents but
considered that there was no indication that Mr Bassett was at risk of suicide and
self-harm. She said that Mr Bassett was relaxed, engaged well and was laughing
and joking with other prisoners.
8. We consider that staff should have started ACCT procedures when Mr Bassett first
arrived, given his clear risk factors for suicide and self-harm. Staff placed too much
weight on Mr Bassett’s appearance and what he told them, rather than considering
his documented risk factors. The failure to start ACCT procedures was a missed
opportunity to put support in place for Mr Bassett.
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Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide and self-harm in line with national guidelines, in particular that reception
staff should:
• have a clear understanding of their responsibilities to identify prisoners at risk of
suicide and self-harm;
• examine all relevant information that arrives with the prisoner, in particular the
PER and SASH form;
• identify risk factors and assess a prisoner’s risk based on their risk factors and not
just personal presentation; and
• document the risk information considered and the reasons for not starting ACCT
procedures.
• The Head of Healthcare should share a copy of this report with the reception nurse
and discuss the Ombudsman’s findings with her.
• The Governor should share a copy of this report with Duty Governor and discuss the
Ombudsman’s findings with him.
• The Governor should share a copy of this report with the reception officer and arrange
for a senior manager to discuss the Ombudsman’s findings with her.
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The Investigation Process
9. The investigator issued notices to staff and prisoners at HMP Swansea informing
them of the investigation and asking anyone with relevant information to contact
him. One prisoner responded.
10. The investigator obtained copies of Mr Bassett’s prison and medical records. He
interviewed ten members of staff and one prisoner at Swansea from 27 to 29
January 2020.
11. Health Inspectorate Wales commissioned an independent clinical reviewer to
review Mr Bassett’s clinical care at the prison. They jointly interviewed staff.
12. We informed HM Coroner for Swansea, Neath and Port Talbot of the investigation.
The Coroner gave us Mr Bassett’s cause of death. We have given the Coroner a
copy of this report.
13. One of the Ombudsman’s family liaison officers contacted Mr Bassett’s next of kin
to ask if the family had any matters they wanted the investigation to consider. The
family wanted to know why he was in a cell on his own and why he was not
watched carefully by staff. We have addressed these points in this report.
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Background Information
HMP Swansea
14. HMP Swansea is a local prison that holds around 500 men and young adult men.
Healthcare is provided by Abertawe Bro Morgannwyg University Health Board.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Swansea was in August 2017. Inspectors
noted that in their survey, a third of prisoners said that they felt depressed or
suicidal or had mental health problems on arrival. Inspectors noted that there had
been four self-inflicted deaths since their previous inspection in October 2014, all
within a week of arrival. Inspectors observed friendly interaction between reception
staff and prisoners, but found that reception risk assessments were not sufficiently
rigorous and first night procedures were inconsistent.
Independent Monitoring Board
16. 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 2017, the IMB noted that
there had been two deaths in custody in the reporting period. The Board said that
PPO recommendations were discussed in Safer Custody meetings but were not
always implemented in a timely manner.
Previous deaths at HMP Swansea
17. Mr Bassett was the second prisoner to die at Swansea since December 2017. The
previous death was also a self-inflicted death during the prisoner’s first days in
custody. There were no other similarities in the circumstances of that death and
those of Mr Bassett’s death. There has been a death from natural causes since Mr
Bassett’s death.
Assessment, Care in Custody and Teamwork
18. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses for supporting and monitoring prisoners assessed as at risk
of suicide and self-harm. The purpose of the ACCT process is to try to determine
the level of risk posed, the steps that might be taken to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Levels of supervision and
interactions are set according to the perceived risk of harm. There should be
regular multi-disciplinary case reviews involving the prisoner. Checks made on
prisoners should be at irregular intervals to prevent the prisoner anticipating when
they will occur. Part of the ACCT process involves assessing immediate needs and
drawing up a caremap to identify the prisoner’s most urgent issues and how they
will be met. Guidance on ACCT procedures is set out in Prison Service Instruction
(PSI) 64/2011.
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Key Events
19. On 27 November 2019, Mr David Bassett was arrested and taken into police
custody charged with arson of his own home and of using dishonestly a quantity of
electricity.
29 November
20. On 29 November, Mr Bassett was taken to Cardiff Magistrates’ Court where he was
remanded in prison custody. As HMP Cardiff was full, Mr Bassett was taken
instead to HMP Swansea where he arrived at 5.15pm. This was his first time in
prison custody for ten years.
