Haydar Jefferies

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Independent investigation into
the death of Mr Haydar
Jefferies, a prisoner at HMP
Coldingley, on 5 March 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, 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 HM Prison and Probation Service 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 Haydar Jefferies died on 5 March 2023 after being found hanged in his cell at HMP
Coldingley on 1 March. He was 50 years old. I offer my condolences to Mr Jefferies’ family
and friends.
Mr Jefferies had received an Imprisonment for Public Protection (IPP) sentence in 2006.
He had subsequently been released from prison in 2013 and recalled in 2022. Mr Jefferies
had only been at Coldingley for two months before he took his life in the segregation unit,
where he had spent 18 days.
Mr Jefferies was found hanging the day before his parole hearing. This seems extremely
unlikely to be a coincidence. I recently issued a learning lessons bulletin outlining my
concerns about the high number of self-inflicted deaths among IPP prisoners.
The clinical reviewer found that the care provided to Mr Jefferies was equivalent to that he
could have expected to receive in the community. I make two recommendations related to
missed opportunities to share and communicate important information between prison and
healthcare staff to assess and manage Mr Jefferies’ risk and mental health.
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 September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
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Summary
Events
1. In 2006, Mr Haydar Jefferies was sentenced to an Indeterminate Sentence for the
Public Protection (IPP). He was released from prison in 2013. On 1 January 2022,
Mr Jefferies licence was revoked due to new charges. On 3 January, he was
recalled and taken to HMP Bullingdon. In May, Mr Jefferies’ solicitor told him that
the charges had been dropped. Due to circumstances beyond Mr Jefferies control,
his parole hearing was delayed and rescheduled for 2 March 2023.
2. Mr Jefferies transferred to HMP Coldingley on 28 December 2022. Staff noted that
he had a history of substance misuse, attempted suicide and self-harm, and
depression, although he had not been monitored by suicide and self-harm
procedures, known as ACCT, for over five months.
3. On 12 February 2023, Mr Jefferies moved to the segregation unit because he
feared for his own safety. It was agreed that he would remain in the segregation unit
until his parole hearing. Staff had no concerns about him and there was no
evidence that he was under threat.
4. In the afternoon of 28 February, Mr Jefferies expressed paranoid thoughts and
believed others wanted to kill him. Two hours later, he stripped naked and was on
the floor barking like a dog. Staff started ACCT procedures. He was due to have a
mental health assessment the next day. Staff told Mr Jefferies to stop his bizarre
behaviour and to put his clothes back on, which he did. For the remainder of the
evening, staff did not witness Mr Jefferies engaging in further bizarre behaviours
such as to cause them any additional concern.
5. Just before 2.40am on 1 March, an officer checked and saw Mr Jefferies slumped
over his toilet unresponsive. He radioed to ask for help from his colleagues before
going into the cell. When staff went into the cell, they saw Mr Jefferies had tied a
thin ligature around his neck. Staff removed the ligature from Mr Jefferies’ neck and
tried to resuscitate him. Ambulance paramedics were already on site and arrived
quickly to assist. They found a pulse and, at 4.10am, took Mr Jefferies to hospital.
Mr Jefferies died on 5 March.
Findings
6. Mr Jefferies had several risk factors for suicide and self-harm. He was an IPP
prisoner, he had a history of depression, substance misuse, attempted suicide and
self-harm. Prison staff appropriately started ACCT procedures the day before Mr
Jefferies was found hanging due to his bizarre behaviour. We concluded that, aside
from his clearly deteriorating mental health, there were no clear signs that he was at
imminent risk of suicide when he died. However, prison staff did not adequately
communicate their concerns about Mr Jefferies’ mental health to healthcare staff
responsible for checking and assessing him in the CSU.
7. The clinical reviewer concluded that the clinical care that Mr Jefferies received at
Coldingley was equivalent to that which he could have expected to receive in the
community. She did, however, highlight areas of concern that related to missed
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opportunities to share and communicate important information between prison and
healthcare staff to assess Mr Jefferies’ mental health.
Recommendations
• The Governor and Head of Healthcare should ensure that relevant information about
a prisoner’s mental health in the CSU is documented and communicated to staff
doing the daily healthcare checks. Staff should also record when they ask whether a
prisoner has any thoughts of suicide or self-harm.
• The Governor and Head of Healthcare should ensure that staff refer prisoners to the
mental health team the same day that they have concerns, using a clear and
consistent template, containing sufficient information to triage the referral.
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The Investigation Process
8. The PPO was notified of Mr Jefferies’ death on 6 March 2023. The investigator
issued notices to staff and prisoners at HMP Coldingley informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded.
