Decland Mooney

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Independent investigation into
the death of Mr Decland
Mooney, a prisoner at HMP
Cardiff, on 6 December 2020
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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© Crown copyright, 2024
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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 Decland Mooney died on 6 December of pneumonia caused by emphysema in his cell
at HMP Cardiff. Mr Mooney was 64 years old. I offer my condolences to Mr Mooney’s
family and friends.
The clinical reviewer concluded that the clinical care that Mr Mooney received at HMP
Cardiff was of a good standard and equivalent to that which he could have expected to
receive in the community. Mr Mooney presented with challenging behaviour and the
clinical reviewer commended healthcare staff for the care provided to Mr Mooney in
difficult circumstances.
Mr Mooney had a history of schizophrenia and his behaviour at Cardiff was often odd and
threatening. The clinical reviewer noted that there was nothing to show if healthcare staff
considered referring Mr Mooney for a possible transfer to a secure psychiatric hospital
(although this had no impact on his death).
I found two non-clinical issues of concern.
There was some missing paperwork for an incident on 6 November when staff used force
to restrain Mr Mooney (although there is nothing to suggest that this played any part in his
death).
I am also concerned that a welfare check was not conducted when Mr Mooney was
unlocked on the morning of his death. He was found unresponsive in his cell about 30
minutes later. We cannot say whether Mr Mooney was still alive at the time he was
unlocked or whether the outcome might have been different if he had been found earlier.
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 August 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 16 October 2020, Mr Decland Mooney was remanded to HMP Cardiff charged
with assault.
2. During his first few days in prison, staff noted that Mr Mooney’s behaviour was
hostile and unusual. On 20 October, Mr Mooney was seen by a mental health
practitioner, who noted that his behaviour was consistent with a previous diagnosis
of schizophrenia. The following day he was allocated a mental health worker.
3. On 22 October, Mr Mooney was seen making cuts to his legs and Prison Service
suicide and self-harm procedures (known as ACCT) were started. Mr Mooney said
that his actions had been misinterpreted as self-harm and denied any intention to
hurt himself. The ACCT was closed that day.
4. On 6 November, Mr Mooney was restrained and returned to his cell after refusing to
put his face mask on. There were no reported injuries to Mr Mooney or wing staff.
5. On 16 November, staff searched Mr Mooney’s cell and found seven litres of
fermented liquid. The items were seized, and Mr Mooney was placed on a
disciplinary charge.
6. On 6 December, at around 7.00am, a prison officer began the morning roll check
(count of prisoners). He checked Mr Mooney’s cell and said he saw him getting
dressed through the observation panel. At around 9.00am, the same officer began
unlocking prisoners for morning association.
7. At around 9.30am, another officer began locking up cells. He found Mr Mooney
unresponsive in his cell, curled around the lavatory and bleeding from the nose. A
code blue (a medical emergency code used when a prisoner is unconscious or
having breathing difficulties) was called and healthcare staff attended. An
ambulance was called at 9.32am.
8. Mr Mooney had no pulse and was not breathing but was warm to the touch. Staff
started CPR immediately. The ambulance arrived in the prison at 9.43am and
paramedics reached Mr Mooney at 9.46am. They took over CPR but, at 10.02am,
they confirmed that Mr Mooney had died.
Findings
9. The clinical reviewer concluded that the clinical care that Mr Mooney received at
HMP Cardiff was of a good standard and equivalent to that which he could have
expected to receive in the community. He commended healthcare staff for the care
provided to Mr Mooney in difficult circumstances, given his challenging behaviour.
10. The clinical reviewer identified one concern – that it was not clear if healthcare staff
considered referring Mr Mooney for transfer to a secure psychiatric hospital under
the Mental Health Act - although this did not impact on Mr Mooney’s death.
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11. Although we are satisfied that Mr Mooney was seen by a nurse after staff used
force on him on 6 November, the prison could not find the form on which her
examination should have been recorded. There is, however, nothing to suggest that
this incident played any part in Mr Mooney’s death a month later.
12. On the morning of 6 December, prison staff did not carry out a welfare check. when
Mr Mooney was unlocked. He was found unresponsive but still warm 30 minutes
later. We cannot say if Mr Mooney was still alive when he was unlocked.