21. The paperwork that accompanied Mr Bassett to Swansea included a Person Escort
Record (PER - a document that accompanies prisoners between police custody,
courts and prisons, which sets out the risks they pose), a suicide/self-harm (SASH)
warning form, and a record of the medical treatment he received while he was in
police custody. The PER said that Mr Bassett was at risk of suicide and self-harm
as he had tried to burn himself on 27 November. The SASH form said that Mr
Bassett was very depressed at present, that he had tried to burn himself on 27
November and was being checked six times an hour. It also said that he had
attempted hanging or self-strangulation within the last six months.
22. When he arrived at Swansea, Mr Bassett was seen for a reception health
assessment by a registered mental health nurse. She noted that Mr Bassett
appeared fit and well and that he had no concerns about his physical health. Mr
Bassett reported that he had a history of depression and was receiving fluoxetine
(antidepressant). As Mr Bassett had some fluoxetine tablets with him, the reception
nurse, who was a nurse prescriber, prescribed a short course of fluoxetine pending
contact with Mr Bassett’s community GP. She noted that Mr Bassett was pleasant
and polite and that he had no thoughts of suicide or self-harm.
23. She said that she saw Mr Bassett’s PER but she did not see the SASH form and did
not know why the SASH form was not given to her. The investigator asked the
reception nurse whether she should have started ACCT procedures based upon the
comment in the PER form that Mr Bassett had tried to burn himself. She said that
she could not specifically recall reading the comment that Mr Bassett had tried to
burn himself, but if she had seen it she would have questioned him further and
might have started ACCT procedures depending on their further discussion.
24. An officer saw Mr Bassett for a reception interview after he had seen the reception
nurse. The reception officer told the investigator that she was still sorting out the
papers for all the newly arrived prisoners when the reception nurse took one of Mr
Bassett’s two files. She told the reception nurse to wait, but she paid no attention.
The reception officer told the investigator that Mr Bassett’s SASH document was on
his other file. She said that Mr Bassett was the last prisoner she saw and that she
spent around 25 to 30 minutes with him. She said that she was an ACCT assessor
and was aware that arson was a risk factor for suicide. She asked Mr Bassett
about the offence and he told her that he had threatened to set fire to his home
following a dispute with his local council about council tax arrears, but he said that it
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had only been a threat and he had not acted upon it. She asked him if he had any
current thoughts of suicide or self-harm and he said that he did not.
25. The investigator asked the reception officer whether the safe option would have
been to start ACCT procedures, but she was adamant that there were no grounds
to do so. She said that Mr Bassett was relaxed, he engaged well, he was laughing
and joking with other prisoners and he denied that he had committed arson. She
did not consider that he was at risk and nor did her colleagues.
26. As arson was recorded as Mr Bassett’s index offence, the reception officer radioed
the Duty Governor to assess whether Mr Bassett would be able to share a cell with
another prisoner (there are various reasons why a prisoner might not be deemed
suitable to share a cell including certain cases of arson).
27. The Duty Governor told the investigator that he was given all Mr Bassett’s reception
documents including the first part of the cell sharing risk assessment (CSRA) form
that had been completed by the reception nurse. The Duty Governor said that he
spoke to Mr Bassett about the incident and he said that he had lit a very small fire in
his house which was prompted by a dispute that he had with his local council. He
said that he extinguished the fire himself before emergency services arrived. The
Duty Governor considered that Mr Bassett would be safe to share a cell.
28. The investigator asked the Duty Governor about the warnings contained in the PER
and SASH form. He said that his role when he spoke with Mr Bassett was not
specifically to assess whether ACCT procedures should be started, and he said that
Mr Bassett had been calm in their interview and also seemed forward thinking as he
asked if the Duty Governor could recommend solicitors to help him in his council
dispute. The Duty Governor acknowledged that in hindsight, it might have been
prudent to start ACCT procedures.
29. An induction unit officer saw Mr Bassett after he had finished in reception. The
induction officer said that he took Mr Bassett to an interview room and worked
through the induction booklet to explain various prison processes and about support
services available to prisoners. The induction officer said that their discussion
lasted around 10 to 15 minutes and Mr Bassett was polite and well mannered, and
he made several witty remarks. The induction officer told Mr Bassett that he was
entitled to make a telephone call but Mr Bassett said that he could not remember
any telephone numbers and he planned to write to friends and family to get their
numbers.