9. The investigator visited Coldingley on 14 March 2023. He obtained copies of
relevant extracts from Mr Jefferies prison and medical records.
10. NHS England commissioned a clinical reviewer to review Mr Jefferies’ clinical care
at the prison. The investigator and clinical reviewer conducted joint interviews with
nine members of staff and one prisoner.
11. We informed HM Coroner for Surrey of the investigation. He gave us the results of
the post-mortem examination. We have sent him a copy of this report.
12. The Ombudsman’s family liaison officer contacted Mr Jefferies’ next of kin to
explain the investigation and to ask if they had any matters they wanted us to
consider. They said that Mr Jefferies was in constant fear for his safety from prison
staff and prisoners. They believed he had had a mental breakdown in the days
leading up to his death and wanted to know the circumstances that led him to take
his own life. We have addressed these issues in the report.
13. Mr Jefferies’ family received a copy of the initial report. The solicitor representing
the family wrote to us and provided some additional information that has been
reflected in this report.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out three factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Coldingley
15. Coldingley is a category C training and resettlement prison for adult males, holding
mostly long-term, including life-sentenced, prisoners. It holds up to 513 prisoners.
Central and Northwest London NHS Foundation Trust provides healthcare services
at the prison. The healthcare services are commissioned to be on site between
7.30am to 6.30pm in the week and between 8.30am to 5.30pm at the weekend.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Coldingley was in January 2022. Inspectors
reported that Coldingley was a well-run and decent prison.
17. Levels of violence at Coldingley were noted to be around average for the category
C estate and the prison generally had a calm and friendly atmosphere. The average
length of stay in the segregation unit was relatively short. Staff and prisoner
relationships in the unit were positive, but the regime was poor and reintegration
planning was inadequate.
18. At the time of inspection, four of the seven prisoners in the segregation unit were
there for their own protection because they felt under threat from prisoners on
residential wings. Staff told inspectors that they would try and relocate such
prisoners to E wing before considering transferring them to another establishment,
but none had a formal plan for their care or the best route for their reintegration.
Independent Monitoring Board
19. 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 July 2022, the IMB reported that
there were still too many prisoners feeling at threat of or suffering violence.
Previous deaths at HMP Coldingley
20. Mr Jefferies was the second prisoner to die at Coldingley since January 2020. The
previous death was from natural causes.
Segregation units
21. Segregation units are used to keep prisoners apart from other prisoners. This can
be because they feel vulnerable or under threat from other prisoners or if they
behave in a way that prison staff think would put people in danger or cause
problems for the rest of the prison. They also hold prisoners serving punishments of
cellular confinement after disciplinary hearings.
22. The unit at Coldingley is known as the Care and Separation Unit (CSU) and
comprises 11 cells. Only four of the cells are wired for television and a kettle.
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Assessment, Care in Custody and Teamwork (ACCT)
23. Assessment, Care in Custody and Teamwork (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.
24. 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,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.Dsafds
Imprisonment for Public Protection (IPP)
25. IPP sentences are indeterminate, which means that when the minimum tariff has
expired, individuals are required to demonstrate to the Parole Board that their risk
has reduced enough to be managed in the community. IPP sentences were
introduced in 2005 and abolished in 2012, but the abolition did not apply
retrospectively to those who had already received the sentence.
26. In September 2023, the PPO published a learning lessons bulletin on the self-
inflicted deaths of IPP prisoners. This was due to an increase in self-inflicted deaths
among IPP prisoners in 2022. We concluded that more needed to be done by
HMPPS to ensure that the high levels of deaths did not continue. We noted that an
IPP sentence should be considered as a potential risk factor for suicide and self-
harm. IPP prisoners can often struggle with their uncertain status leading to feelings
of hopelessness and frustration. We found that this can cause a lack of
engagement with the parole process and sentence planning and create a lack of
trust in the system.
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Key Events
27. In 2006, Mr Haydar Jefferies was sentenced to an Indeterminate Sentence for
Public Protection (IPP). He was required to serve a minimum of two years in prison,
for offences of wounding and other acts of endangering life. He was released from
custody, on licence, in August 2013.
HMP Bullingdon, 1 January 2022- 28 December 2022
28. On 1 January 2022, Mr Jefferies’ licence was revoked following new charges. On 3
January, he was recalled to custody and taken to HMP Bullingdon.
29. On arrival at Bullingdon, Mr Jefferies said he felt low because it was the first
anniversary of his husband’s death the next day. Although he denied having any
thoughts of suicide or self-harm, staff started suicide and self-harm procedures,
known as ACCT, to support him. Mr Jefferies said he had the support of his family.
