George Bull

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr George Bull,
while a prisoner at
HMP Stafford, on 29 May 2023
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, 2026
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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 George Bull died in hospital on 29 May 2023, of a large subdural bleed, while a
prisoner at HMP Stafford. He was 73 years old. I offer my condolences to Mr Bull’s friends.
On 27 May, Mr Bull was found semi-conscious on the floor of a toilet at HMP Stafford. It
became apparent that he had attempted suicide by hanging, but the ligature had broken,
which caused him to fall to the ground and hit his head.
Mr Bull had been at Stafford for almost seven years and during this time he was subject to
suicide and self-harm monitoring (ACCT) on two occasions. My investigation found that
this was managed well, and Mr Bull was well supported both by prison and clinical staff.
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 November 2023
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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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 26 February 2012, Mr George Bull was remanded to HMP Birmingham, charged
with sexual offences. He was 61 years old. On 2 June 2012, Mr Bull was sentenced
to 18 years imprisonment. On 8 June 2016, Mr Bull was transferred to HMP
Stafford.
2. Mr Bull had several chronic health conditions which affected his mobility, and he
used a wheelchair and a walking frame to get around. His mobility issues also
resulted in him having a number of falls in his cell. Suitable adjustments were made
to his cell and a social care package was put in place to support him. Mr Bull was
assigned a cellmate who also functioned as his carer, to assist with day to day
living. In 2019, Mr Bull was diagnosed with Alzheimer’s type dementia. His
keyworker, nursing staff, social care staff and dementia nurses saw Mr Bull
regularly.
3. On 9 January 2023, a mental health nurse started suicide and self-harm prevention
measures, known as ACCT, after Mr Bull said that he was going to kill himself. Mr
Bull was frustrated by his deteriorating health and was in a lot of pain. He wanted to
see a GP and attend hospital. The ACCT remained open until 16 January when
staff considered he was more settled.
4. In the afternoon on 26 May, Mr Bull attended a Senior Support Group (SSG) and
went to use the toilet. A prisoner waiting outside the toilet heard a bang, and
knowing that Mr Bull was in there, alerted staff. Staff attended and found Mr Bull on
the floor and semi-conscious. They placed Mr Bull into the recovery position and
radioed a medical emergency code. It became apparent that Mr Bull had tried to
attempt suicide at the time of his fall.
5. Nursing staff arrived and cared for Mr Bull until paramedics arrived at 3.40pm. Mr
Bull was taken to hospital.
6. At hospital, it was confirmed that Mr Bull had a bleed on the brain, but there were
no plans to operate.
7. Mr Bull’s condition deteriorated over the weekend, and hospital staff provided
palliative care to make him more comfortable. At 11.00am on 29 May, it was
confirmed that Mr Bull had died.
Findings
8. Mr Bull had previously been identified as being at risk of suicide and self-harm. The
ACCT procedures provided good support to Mr Bull. Case reviews were multi-
disciplinary and involved all those who were caring for him, and care map actions
reflected his concerns about his on-going pain, and his GP and hospital
appointments. ACCT procedures ended when staff considered his risk had
sufficiently decreased and they had no particular concerns about him in the days
and weeks before he died.
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9. The clinical reviewer concluded that the clinical care Mr Bull received at Stafford
was of a good standard and equivalent to what he could have expected to receive
in the community.
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The Investigation Process
10. On 29 May 2023, HMPPS notified us of Mr Bull’s death.
11. The investigator issued notices to staff and prisoners at HMP Stafford informing
them of the investigation and asking anyone with relevant information to contact
him. One prisoner responded and was interviewed as part of the investigation.
12. The investigator obtained copies of relevant extracts from Mr Bull’s prison and
medical records.
13. The investigator interviewed one member of staff, and one prisoner at Stafford on
20 July.
14. NHS England commissioned two clinical reviewers to review Mr Bull’s clinical care
at the prison. The investigator completed two interviews with healthcare staff with
the clinical reviewers using Microsoft Teams on 28 July.
15. We informed HM Coroner for Staffordshire South of the investigation. The Coroner
informed us that no post-mortem was completed and gave us the cause of death.
We have sent the Coroner a copy of this report.
16. Mr Bull had no identified next of kin.
17. An inquest was concluded on 25 November 2025. A jury found that Mr Bull died as
a result of a large subdural bleed which was the result of a suspected ligature injury
with unknown intent.
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Background Information
HMP Stafford
18. HMP Stafford is a medium security training prison for adult male prisoners
convicted of sexual offences. It holds about 750 prisoners, over half of whom are
aged over 50. Practice Plus Group (PPG) provide healthcare services. Mental
healthcare and psychosocial substance misuse services are sub-contracted to
Inclusion.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Stafford was in 2020. Inspectors reported a
safe, calm and well-ordered prison. Levels of self-harm were lower than most
similar prisons. The weekly safety intervention meeting (SIM) provided a good
forum to monitor individual prisoners. The quality of suicide and self-harm
monitoring delivered through the ACCT process was mostly good. The mental
health team was well integrated into the prison, attended the SIM and contributed
consistently to ACCT reviews. Over 90% of staff had received mental health
awareness training.