30. The induction officer said that he asked Mr Bassett whether he had any thoughts of
suicide or self-harm and he said that he did not. He said that he saw Mr Bassett’s
PER, but he did not see the SASH form. The investigator asked the induction
officer about the warning contained in the PER. The induction officer said that
because the reception area was quite crowded, prisoners might not be open about
their feelings but when they come to the first night centre they might then reveal that
they are struggling and he would then start ACCT procedures. He said that Mr
Bassett did not give him cause for concern.
31. The induction officer said that prisoner Insiders had then spoken to Mr Bassett.
(Insiders are experienced and trusted prisoners who speak to new arrivals about
prison processes and the support that is available.) The induction officer said that
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the Insiders will speak to officers if they consider that a new prisoner needs
additional support. They did not report any concerns about Mr Bassett.
32. At Swansea, the practice is to try to ensure that new arrivals share a cell for at least
their first night in custody. Once Mr Bassett had completed his initial induction, he
was moved to a shared cell.
33. The cellmate refused to speak to the investigator but gave no reason.
30 November
34. A second induction officer met Mr Bassett on 30 November. He unlocked the cells
in the morning for prisoners to come out for the ‘domestic’ period when they can
collect breakfast, make telephone calls and have a shower. He said that he
recalled Mr Bassett collecting breakfast but he did not have a conversation with
him. He said that Mr Bassett did not seem uncomfortable with being in prison and
he saw that he was chatting with his cellmate.
35. A Supervising Officer (SO), an offender manager working in the Offender
Management Unit, saw Mr Bassett early on the morning of 30 November for a basic
custody screening interview. The SO told the investigator that before speaking to
Mr Bassett, he reviewed his electronic prison record (the NOMIS record). This was
the only record he checked. The SO said that the issues he covered during his
interview with Mr Bassett included questions about possible issues with drugs or
alcohol and questions about accommodation. The SO said that Mr Bassett was
cooperative and “quite chatty’. The SO asked Mr Bassett if he had any thoughts of
self-harm or suicide and Mr Bassett said that he did not.
36. A 10.50am, a second nurse saw Mr Bassett for a second reception screening
interview. She told the investigator that the purpose of the second reception
interview is to identify any issues that might not have been identified in the first
interview. She noted that Mr Bassett engaged well with her and was polite and
calm throughout the interview. She said that Mr Bassett told her that he was
receiving fluoxetine and she told him that Swansea would contact his community
GP. She said that she asked Mr Bassett if he had any thoughts of self-harm or
suicide and he said no, and he laughed. She said that his laughter was in the
context of questioning her why she needed to ask such a question. She said that
she did not have access to Mr Bassett’s paper records, only his electronic medical
records.
37. Later that day, Mr Bassett’s cellmate was moved to a new cell after he was found in
possession of an unauthorised item. Mr Bassett remained in the cell on his own.
38. Another prisoner at Swansea, wrote to the investigator making an allegation against
an officer. He said he had told the officer that Mr Bassett might harm himself. In a
telephone interview, he told the investigator that he had known Mr Bassett for
around 20 years. He said that they met when Mr Bassett bought a car from a friend
and although they had not met again since then, they had spoken from time to time
over the telephone. The prisoner said that at about 3.30pm on 30 November, he
had gone to the OMU office which was in a portacabin opposite Mr Bassett’s cell.
He said that as he was walking away from the OMU office, Mr Bassett had called
out to him saying “[name redacted], it’s Bassett”, and he then said that he was
going to harm himself. The prisoner said he shouted back not to do it. He said that
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when he returned to his wing he told an officer what Mr Bassett had said and that
she needed to go to see him. He said that he challenged the officer after Mr
Bassett’s death and she said that she had forgotten to speak to him.
39. The investigator spoke to the officer about the prisoner’s allegation. She denied
categorically that the prisoner had spoken to her about Mr Bassett. She said that
she and the prisoner did not have a good relationship.
40. Another induction officer said that he went off duty at 5.00pm that afternoon. Just
before that time, Mr Bassett had collected his evening meal and had been locked
back into his cell.
41. An officer, who worked a shift that evening, told the investigator that during their
initial nights in custody, all prisoners on the induction unit are checked by officers on
an hourly basis up to midnight and after midnight, the duty nurse makes three
checks during the night. The records show that the night officer checked Mr
Bassett three times between 8.00pm and 11.00pm and another night officer made
the last check before midnight. The night officer said that each time she checked
Mr Bassett, he was in bed and appeared to be asleep.
1 December
42. The investigator checked the CCTV recording taken for the night of 1 December.
He saw that a nurse checked Mr Bassett at around midnight and at around 2.00am
(the precise times are difficult to determine as the timings shown on the CCTV
recording would appear to be around 45 minutes behind real time).