Staff referred Mr Jefferies to the chaplaincy for bereavement counselling.
30. A nurse completed Mr Jefferies’ reception health screen. She noted his history of
attempted suicide (overdose) and self-harm, substance misuse and that he had
depression and anxiety, for which he was prescribed mirtazapine (an
antidepressant). The nurse referred him to the GP and the mental health team. Mr
Jefferies declined to be referred to the substance misuse service. He was
subsequently prescribed antidepressant medication.
31. Staff stopped ACCT monitoring on 12 January when he was no longer considered a
risk to himself. On 14 January, Mr Jefferies told his key worker that he had no drug
or alcohol issues and wanted to focus on his time in prison to improve himself. He
obtained a prison job and staff commented that he always demonstrated positive
behaviour, followed the regime and worked hard.
32. On 30 March, following a telephone consultation with the GP, Mr Jefferies stopped
taking his antidepressant medication. He told the GP that he had already, over the
previous weeks and of his own accord, reduced the daily dose of his antidepressant
medication and felt that he no longer needed to take them.
33. By April, Mr Jefferies had become a representative for the violence reduction team
and staff described him as “an excellent example of how to conduct yourself in the
face of adversity”.
34. At the beginning of May, Mr Jefferies told his key worker that he was frustrated as
his solicitor had told him that the police had dropped the charges against him, and
he was unsure of when he would be released from prison. His key worker noted,
however, that Mr Jefferies remained positive and kept himself busy.
35. On 11 May, staff started ACCT procedures after Mr Jefferies made a ligature and
attempted suicide. Mr Jefferies was frustrated that he had not been released from
prison yet. On 18 May, staff stopped ACCT monitoring. Mr Jefferies mood had
improved, and he said he no longer had any thoughts to harm himself. He had
spoken to his probation officer who had updated him on his current situation and
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who was also in the process of setting up a parole hearing. Mr Jefferies said his
family continued to support him.
36. On 28 September, Mr Jefferies referred himself to the substance misuse team. He
said that he had been “stitched up” by his probation officer and believed that he
needed to complete relapse prevention work. Subsequently, Mr Jefferies was seen
regularly by the substance misuse team until November, when he discharged
himself from their services as he stated that he no longer needed their support.
37. On 13 October, Mr Jefferies’ scheduled parole hearing was postponed due to the
Parole Board chair being unwell. It was noted that the hearing should be relisted at
the earliest possible opportunity, but Mr Jefferies’ legal representative had no
availability until March 2023. Mr Jefferies’ hearing was scheduled for 2 March 2023.
38. In November, a nurse from the mental health team saw Mr Jefferies after wing staff
reported that his mood was low and that he had voiced paranoid thoughts that he
could not trust anyone. Mr Jefferies told the nurse that he had been frustrated
because his parole hearing had been delayed but he felt much better now and was
coping. He denied having any thoughts of suicide or self-harm. The nurse’s
assessment noted that Mr Jefferies mood was settled, and she had no concerns
about his mental health.
HMP Coldingley, 28 December 2022 onwards
39. On 28 December, Mr Jefferies transferred to HMP Coldingley. A nurse completed
an initial health screen and noted Mr Jefferies’ history of depression, substance
misuse and self-harm. Mr Jefferies told the nurse that he had no current thoughts of
suicide or self-harm and no concerns about his transfer to Coldingley. He declined
the offer of support from the substance misuse team.
40. On 29 December, a nurse from the mental health team saw Mr Jefferies. She noted
that he was not taking any medication and his mood was positive. Mr Jefferies told
the nurse that his husband had died two years ago and that he had tried to kill
himself when this had happened. However, he said he had no current thoughts of
suicide or self-harm. She discussed support for Mr Jefferies as the anniversary for
his husband’s death was approaching. Mr Jefferies said he was okay and had the
support of his family.
41. On 17 January 2023, Mr Jefferies moved to D Wing. An officer said Mr Jefferies
was well behaved, positive and never raised any concerns. On 24 January, Mr
Jefferies’ application to be located on E Wing (the enhanced/drug free wing) was
successful. Mr Jefferies was placed on the waiting list pending a space becoming
available. Over the next two weeks staff noted Mr Jefferies positive behaviour.
42. On 10 February, a Senior Probation Officer met Mr Jefferies to discuss the recent
proposal from the Justice Select Committee to re-sentence those prisoners that
were subject to an IPP sentence. She informed Mr Jefferies that the Government
had rejected the recommendations and provided him with a letter to support him
and explain this. She reminded Mr Jefferies of the support available to him. Mr
Jefferies said that he was feeling okay and had expected this outcome. He said that
his parole hearing was soon.