Independent Monitoring Board
20. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to April 2022, the IMB reported that
their main concern was inefficient medicines management. Despite this, most
comments the IMB received about mental and physical healthcare were positive.
Previous deaths at HMP Stafford
21. Mr Bull’s death was the third self-inflicted death at HMP Stafford since 2012. There
are no similarities between our findings in the investigation into Mr Bull’s death and
our investigation findings for the previous deaths.
Assessment, Care in Custody and Teamwork
22. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
23. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
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which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
Key worker scheme
24. The key worker scheme provides prisoners with an allocated officer that they can
meet regularly to discuss how they are and any day-to-day issues they would like to
address. Improving safety is a key aim of the scheme. All adult male prisoners
should have around 45 minutes of key work each week, including a meaningful
conversation with their allocated officer.
25. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
Parole Board
26. The Parole Board for England and Wales is an independent public body. Its role is
to make risk assessments about prisoners to decide whether they can safely be
released into the community once they have served the minimum term imposed by
the courts.
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Key Events
27. On 28 February 2012, Mr George Bull was remanded to HMP Birmingham, charged
with sexual offences. He was 61 years old. On 2 June, Mr Bull was sentenced to 18
years imprisonment. He remained at Birmingham until 8 June 2016, when he was
transferred to HMP Stafford.
28. Mr Bull had long-term health conditions including type 2 diabetes, chronic
obstructive pulmonary disorder (COPD), asthma and hypertension. He also had
mobility issues and used a wheelchair and walking frame to move around. In 2019,
Mr Bull was diagnosed with Alzheimer’s type dementia and in 2022, he had a
stroke.
29. Mr Bull settled in well at Stafford and attended work despite his mobility issues. He
experienced a series of falls and was supported by social care who provided him
with aids to help with his mobilisation, and guards to prevent him falling from his
bed. He was also allocated a carer who shared a cell with him. HMP Stafford has a
group of prisoners who volunteer to function as carers for those prisoners with
reduced mobility and other long term health conditions. Their role is to assist with
day-to-day routines.
30. On 16 May 2022, Mr Bull’s keyworker conducted a keywork session. He spoke to
Mr Bull about his upcoming Parole Board review. He recorded that Mr Bull was
happy with what they had discussed and understood the parole process. Mr Bull
raised no other issues.
31. On 14 June, another officer took over the keyworker role. He recorded that he had
spoken to Mr Bull about his parole review, but he felt that Mr Bull had shown some
confusion. Mr Bull’s carer talked to the keyworker and reminded him that his prison
offender manager (POM) had recently seen him and explained the process to him.
32. The keyworker recorded that Mr Bull was in receipt of a social care package and
had begun attending the Senior Support Group (SSG) again, following its
suspension during the COVID-19 pandemic. (The SSG provides a space for elderly
prisoners to get together and socialise and participate in arts and crafts and other
activities.) Mr Bull confirmed that he had no family contact and that he was not
interested in seeing an official prison visitor, as he was happy with the interaction he
had with his peers.
33. Between 14 June and 29 December, the keyworker completed keyworker sessions
with Mr Bull on twelve occasions. During these sessions, he discussed Mr Bull’s
parole and noted that he was anxious about his possible release. Mr Bull raised no
other concerns and said that he was attending the SSG as often as he was able.
2023
34. On 9 January 2023, Mr Bull submitted an application to see someone from the
mental health team and he was triaged that morning. During the appointment, he
talked about his physical health conditions and said that he had had enough. He
talked of his intention to attempt suicide by hanging, although he had no plans. Staff
started suicide and self-harm prevention procedures known as ACCT. A senior
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officer met with Mr Bull to complete an ACCT assessment later that morning. She
recorded that Mr Bull presented as low, he felt suicidal, and said that he would hang
himself if he were able. Mr Bull said that he had been unable to go to the toilet for
weeks and was in an incredible amount of pain.
35. After the assessment, a Supervising Officer (SO) chaired an ACCT review. The
Deputy Head of Healthcare, a nurse, a worker from the mental health team and a
senior officer also attended. The Deputy Head advised Mr Bull to drink water
regularly to assist with the movement of his bowels, but Mr Bull said that he was
drinking water, but had not been taking his medication, despite being advised that
this would benefit him. The review asked Mr Bull whether he had any plans to harm
himself and he replied, ‘I don't know’. Mr Bull said that he had regular thoughts
about self-harming due to the pain he was in, and that he wanted a hospital and GP
appointment.