Recommendations
• The Head of Healthcare should ensure that where a patient has a confirmed
history of a serious mental illness and there is evidence of risk to others, the
mental health team should:
• document whether they have considered detention under the
appropriate section of the Mental Health Act;
• if this is not felt to be appropriate, record a rationale for this decision;
and
• record all considerations and decisions in the multi-disciplinary
meeting notes and SystmOne clinical record.
• The Governor should ensure that when a cell door is unlocked, staff satisfy
themselves of a prisoner’s safety and welfare and that there are no matters that
need immediate attention.
• The Governor and Head of Healthcare should ensure all key Use of Force
documentation is appropriately retained and stored, and that clinical staff record
all interventions on the patient’s medical record.
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The Investigation Process
13. HMPPS notified us of Mr Mooney’s death on 6 December 2020.
14. The investigator wrote to Cardiff on 7 December 2020. He obtained a range of
documents including copies of relevant extracts from Mr Mooney’s prison and
medical records, as well as CCTV and Body-Worn Camera (BWC) footage. He
requested and received a statement from a member of staff.
15. Health Inspectorate Wales commissioned a clinical reviewer to review Mr Mooney’s
clinical care at the prison.
16. We informed HM Coroner for South Wales Central of the investigation. The coroner
gave us the results of the post-mortem examination. We have sent the coroner a
copy of this report.
17. Our family liaison officer wrote to Mr Mooney’s next of kin, his daughter, to explain
the investigation and to ask whether she had any matters she wanted the
investigation to consider. His daughter raised a number of matters, including
questions about to his physical and mental health care, his location within the
prison, the use of force against Mr Mooney, and the prison’s communication with
her. We have addressed questions relating to his health and care in our report.
18. Mr Mooney’s daughter received a copy of the initial report. She raised a number of
issues/questions that do not impact on the factual accuracy of this report and have
been addressed through separate correspondence.
19. The initial report was shared with the Prison Service. The Prison Service did not
find any factual inaccuracies.
20. Following discussion between the prison and the PPO, we agreed to remove the
recommendation relating to a specific member of staff. We are satisfied that there
was a lack of clarity in the local policy about welfare checks. We accept this was a
systemic issue rather than an individual failure. The Prison Service have accepted a
recommendation about welfare checks.
21. The mental healthcare provider at HMP Cardiff did not accept the clinical
recommendation.
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Background Information
HMP Cardiff
22. HMP Cardiff is a medium security prison holding remand and sentenced adult male
prisoners. As part of its role, it serves the courts of South Wales. The prison is
operated by HM Prison Service.
23. Physical and mental healthcare services are provided by Cardiff and Vale University
NHS Health Board. HMP Cardiff has an inpatient healthcare unit and 24-hour
nursing provision. Substance Misuse services are provided by Cardiff and Vale
University NHS Health Board with the Dyfodol consortium.
HM Inspectorate of Prisons
24. The most recent inspection of HMP Cardiff was carried out in July 2019. Inspectors
reported that there was a high demand for mental health services in the prison and
long waits for treatment. They found that the mental health team was not sufficiently
staffed to meet the needs of prisoners. They also noted a rising number of use of
force incidents and recommended that the prison should investigate this.
Independent Monitoring Board
25. 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 August 2020, the IMB
reported that, despite improvements, they considered that the prison’ mental health
services were understaffed. They noted there were over 30 referrals a week to
mental health services and nearly 30 referrals a month to the psychiatrist. They
were also concerned about the increasing use of force on prisoners by staff.
Previous deaths at HMP Cardiff
26. Mr Mooney was the eighth prisoner to die at Cardiff since December 2018. Of the
previous deaths, four were from natural causes. There are no similarities between
Mr Mooney’s death and the previous deaths.
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Key Events
27. On 16 October 2020, Mr Decland Mooney was remanded to HMP Cardiff charged
with assault. He began a 14-day period of isolation in line with the Prison Service
COVID-19 guidelines on new arrivals in prison.
28. On arrival at the prison, he had a reception health screen completed by a nurse. Mr
Mooney reported several physical health issues including asthma and said that he
had had a stroke and a heart attack in the recent past. He also reported a history of
bipolar disorder and schizophrenia. The nurse made a referral to the prison’s
mental health team.
29. On 17 October, Mr Mooney had a secondary health screen with a prison GP. She
noted his community prescriptions and prescribed these again. The prison waited
for the remainder of Mr Mooney’s NHS community records to arrive.