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43. On 12 February at 10.24am, Mr Jefferies telephoned his mother from his in-cell
prison phone. (Prison staff were not monitoring Mr Jefferies calls so would have
been unaware of the content of them.) He told her that he feared for his safety and
asked her to contact the prison to tell them that he needed protecting. He said that
“they” had been talking about him on the wing landing and he believed that prison
staff had disclosed details about his offence to other prisoners. He said that
prisoners were waiting outside of his cell for him to come out so that they could cut
him with cans.
44. At 10.36am, Mr Jefferies phoned his mother again. She had spoken to the prison
and relayed his concerns. At 10.50am, Mr Jeffries phoned his brother and repeated
his concerns. He said that he had barricaded himself in his cell and that “they”
believed he was a sex offender. His brother stated that this was a false accusation
and said he would contact the prison. Mr Jefferies said he feared for his life and
wanted to be moved to Care and Separation Unit (CSU - segregation unit).
45. Wing staff noted that they had had no concerns about Mr Jefferies, prior to his
family contacting the prison, and had not observed anything untoward happening
around his cell or on the wing landing, including on that day.
46. A Supervising Officer (SO) from the Safer Custody Team and a Custodial Manager
(CM) spoke to Mr Jefferies. He had blocked his cell door but agreed to leave his cell
and spoke to staff in the wing office. Mr Jefferies said that he was worried about his
safety. He believed that people were talking about him and thought he was a sex
offender. He said his parole hearing was soon and he wanted to remain safe until
then. Staff agreed to move Mr Jefferies to the CSU for his own safety.
Care and separation Unit (CSU), 12 February onwards
47. Around 11.30am, Mr Jefferies arrived in the CSU. A nurse assessed him and
completed a segregation algorithm. This noted that Mr Jefferies was suitable, from
a healthcare perspective, to remain in the CSU. Mr Jefferies had no thoughts of
suicide or self-harm. He told the nurse that he wanted to stay in the CSU until he
was transferred or released.
48. A manager signed CSU paperwork to authorise Mr Jefferies’ stay in the CSU.
Segregation unit regimes are restricted, and prisoners are permitted to leave their
cells only for specific activities such as to have a shower and exercise in the open
air. As part of the segregation regime, all prisoners are seen daily by the duty
governor and healthcare staff. They are also seen three times a week by a GP and
a nurse from the mental health team. During these rounds, cell doors are opened so
healthcare staff can observe and interact with the prisoner. The IMB and a member
of the chaplaincy team also visit prisoners. Prisoners still have access to the prison
phone.
49. Soon after he arrived in the CSU, Mr Jefferies phoned his mother. Part of their
conversation was in English, the other part in their native language. Mr Jefferies told
his mother that he was now in the CSU. He said that for the last six weeks, he had
been terrified that he would be hurt because other prisoners believed that he was a
sex offender. He wanted to stay in the CSU until his parole hearing in two weeks’
time. Here, he was no longer worried and, although he did not have access to a
television, he was able to read books, had use of the phone and was allowed 30
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minutes of exercise daily. He said he felt much better and safer. He told his mother
that she should cancel her visits to see him as he did not want contact with other
prisoners on the way to the visit’s hall. He also phoned his brother and updated him
on his move to the CSU.
50. At a routine CSU visit on the morning of 13 February, Mr Jefferies was seen by a
prison GP and a nurse. They noted no concerns about him.
51. At 9.00am on 14 February, a senior manager chaired a review board with the nurse
to consider Mr Jefferies’ ongoing segregation. They discussed the reason that Mr
Jefferies was in the CSU and offered him a move to E Wing, which was not
attached to any of the main residential wings. Mr Jefferies refused this as he
believed that he would be under threat on any of the prison wings and wanted to
remain in the CSU until his parole hearing on 2 March. He said his mood was low,
but he did not want to be prescribed any medication. He had no thoughts to harm
himself. The nurse suggested yoga workout sheets to help to support Mr Jefferies
and improve his mood. Mr Jefferies refused this. The review board authorised Mr
Jefferies’ continued stay in the CSU until his parole hearing.
52. In the morning of 15 February, healthcare and prison staff making routine visits to
Mr Jefferies raised no concerns. Around midday, Mr Jefferies’ mother contacted the
prison because Mr Jefferies had told her that he was being threatened in the CSU.