43. The first officer told the investigator that she made another check on Mr Bassett at
around 4.00am. She said that there had been a disturbance with another prisoner
on the upper landing of the induction unit, so she wanted to ensure that other
prisoners had not been disturbed. She said that when she checked Mr Bassett, he
again appeared to be asleep.
44. The nurse next checked Mr Bassett at around 5.43am. The nurse told the
investigator that when she opened Mr Bassett’s cell door observation panel, she
saw him on his knees hanging from a ligature tied to the upper rail of the bunk bed.
She radioed a medical emergency code blue (used to indicate a prisoner is
unconscious or having breathing difficulties) and went to the treatment room to
collect emergency equipment. (The nurse does not carry a cell key.)
45. The first night officer told the investigator that when she heard the code blue alarm,
she was in the wing office, around 30 metres from Mr Bassett’s cell, with two other
officers. She said that when she reached Mr Bassett’s cell, she and an officer
looked through the observation panel and saw Mr Bassett hanging. She broke
open her sealed key pouch and unlocked the door. She said that although Mr
Bassett appeared to be on his knees, the ligature was taking most of his
bodyweight. She said that she and the second night officer lifted Mr Bassett a little
and used an anti-ligature knife to cut the ligature.
46. The second night officer told the investigator that Mr Bassett had made the ligature
from a bedsheet and as it was twisted and thick it took him several attempts to cut
through it. Once he cut it, the remainder of the ligature came away from Mr
Bassett’s neck.
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47. Once the ligature was cut away, the officers laid Mr Bassett on the floor and at that
point the nurse returned and ordered them to start chest compressions.
48. The nurse told the investigator that even without making checks on Mr Bassett she
could see there were no signs of life so she did not want to waste any time in
checking for a pulse or any signs of breathing. She said that while the officers
began giving chest compressions, she inserted an airway tube to give Mr Bassett
oxygen and also checked him with a defibrillator.
49. Ambulance paramedics were called when the code blue call was made and their
records show that they arrived at the cell at 5.57am. The paramedics assisted with
efforts to resuscitate Mr Bassett. Efforts continued until 6.20am, when the
paramedics declared that further efforts should cease as Mr Bassett was dead.
Contact with Mr Bassett’s family
50. The prison appointed a prisoner counsellor as family liaison officer (FLO). At just
before 8.00am, the FLO and a colleague left Swansea to drive to Mr Bassett’s next
of kin’s home, where they arrived at 8.50am. They tried several times to get a
response from the house and they also tried adjoining properties, all without
success. The FLO continued with his efforts and also sought guidance from the
Duty Governor. At 10.45am, the FLO tried again to get an answer from the home
and this time Mr Bassett’s next of kin responded (she had not heard the previous
attempts). The FLO broke the news and he and his colleague then took her to her
next of kin’s home where they also informed her of the news.
51. Swansea contributed to the cost of Mr Bassett’s funeral in line with national
instructions.
Support for prisoners and staff
52. A CM debriefed the staff who were involved in the response when Mr Bassett was
found. The staff care team also offered support.
53. The prison posted notices informing other prisoners of Mr Bassett’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 Bassett’s death.
Post-mortem report
54. Toxicology tests showed the presence of amphetamine in Mr Bassett’s blood. The
toxicologist noted that it was unlikely that the drug would have caused Mr Bassett’s
death or would have had a significant effect on his cognition or motor skills. Mr
Bassett’s cause of death was hanging.
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Findings
Assessment of Mr Bassett’s risk of suicide and self-harm
55. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), sets out the procedures for
identifying and supporting prisoners at risk of suicide and self-harm. PSI 64/2011
sets out a list of risks and triggers that can increase the risk of suicide and self-
harm. It also sets out the procedures (known as ACCT) that should be followed
when a prisoner is identified as at risk.
56. Mr Bassett’s PER and SASH form both noted that he had tried to burn himself. In
addition, Mr Bassett’s SASH form noted that he was very depressed, that he had
attempted hanging or self-strangulation in the past six months and that he was
being checked six times an hour. PSI 64/2011 lists deliberate self-harm as a risk
factor, along with a mental illness diagnosis (including depression). It also lists the
offence of arson as a risk factor. Therefore, Mr Bassett had clear risk factors for
suicide and self-harm.
57. The reception nurse did not see the SASH form because it was not included in the
folder of documents she had when she assessed Mr Bassett. We are concerned
that she carried out her assessment without sight of a key document that
highlighted Mr Bassett’s risk of suicide and self-harm.