30. On 19 October, a nurse recorded that Mr Mooney had signs of an infected leg
wound (which had occurred seven days prior to coming to prison while climbing
through a broken window). He was prescribed appropriate dressings and an
antibiotic.
31. During his first few days at Cardiff, staff noted that Mr Mooney’s behaviour was
hostile and unusual. On 20 October, Mr Mooney was seen by a mental health
practitioner. She noted that his behaviour was consistent with a previous diagnosis
of schizophrenia. She also noted that he had not been on any psychiatric
medication in the community and had not engaged with community mental health
services. She considered that he needed to be moved to the prison’s healthcare
unit, and Mr Mooney was moved later that day.
32. On 21 October, Mr Mooney made threats to kill nursing staff. This was reported to
prison staff who conducted a search of Mr Mooney’s cell and found an improvised
weapon. Staff held an urgent mental health case review and Mr Mooney was
allocated a mental health worker. Over the following days, mental health staff
recorded that they could see no evidence of serious mental health issues or
psychotic symptoms.
33. On 22 October, Mr Mooney was seen making cuts to his legs and Prison Service
suicide and self-harm procedures (known as ACCT) were started. An officer
assessed Mr Mooney and discussed his actions, feelings and wellbeing with him.
Mr Mooney said that he had been trying “to release fluid” and his actions had been
misinterpreted as self-harm. He denied any intention to hurt himself. The ACCT was
closed that day with a post-closure review set for 29 October.
34. On 27 October, Mr Mooney saw his allocated mental health worker. Mr Mooney
denied any problems with his mental health. However, he continued to display
hostility towards staff. He made threats to staff which were reported to the police
and sent a sexually explicit letter to a female healthcare worker.
35. On 28 October, the remainder of Mr Mooney’s community GP records arrived, and
a prison GP noted that Mr Mooney had a history of Chronic Obstructive Pulmonary
Disease (COPD), asthma and throat cancer. She requested blood and other
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investigative tests. When the results of these tests were received on 31 October,
she started Mr Mooney on medication to reduce his cholesterol.
36. On 30 October, Mr Mooney met with staff for his ACCT post-closure review. Mr
Mooney reported that he had no problems and had sources of support. The ACCT
was not reopened, and staff assessed no further reviews were needed.
37. On 31 October, Mr Mooney completed his period of COVID-19 isolation and
healthcare staff assessed there was no clinical need for him to remain in the
healthcare unit. He was moved onto F Wing.
38. The following day he racially abused his cellmate, who was moved to another cell
for his safety. Mr Mooney was assessed as high risk for cell sharing, which made
him unsuitable to share a cell.
39. On the morning of 6 November, staff on F Wing asked Mr Mooney to put his face
mask back on, in line with COVID-19 policy. Mr Mooney refused and made threats
to staff. He was then told to return to his cell which he refused. Two officers then
applied guiding holds to Mr Mooney’s arms to take him back to his cell. Mr Mooney
resisted. Officers placed Mr Mooney in arm locks and a head hold and returned him
to his cell. Mr Mooney was debriefed by staff as to why he had been restrained. He
was seen by a nurse following the incident. There were no recorded injuries to Mr
Mooney or officers.
40. On 16 November, staff searched Mr Mooney’s cell and found seven litres of
fermented liquid (‘hooch’). The items were seized, and Mr Mooney was placed on a
disciplinary charge.
41. On 18 November, Mr Mooney’s mental health worker saw him, but he refused to
engage with her. The mental health team decided he needed to be seen by the
prison psychiatrist.
42. Over the following days, Mr Mooney flooded his cell and posted abusive messages
to staff under his cell door. On 25 November, the mental health team met and
carried out a screening assessment for Mr Mooney. It was agreed that he should be
seen by a consultant psychiatrist, and Mr Mooney was added to the next clinic list.
He was not seen before his death.
43. Mr Mooney phoned his family on 30 November, 1 December and again on 3
December. In one of the calls, he told his family that he was struggling to breathe
and had a tight chest. He said that the prison would not provide him with a
nebuliser.
Events of 6 December 2020
44. At around 7.00am, an officer began the morning roll check. He checked Mr
Mooney’s cell and said he saw him through the observation panel sitting on his bed,
apparently bending down to adjust his shoes, and that Mr Mooney looked at him
and acknowledged him. At around 9.00am, he began unlocking prisoners for
morning association. He unlocked Mr Mooney’s cell door and said that he did not
see anything out of the ordinary.