Staff spoke to Mr Jefferies and reassured him that he was safe. That afternoon, two
IMB members visited Mr Jefferies. They spoke at length to Mr Jefferies about his
IPP status and the recent Government decision, that he had already been informed
of. Mr Jefferies said he was not surprised at the Government’s decision. Regarding
his own situation, Mr Jefferies said that his initial parole hearing had been delayed
by five months. He said that he felt he had done everything to turn his life around
but had “lost hope” and felt that his probation officer had not helped.
53. During daily routine welfare checks between 16 and 25 February, healthcare,
prison, IMB and chaplaincy staff had no concerns about Mr Jefferies.
54. On 17 February, Mr Jefferies had a video-link meeting with his Community Offender
Manager (COM). This meeting had been delayed due to Mr Jefferies previous COM
leaving the service. The COM noted that Mr Jefferies had completed extensive work
around violence, substance misuse and domestic abuse when he was previously in
prison. Since his recall, he had demonstrated good behaviour, completed courses
and been employed. The COM noted that the current charges that led to Mr
Jefferies’ recall to prison had been dropped. He intended to recommend to the
Parole Board that Mr Jefferies could be released from prison or moved to an open
prison or an Approved Premises.
55. On 18 February at 11.50pm, an officer noted that Mr Jefferies had called staff to his
cell and said that he was in fear for his safety from “everyone”. Mr Jefferies made
references to staff coming into his cell or opening his cell door. The officer
reassured Mr Jefferies that no one would open his cell throughout the night and that
he was safe in the CSU.
56. On 20 February, Mr Jefferies was again offered a move to E Wing but refused. An
officer described Mr Jefferies as a model prisoner while he had been in the CSU.
He was aware that Mr Jefferies was nervous about his upcoming parole hearing
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and was observed regularly in his cell checking that his parole paperwork was in
order.
57. In the evening of 24 February, Mr Jefferies family called the prison concerned about
his welfare. Staff told them that Mr Jefferies was fine, and they had no concerns.
58. An officer told us that around this time, Mr Jefferies had started to become
intermittently paranoid and believed that staff were conspiring with other prisoners,
who they intended to let out of their cells, to harm him. Mr Jefferies said that he
believed staff intended to sexually abuse him. The officer said he reassured Mr
Jefferies that he was safe on the unit. He told us that Mr Jefferies’ paranoia would
last only for a short period and then he would revert to being his normal quiet self.
There were also two prisoners on the unit that had been shouting abuse directed at
Mr Jefferies, that related to a sexual offence. The officer again spoke to Mr Jefferies
and reassured him that he was safe and reminded him that he would not have any
physical contact with other prisoners in the CSU. He offered to move Mr Jefferies to
a different cell and one that also had a television. Mr Jefferies declined. The officer
spoke to the two noisy prisoners about their behaviour and reassured them that any
information they had heard about Mr Jefferies was mistaken, to try and stop their
poor behaviour. The two prisoners were subsequently transferred out of the CSU
within two days.
59. On 25 February, Mr Jefferies phoned his brother. Part of their conversation was in
English, the other part in their native language. His brother said that since Mr
Jefferies had been at Coldingley, he had claimed daily that he would be stabbed,
and that other people were coming to get him. Mr Jefferies appeared fixated that
others were trying to hurt him. Mr Jefferies’ brother told him that he was in a safe
place and that he should stop putting pressure on their mother to help him, which
prompted her to then contact the prison. He said Mr Jefferies’ paranoia was
affecting him and he needed to manage it.
60. On 26 February around 9.50am, a nurse saw Mr Jefferies. She had no concerns
about him. However, there is no evidence that she was aware that he was
sometimes paranoid that others were going to harm him. Later, while conducting a
routine check, the Head of Security noted that while speaking to Mr Jefferies, his
conversations were very repetitive. Concerned about this, he planned to refer him to
the mental health team. He did so on 28 February.
61. On the morning of 27 February, during the routine CSU visit, a prison GP and two
nurses saw Mr Jefferies. They had no concerns about him. Shortly afterwards, Mr
Jefferies phoned his mother and told her not to worry about him. They spoke about
his parole hearing.
Events on Tuesday 28 February
62. At 8.30am on 28 February, a nurse and a member of the chaplaincy team visited Mr
Jefferies and had no concerns. At 9.54am, a SO noted in the wing observation book
that Mr Jefferies had told staff that he had made his peace and was ready for them
to kill him. Mr Jefferies denied having any thoughts of suicide or self-harm. Due to
his unusual behaviour, she referred him to the mental health team by email.
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63. Staff entries made in the segregation observation log for the remainder of the
morning raised no concerns about Mr Jefferies. He was sat on his bed most of the
time and around midday had his lunch.