58. The reception officer saw both the PER and the SASH form. When interviewed,
she said she considered there were no grounds to start ACCT procedures. She
said Mr Bassett was relaxed, engaged well and was laughing and joking with other
prisoners. She acknowledged that arson was a risk factor but said that Mr Bassett
told her he had only threatened to burn his house and had not carried out his threat.
59. In February 2016, we published a Learning Lessons Bulletin which examined self-
inflicted deaths of prisoners within the first month of custody. We found that in
many instances staff based their assessments on the prisoner’s presentation and
their statements that they had no thoughts of suicide or self-harm. We noted that
known risk factors, such as a history of suicidal behaviour, were often overlooked.
60. We consider that the warnings on the PER and SASH form were sufficient for staff
to start ACCT procedures. We consider that staff placed too much weight on Mr
Bassett’s presentation and his own statements that he had no thoughts of suicide or
self-harm, and insufficient weight on the warnings that arrived with him and his risk
factors. The failure to start ACCT procedures was a missed opportunity to put
support in place for Mr Bassett. We make the following recommendation:
The Governor and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide and self-harm in line with national guidelines, in
particular reception staff should:
• have a clear understanding of their responsibilities to identify prisoners at
risk of suicide and self-harm;
• examine all relevant information that arrives with the prisoner, in particular
the PER and SASH form;
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• identify risk factors and assess a prisoner’s risk based on their risk factors
and not just personal presentation; and
• document the risk information considered and the reasons for not starting
ACCT procedures.
The Head of Healthcare should share a copy of this report with the reception
nurse and discuss the Ombudsman’s findings with her.
The Governor should share a copy of this report with the Duty Governor and
discuss the Ombudsman’s findings with him.
The Governor should share a copy of this report with the reception officer and
arrange for a senior manager to discuss the Ombudsman’s findings with them.
Mr Bassett’s cellmate
61. When Mr Bassett’s cellmate was moved, he was then left as the sole occupant of
his cell. A Custodial Manager (CM) told the investigator that she managed the
induction unit. The CM told the investigator that the aim in Swansea is to try to
ensure that prisoners share a cell for at least their first night in custody. She said
that if a prisoner is subject to ACCT procedures, or has otherwise been identified as
vulnerable, Swansea will try to keep them with a cellmate for a longer period. She
said that with Mr Bassett, there was no apparent reason why he needed to be found
a new cellmate.
62. The Prison Service acknowledges that having a cell-mate is a source of support for
prisoners who might be at risk of suicide and self-harm. We have already explained
why we consider that staff should have started ACCT procedures. Had this been
the case, Swansea would have made efforts to find a new cellmate for Mr Bassett.
However, as ACCT procedures had not been started, staff in the induction unit had
no reason to believe that they needed to find him a new cellmate.
A prisoner’s allegation against an officer
63. A prisoner wrote to the investigator and said that he was returning from the exercise
yard when Mr Bassett called out to him that he was thinking of harming himself.
Before speaking to him, the investigator re-visited Mr Bassett’s cell. He noted that
Mr Bassett’s cell did not overlook the exercise yard, in addition, he noted that it
would be difficult for Mr Bassett to have seen anyone below his cell as the cell
window only opened a few centimetres and had an external grill. When the
investigator challenged the prisoner about this, the prisoner said that when Mr
Bassett called out to him he was not on the exercise yard, he said instead that he
had gone to the OMU office, which was opposite Mr Bassett’s cell, and he was
returning to his wing via the exercise yard when Mr Bassett called out to him. He
said that this was at about 3.30pm on 30 November, a Saturday.
64. The investigator asked an OMU SO about the opening hours of the OMU office. He
said that OMU staff usually work Monday to Friday but he and a colleague had
gone into Swansea on the morning of Saturday 30 November to catch up on a
backlog of work. He said that OMU staff always visit prisoners on the prison wings,
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that the OMU office is used to hold secure files and that prisoners do not attend the
OMU office. We do not consider the prisoner’s account to be credible.
Clinical care
65. The clinical reviewer found that Mr Bassett’s care at Swansea was equivalent to
that which he could have expected to receive in the community. In particular, he
received comprehensive first and second health screens that covered both his
physical and mental health and there was no delay in him receiving medication.
Inquest
66. An inquest into Mr Bassett’s death held from 21 to 29 July 2025 found that his
cause of death was suicide by hanging. The jury found that failures to respond to an
obvious risk of self-harm contributed to Mr Bassett’s death.
12 Prisons and Probation Ombudsman
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