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45. At around 9.30am, an officer began locking prisoners in their cells at the end of the
association period. When she entered Mr Mooney’s cell, she found him
unresponsive, curled around the lavatory and bleeding from the nose. She called a
code blue (a medical emergency code used when a prisoner is unconscious or
having breathing difficulties) and healthcare staff attended. A 999 call was made at
9.32am to Wales Ambulance Service.
46. Mr Mooney had no pulse and was not breathing but was warm to the touch. Staff
started CPR immediately. The ambulance arrived in the prison at 9.43am and
paramedics reached Mr Mooney at 9.46am. They took over CPR but at 10.02am,
they confirmed that Mr Mooney had died.
Contact with Mr Mooney’s family
47. At 11.20am, the prison Family Liaison Officer (FLO) rang Mr Mooney’s daughter to
tell her that her father had died. Over the following days the FLO spoke with Mr
Mooney’s daughter and other family members to offer condolences and to help
make arrangements for the funeral.
48. Mr Mooney’s funeral was held on 29 December 2020. In line with prison policy,
Cardiff made a financial contribution to the cost of the funeral.
Support for prisoners and staff
49. After Mr Mooney’s death, a Custodial 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.
50. The prison posted notices informing other prisoners of Mr Mooney’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 Mooney’s death.
Events following Mr Mooney’s death
51. Mr Mooney’s next of kin wrote to us in April 2021. She told us that Mr Mooney rang
her in the days before his death and told her that prison officers had used force
against him and thrown him on his back. We asked the prison for all use of force
records relating to Mr Mooney. The only record the prison had relating to Mr
Mooney was an incident almost a month earlier on 6 November.
Post-mortem report
52. The post-mortem found that Mr Mooney died of pneumonia (inflammation of the
tissues of the lungs) caused by emphysema (damage to the air sacs in the lungs). A
COVID-19 test was negative.
53. The pathologist noted that Mr Mooney had a 0.7cm superficial laceration to the right
side of his nose. The clinical reviewer considered that this injury was probably
caused when Mr Mooney collapsed.
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Findings
54. The clinical reviewer concluded that the clinical care that Mr Mooney received at
HMP Cardiff was of a good standard and equivalent to that which he could have
expected to receive in the community. He noted that Mr Mooney displayed
challenging behaviour and he commended healthcare staff for the care provided to
Mr Mooney in difficult circumstances.
55. Mr Mooney told his daughter that prison healthcare staff had refused to provide him
with a nebuliser when he reported that he was struggling to breathe and had a tight
chest in the last week of his life. The clinical reviewer found that Mr Mooney was
issued with a salbutamol inhaler on 3 November and again, at his request, on 2
December. There is no record that he asked for a nebuliser or that healthcare staff
refused to prescribe one. There is no medical record to suggest Mr Mooney
required a nebuliser.
Mental Health Act assessment
56. The clinical reviewer did, however, identify some shortcomings in relation to
documenting Mr Mooney’s mental health treatment (although these did not impact
on his death).
57. He noted that Mr Mooney had a confirmed diagnosis of schizophrenia. In the first
days in prison, Mr Mooney displayed hostile, paranoid and threatening behaviour
towards staff, including fashioning a weapon. He was reviewed by the prison mental
health team within four days of arrival and allocated a case worker.
58. The clinical reviewer found that Mr Mooney was appropriately undergoing
assessment and observation of his behaviour at Cardiff to determine the nature and
extent of his psychiatric illness in a safe and secure environment and was
appropriately escalated for review by a senior psychiatrist to produce a formulation
within one month of his arrival at the prison. The review did not happen as Mr
Mooney died prior to his appointment with the psychiatrist. We note from the most
recent HMIP and IMB reports that demand for psychiatric assessments at HMP
Cardiff was high.
59. However, the clinical reviewer found that it was not clear if the prison’s mental
health team had considered whether Mr Mooney should be assessed under the
Mental Health Act 1983, given that he was showing evidence of risk towards others.
The clinical reviewer considered that there was reasonable evidence from the
records that Mr Mooney’s reported behaviour warranted consideration for
assessment with a view to a possible transfer to a secure psychiatric hospital. If the
mental health team felt Mr Mooney did not need such an assessment they should
have documented why not.