64. Mr Jefferies phoned his mother twice in the afternoon. In his first call at 1.50pm, he
said that he was being moved back to a main residential wing and therefore would
not be able to attend his parole hearing. (This was not the case, there was no plan
to move Mr Jefferies). He said “everybody” was saying that he was a sex offender,
and prisoners were waiting outside to “cut him up”. He told his mother that her life
was also under threat. In his second phone call at 2.03pm, Mr Jefferies said that he
would not get his parole if they moved him. His mother tried to calm him down and
said she that she would contact the prison. Mr Jefferies promised to phone his
mother back later.
65. At 2.50pm, a SO chaired a segregation review board. Two officer, a mental health
nurse and a member of the IMB were present. The panel noted that Mr Jefferies
was displaying some bizarre behaviour. The nurse told us that before the review
meeting, staff had told her that Mr Jefferies’ had displayed some unusual behaviour
and referred him to the mental health team. She also received the referral, although
there was no detail contained within this about why he had been referred to the
team. During the review, she noted that Mr Jefferies appeared paranoid and was
fixated on being kept safe until his parole review on Thursday. Mr Jefferies believed
others, including staff, wanted to kill him. He made spiritual references about his life
and “having an awakening after he had attempted suicide” in 2018. He said he
would not leave his cell. Staff said that Mr Jefferies told them he had no thoughts of
suicide or self-harm although this is not recorded. The nurse arranged to carry out a
mental health assessment the next day. She told us that she was not overly
concerned about Mr Jefferies from a mental health perspective and completed a
segregation algorithm which documented that he could cope with segregation. An
officer told us that Mr Jefferies appeared in a better mood by the end of the review.
66. At 4.03pm, Mr Jefferies phoned his mother. He told her that he was okay and said
that “they” were not moving him now and so he would still be able to attend his
parole hearing. He said his mother should not worry about him, his parole hearing
would be good and that he would call her on Friday.
67. Around 4.15pm, two officers checked Mr Jefferies after hearing strange noises
coming from his cell. Mr Jefferies was naked, on his hands and knees, barking like
a dog. He also flushed his head down the toilet. Other prisoners on the unit could
be heard heckling Mr Jefferies and mimicking the sounds that he was making. One
officer told Mr Jefferies to stop what he was doing. Mr Jefferies did so. The officer
went to the wing office to inform his manager. On his return, Mr Jefferies had
resumed barking and continued to act in a strange manner. He asked Mr Jefferies
to stop and stand up. Mr Jefferies did, then thanked the officer and asked if he
could put his clothes back on. He said that “she” had told him to behave in the way
that he had. As there were only male officers working in the unit that day, the officer
was confused who Mr Jefferies was referring to.
68. Concerned about Mr Jefferies’ welfare and mental health, the officer started ACCT
procedures. A SO attended the CSU and put in place the ACCT immediate action
plan. It was noted that the CSU was the most appropriate location for Mr Jefferies at
that time and he would be checked twice an hour. Mr Jefferies was reminded of the
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support of the Listeners (prisoners who are trained by the Samaritans to offer
confidential, emotional support to other prisoners) and Samaritan services. He also
had writing material in his cell for distraction purposes. The SO was aware that Mr
Jefferies was also due to be assessed by the mental health team the following day.
69. Staff later observed Mr Jefferies sat on his bed. He asked staff for his vape pen,
which was being charged in the office, which they gave to him. For the remainder of
the evening, the officer completed ACCT observation checks. He noted that Mr
Jefferies seemed “fine”, had calmed down and appeared “back to his old self”.
70. Officer A started work in the CSU around 8.30pm as the night duty officer. He
carried out ACCT observations throughout the evening and raised no concerns
about Mr Jefferies.
Events on Wednesday 1 March
71. In the early hours of 1 March, Officer A continued to complete ACCT checks for Mr
Jefferies, noting that he appeared to be asleep. When he checked Mr Jefferies at
2.00am, he had no concerns about him.
72. At 2.34am, while conducting an ACCT check, Officer A looked through Mr Jefferies’
observation panel and saw him slumped in the toilet area. He called his name and
banged on the door. Mr Jefferies did not respond. He radioed Officer B, the deputy
night orderly manager, for assistance. There is no CCTV coverage in the CSU and
staff responding did not turn on their body worn cameras.