36. The review considered whether Mr Bull needed to be moved to another cell for
closer observation, but due to his mobility issues and the adjustments that had been
made to his cell, they decided that he would be better to remain in his own cell with
his carer, but on a high level of observations. The nurse also confirmed that a GP
appointment had been arranged and that he was due a hospital appointment in the
next two weeks. Mr Bull said that he felt better and relieved that he was going to be
seen by the GP and the hospital. The review completed a care plan which included
the scheduled GP and hospital appointments. Observations were set at three per
hour and three conversations per day. The next ACCT review was set for 13
January.
37. On 10 January, the SO completed an ACCT review, three days earlier than planned
because Mr Bull needed a higher level of care due to his physical and mental health
issues and because of the comments he had made the previous day. Members of
the mental health team and a nurse also attended. Mr Bull told the review that his
only issue was that he had not slept well due to the night officer checking on him
three times per hour. Nursing staff told him that he needed to start taking his
medication prior to his hospital appointment, otherwise the examination might not
be able to go ahead. Mr Bull agreed.
38. Mr Bull told the review that he would not harm himself, and staff reminded him that
they had his best interests in mind and that they had a duty of care towards him,
which he accepted. Mr Bull said that he was looking forward to his hospital and GP
appointments and eventually being released from prison. The review considered his
level of observations, and they agreed that due to his brighter outlook and the fact
that he was sharing a cell with his carer, observations would be reduced to two per
hour, day and night. A further review was set for 16 January.
39. Another SO chaired an ACCT review on 16 January. The keyworker and a member
of the chaplaincy team attended. It was recorded that Mr Bull displayed a good
sense of humour during the review. He said that he was due to go out to hospital,
was attending the SSG regularly, and was being supported by his cellmate. Mr Bull
denied any thoughts of self-harm and told the review that he had been angry when
he had initially made the comments about harming himself, but that he was positive
about the future, his forthcoming hospital appointment, and that he was
approaching the last year before his release. Mr Bull said that he got on well with
the wing staff and that he would speak with them or his carer if he had suicidal
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thoughts in the future. The review agreed to stop ACCT monitoring and a post
closure review was arranged for 23 January.
40. The first SO completed the post closure review on 23 January. He recorded that Mr
Bull was positive about the future and felt things were moving forward with his
hospital appointments. He also spoke about his release from prison and not
returning to prison. The SO reminded Mr Bull that staff were available if he needed
to talk about how he was feeling.
41. On 28 January, the keyworker completed a keywork session with Mr Bull. Mr Bull
said that he was currently on a limited diet due to attending hospital on the Monday
for an endoscopy and colonoscopy. He said that he had been waiting for the
appointment for a while, but now it was close, he was worried about what the
results might show. Mr Bull had the procedures at the hospital and the results
showed nothing abnormal and no signs of cancer.
42. Between 11 February and 1 May, the keyworker had six keywork sessions with Mr
Bull. During these sessions, Mr Bull talked about feeling better since his hospital
appointment and said that he was eating normally again. Mr Bull’s parole hearing
had been set for 9 May, and he was feeling anxious about his release due to his
age. The keyworker reassured Mr Bull that when he was released, a support
package would be in place for him, and he would be cared for. Mr Bull said that he
was being supported by his carer and seeing healthcare staff regularly and had
recently been seen by the dementia nurse. The keyworker recorded that Mr Bull
remained positive.
43. A Parole Board directions hearing took place on 9 May by video link. The hearing
was adjourned for further assessments and was to reconvene on 14 November
2023.
44. On 22 May, the keyworker met with Mr Bull for a keywork session. The keyworker
spoke to a senior officer before seeing Mr Bull and she updated him about the
adjourned parole hearing. The keyworker recorded that Mr Bull had suffered
another fall the previous day and had attended hospital due to a cut to his eye. He
noted that the cut to Mr Bull’s eye did not appear that bad and that he was in good
spirits.
45. Mr Bull said that he had been attending the medication hatch daily with the aid of
his walking frame but said that his feet were hurting, and that nursing staff saw him
daily. Mr Bull spoke about attending the SSG and said that he enjoyed sitting
outside talking to his peers. The keyworker recorded that Mr Bull continued to be
supported by his carer, staff from the social care team and a dementia nurse. He
said that he had no concerns about Mr Bull’s well-being and there was no indication
that he was feeling low or harbouring thoughts of suicide or self-harm.
Events of 26 to 29 May
46. On the afternoon of 26 May, Mr Bull went to the SSG. He was taken across by his
cellmate, who stayed with him initially, but then had to leave. The cellmate said that
he had no concerns about Mr Bull and that he had never been concerned about Mr
Bull harming himself.