The Head of Healthcare should ensure that where a patient has a confirmed
history of a serious mental illness and there is evidence of risk to others, the
mental health team should:
• document whether they have considered detention under the
appropriate section of the Mental Health Act;
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• if this is not felt to be appropriate, record a rationale for this decision;
and
• record all considerations and decisions in the multi-disciplinary
meeting notes and SystmOne clinical record.
Welfare Checks
60. Prison Service Instruction (PSI) 75/2011, Residential Services, say:
“The appropriate arrangements will depend on the local regime, but there
need to be clearly understood systems in place for staff to assure
themselves of the well-being of prisoners during or shortly after unlock. For
example, if a prisoner is expected to leave their cell for an activity shortly
after being unlocked, then it will be sufficient for there to be a check on any
prisoner who does not do so. Where prisoners are not necessarily expected
to leave their cell, staff will need to check on their well-being, for example by
obtaining a response during the unlock process.”
61. In his statement to the police which has been shared with the PPO in lieu of an
interview, an officer said that when he unlocked Mr Mooney’s cell at around
9.00am, he looked into Mr Mooney’s cell but could not remember what Mr Mooney
was doing at that time, although he said that he would have noticed had Mr Mooney
been slumped on the floor.
62. The prison conducted a review for the coroner of CCTV on Mr Mooney’s wing and
reported that between the officer unlocking the cell at around 9.00am and the
second officer finding Mr Mooney unresponsive at around 9.30am, Mr Mooney had
not left the cell, and no one had entered it.
63. Due to the format of the footage provided by the prison and the limited IT options
available to the investigator due to COVID-19 restrictions, we could not view the
prison’s CCTV footage to confirm that the first officer looked into Mr Mooney’s cell
when he unlocked it at about 9.00am.
64. We are concerned that no-one completed a welfare check on Mr Mooney at the
point of unlock or shortly after unlock. No-one obtained a response from Mr Mooney
to confirm that he was well.
65. When Mr Mooney was found unresponsive in his cell, he was still warm to the
touch, which means he may have been alive but unwell when he was unlocked half
an hour earlier. We cannot say that the outcome would have been different for Mr
Mooney if he had been found sooner, but it could prove to be critical in future cases.
66. We make the following recommendation:
The Governor should ensure that when a cell door is unlocked, staff satisfy
themselves of a prisoner’s safety and welfare and that there are no matters
that need immediate attention.
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Use of Force record keeping
67. On 6 November, Mr Mooney was subject to use of force by staff after refusing to
comply with the prison’s COVID-19 rules about wearing a face mask in a communal
area. We have not looked at this incident in detail as it took place a month before
Mr Mooney’s death and there is nothing to suggest that it played any part in his
death. However, we did confirm that prison staff completed use of force paperwork
in line with Prison Service policy.
68. Prison Service Order (PSO) 1600 and PSI 30/2015 which set out the prison policy
on use of force require that a doctor or nurse must examine any prisoner who has
been subject to a use of force as soon as possible afterwards. The use of force
paperwork completed by the supervising officer in charge records that Mr Mooney
was seen by a nurse, who assessed he had suffered no injuries. Mr Mooney’s
medical records show that the nurse saw him twice on 6 November after the use of
force incident. However, her entries do not refer to the use of force or that she
assessed Mr Mooney for any injuries.
69. PSO 1600 states that report of injury to prisoner form (known as a F213) must be
completed on all prisoners after a use of force and a copy must be kept in the use
of force incident file. The F213 should be completed by the doctor or nurse who has
seen the prisoner after the use of force and must provide an account of their
examination of the prisoner, regardless of whether any injuries are found.
70. When we asked for the use of force documentation, Cardiff could not find the F213.
This is poor practice. We make the following recommendation:
The Governor and Head of Healthcare should ensure all key Use of Force
documentation is appropriately retained and stored, and that clinical staff
record all interventions on the patient’s medical record.
71. Mr Mooney’s daughter said that he told her that staff had also used force on him
and had thrown him on his back in the days before his death. The prison has no
record that force was used on Mr Mooney apart from the incident on 6 November.
There is nothing in the post-mortem report to suggest that a use of force by staff (or
anyone else) played any part in Mr Mooney’s death.
Inquest
12. The inquest, heard on 10 and 11 September 2024, concluded that Mr Mooney died
from natural causes.
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