73. Officer B immediately attended the CSU and looked through Mr Jefferies’
observation panel. She saw Mr Jefferies slumped at the side of the toilet, his head
tilted towards the toilet bowl, as if he was in a position to vomit. Mr Jefferies still
failed to respond, although staff believed they saw his hand twitch. Officer B thought
something might be wrong and, as a precaution, radioed a CM. She told him to stop
the ambulance paramedics (who had attended the prison due to another
emergency) from leaving the prison and to escort them to the CSU. She told Officer
C to attend the CSU, as she intended to enter Mr Jefferies’ cell. Due to the position
Mr Jefferies was in, his location in the CSU and it being night state she wanted
three officers present before they unlocked his cell. Officer C arrived within minutes.
74. Officer B unlocked and went into Mr Jefferies’ cell followed by Officers A and C. As
they approached Mr Jefferies, Officer A saw a ligature tied around his neck. It was a
thin, dark blue piece of fabric that was tied around the taps on the sink above the
toilet. Officer B immediately radioed a medical emergency code blue (used when a
prisoner is unconscious or having breathing difficulties). The control room recorded
that this occurred at 2.40am. The ambulance crew in the prison radioed the
Ambulance Control Centre to inform them of a new incident within the prison.
75. Officers B and C moved Mr Jefferies away from the toilet area while Officer A cut
the ligature from around his neck. Officer B could not find any signs of life so started
cardiopulmonary resuscitation (CPR). Officer A had retrieved the defibrillator from
the office. Officer C set it up and it instructed that chest compressions should be
continued. Officers B and C alternated chest compressions until the paramedics,
that were on site, arrived. (Healthcare staff are not on duty overnight.)
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76. At 2.41am, the paramedics arrived at Mr Jefferies’ cell. On their instruction, staff
moved Mr Jefferies to the corridor and the paramedics administered emergency
care. The paramedics requested further medical assistance. Officer B radioed the
control room and requested a further ambulance, which was requested at 2.49am.
77. The second ambulance arrived at 2.55am and paramedics established a pulse. At
4.15am, the ambulance transferred Mr Jefferies to hospital, where he was taken to
the intensive care unit and placed in an induced coma. On Sunday 5 March at
3.11pm, Mr Jefferies died.
Contact with Mr Jefferies’ family
78. After Mr Jefferies was taken to hospital on 1 March, the Head of Safety phoned Mr
Jefferies’ brother and mother, as his next of kin, to inform them that Mr Jefferies
was in hospital. The prison appointed a family liaison officer. At around 9.30am, she
met Mr Jefferies’ family at the hospital and offered ongoing support. After Mr
Jefferies’ death, Coldingley contributed to his funeral costs in line with national
instructions.
Support for prisoners and staff
79. The prison posted notices informing other prisoners of Mr Jefferies’ death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by his death.
80. After Mr Jefferies’ death, staff involved in the incident were given the opportunity to
discuss any issues arising and the staff care team also offered support.
Post-mortem report
81. The post-mortem examination found that Mr Jefferies cause of death was hypoxic
brain injury (caused by a lack of oxygen) and pneumonia caused by suspension.
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Findings
Identifying Mr Jefferies’ risk of suicide and self-harm
82. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of self-harm or suicide posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under ACCT procedures. PSI 64/2011
also states that any information that becomes available which may affect a
prisoner’s risk of harm to self must be recorded and shared, to inform proper
decision making.
83. When Mr Jefferies arrived at Coldingley in December 2022, he had a number of risk
factors: he was an IPP recalled prisoner, he had a history of attempted suicide and
self-harm, depression and substance misuse. He had last been monitored under
ACCT procedures (for one week) in May 2022, and since then, no concerns had
been raised about him.
84. During his time in the CSU, Mr Jefferies initially did not cause any concern to staff.
However, he became increasingly paranoid in the days leading up to his parole
hearing and it seems unlikely to be coincidental that his mental health declined at
this time.
85. On 28 February, at the segregation review, Mr Jefferies was paranoid and said that
he had “made peace” with knowing staff wanted to kill him. Staff told us that Mr
Jefferies denied having thoughts to harm himself although this was not reflected in
either his prison or medical records. The mental health nurse who saw him was not
overly concerned by his presentation and booked him in for a mental health
assessment with herself the next day. Later that day, when Mr Jefferies displayed
increasingly bizarre behaviour, prison staff appropriately started ACCT procedures.
Mr Jefferies was subject to two observations per hour which we consider was
sufficient in the circumstances. He had not harmed himself or said anything to
indicate that was his intention. Later that evening, his behaviour returned to normal,
and staff raised no concerns about him.
86. Mr Jefferies was found hanging early next morning, the day before his parole
hearing. IPP prisoners can struggle with their uncertain status leading to feelings of
hopelessness and frustration. This can cause a lack of engagement with the parole
process and sentence planning and create a lack of trust in the system. However,
Mr Jefferies had not recently voiced concerns about his parole hearing to staff, only
about being kept safe until his parole hearing. We conclude that staff could not
reasonably have foreseen that Mr Jefferies was at an imminent risk of suicide in the
days leading to his death.