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47. At around 3.20pm, Mr Bull went to use the toilet. A prisoner had been waiting
outside and heard a bang. Knowing that Mr Bull was in the toilet, the prisoner
alerted staff. An officer attended and found the door locked, so he unlocked it from
the outside. When he entered, he found Mr Bull on the floor, semi-conscious. The
officer, with the help of the prisoner, placed Mr Bull into the recovery position. He
then radioed a code blue (indicating a prisoner is unconscious or is having
breathing difficulties).
48. The prisoner handed a piece of torn sheet to the officer and indicated to him that Mr
Bull had attempted to hang himself. Nursing staff arrived within a few minutes and
took over Mr Bull’s care. The officer said that at this point he noticed another piece
of green sheet hanging down from the toilet window.
49. At approximately 3.40pm, paramedics arrived and took Mr Bull to hospital.
50. On arrival at hospital, hospital staff noted that Mr Bull was not in respiratory distress
and there were no signs of suffocation. There were no obvious injuries, other than
what was described as a superficial mark on his neck, but Mr Bull complained of a
headache. Mr Bull was stable and was eating and drinking.
51. A CT scan later showed that Mr Bull had a large subdural bleed in his brain.
Nursing staff informed prison staff that there were no plans to operate, but that they
would admit Mr Bull to hospital as an inpatient and observe him over the weekend.
52. On 27 May, prison staff started ACCT monitoring and conducted an assessment
with Mr Bull at the hospital. Mr Bull told staff that he could not recall why he had
attempted suicide. Observations were considered adequate as Mr Bull had two
escort officers with him. An ACCT review was scheduled for 2 June, as hospital
staff had indicated that Mr Bull might be discharged then.
53. While in hospital, Mr Bull’s levels of consciousness declined. A further CT scan
showed that the subdural bleed had expanded. A hospital consultant told prison
staff that Mr Bull’s prognosis was poor. Mr Bull continued to receive palliative care
to make him more comfortable.
54. At 11.00am on 29 May, it was confirmed that Mr Bull had died in hospital.
Contact with Mr Bull’s family
55. Mr Bull had no family. Following his death, the prison paid for his funeral in line with
national policy. A memorial service was also held at Stafford, attended by prisoners
and staff.
Support for prisoners and staff
56. After Mr Bull’s death, the prison posted notices informing other prisoners of Mr
Bull’s death and offering support.
57. Staff reviewed all prisoners assessed as being at risk of suicide or self-harm in case
they had been adversely affected by Mr Bull’s death.
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Cause of death
58. The Coroner accepted the cause of death provided by the hospital doctor and no
post-mortem examination was carried out. The hospital doctor gave Mr Bull’s cause
of death as a large subdural bleed (a collection of blood between the skull and the
brain).
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Findings
Management of Mr Bull’s risk of suicide and self-harm
59. Prison Service Instruction (PSI) 64/2011 on safer custody, requires all staff who
have contact with prisoners to be aware of the triggers and risk factors that might
increase the risk of suicide and self-harm, and take appropriate action. Mr Bull had
been at Stafford for almost seven years and was subject to ACCT monitoring on
two occasions, from 9 to 16 January and again on 27 May 2023, after he had been
admitted to hospital following his suicide attempt. Mr Bull had poor physical and
mental health, was anxious about the parole process and being released from
prison due to his age.
60. We consider that the ACCT procedures provided good support to Mr Bull. Staff held
supportive multi-disciplinary case reviews which appropriately assessed his risk.
Observations were set based on the perceived risk Mr Bull presented but took into
consideration the support he would receive from his carer, with whom he shared a
cell. Staff added actions to his caremap which reflected his concerns about his on-
going pain and medical appointments. Mr Bull also talked about his anxiety around
being released due to his age, but staff reassured him that a support package
would be in place for him in the community. The ACCT was closed when staff were
satisfied that Mr Bull was no longer thinking of suicide.
61. There were no indications that Mr Bull’s risk of suicide had noticeably risen in the
days or weeks leading to his death.
Clinical care
62. The clinical reviewer concluded that the care Mr Bull received at HMP Stafford was
good and was equivalent to what he could have expected to receive in the
community.
63. She noted that while Mr Bull had a number of physical health conditions and mental
health concerns, his erratic compliance with care plans, medication and health
advice made it particularly challenging for staff to help him maintain good physical
and mental health. The clinical reviewer found no issues of concern with the care
staff at Stafford provided.
Good practice
64. We consider the provision of the Senior Support Group at Stafford to be good
practice. It offers an outlet to older prisoners who are often isolated due to age, to
socialise and engage in a range of activities. It was clearly an important source of
support for Mr Bull.
65. We consider the keyworker’s interactions with Mr Bull was an example of good
practice. It is clear that he delivered consistent and supportive keywork to Mr Bull
and sought to address his immediate needs on each occasion.
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