87. However, there is no evidence that prison staff shared the concerns they had about
Mr Jefferies’ mental health in any detail with healthcare staff carrying out the daily
CSU rounds. There was no information about the mental health referrals in Mr
Jefferies’ medical record. This would have provided useful additional information
and was a further missed opportunity to provide a more detailed audit trail of the
conversations and holistic assessment of Mr Jefferies’ mental health concerns. We
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also note that staff conducting the daily checks and segregation review did not
routinely document when they had asked him whether he had any thoughts of
suicide or self-harm.
88. We make the following recommendation:
The Governor and Head of Healthcare should ensure that relevant information
about a prisoner’s mental health in the CSU is documented and
communicated to staff doing the daily healthcare checks and segregation
reviews. Staff should also record when they ask whether a prisoner has any
thoughts of suicide or self-harm.
Care and Separation Unit - Segregation
89. Mr Jefferies appeared to have a genuine fear for his safety not just on D Wing, but
all residential wings. While we found no substantive evidence to support that he
was at risk from others, we accept the decision to relocate him to the CSU was a
reasonable decision in the circumstances. Certainly, much of Mr Jefferies’ time
spent in segregation was uneventful and staff had no concerns about him during the
daily welfare checks.
90. We were told by CSU staff that during Mr Jefferies’ stay in the CSU, there were two
loud and vocal prisoners. The atmosphere these prisoners created may well have
impacted on Mr Jefferies’ mental well-being and contributed to him feeling less safe.
The small size of the CSU meant that any significant sound travelled throughout.
Thus, other than staff instructing prisoners to be quiet, which was apparently done,
or relocating them, which is difficult because of the reason the prisoners are located
in the CSU, there is little than can be done. However, the two main prisoners
referred to spent only a short time in the CSU before they were relocated.
Clinical care
91. The clinical reviewer noted that the care Mr Jefferies received was of a reasonable
standard and equivalent to that which he would have received in the community.
However, she found that there were missed opportunities to share and
communicate important information between prison and healthcare staff to manage
Mr Jefferies’ risk. The Head of Healthcare will wish to review the recommendations
made by the clinical reviewer in this area.
Mental Healthcare
92. A prison manager was concerned about Mr Jefferies’ mental health on 26 February
but did not refer him to the mental health team until two days later. We were told
that the referral was not triaged with any urgency because it lacked any detailed
information about Mr Jefferies’ mental state or reason for the referral. It simply
requested that a member of the mental health team review him. Had the referral
been received on 26 February, and contained relevant information, the mental
health team would likely have reviewed Mr Jefferies the next day, 27 February. We
agree with the clinical reviewer that this was a missed opportunity for staff to have
provided the mental health team with detailed information about Mr Jefferies’
changing mental state in a timely manner. We make the following recommendation:
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The Governor and Head of Healthcare should ensure that staff refer prisoners
to the mental health team the same day that they have concerns, using a clear
and consistent template, containing sufficient information to triage the
referral.
93. That said, we noted that when Mr Jefferies was seen as part of the routine CSU
healthcare round on 27 February, healthcare staff had no concerns about his
mental health and so took no further action. This decision appeared reasonable
given Mr Jefferies’ reported presentation.
Head of Healthcare to note
CSU healthcare documentation
94. Healthcare staff complete a template on prisoners’ medical records as part of the
CSU healthcare rounds. In Mr Jefferies’ case, staff consistently recorded that they
had no concerns about him and that he was medically fit to remain in the CSU.
From interviews, we ascertained that there is an option to add free text to the
template to provide more detailed information about the consultations. Staff told us
that they would not add additional details unless they had concerns. No additional
details were recorded about Mr Jefferies in the template, including whether he was
asked if he had any thoughts of suicide or self-harm. The Head of Healthcare may
wish to consider whether the free text box could be made better use of.
Risk formulation
95. The clinical reviewer notes that a risk formulation should have been completed for
Mr Jefferies during his time at Coldingley. A risk formulation is developed to identify
holistic factors that may increase a person’s risk of suicide and self-harm. It can
then be used as a monitoring and assessment tool to determine a level of risk in
response to significant incidents and events in a person’s life. This is in line with the
NICE guideline for ‘self-harm: assessment, management and preventing
recurrence’ (2022). Had a risk formulation approach been used during Mr Jefferies’
CSU reviews, earlier indicators of his risk could have been identified. Furthermore,
this could then have been used when Mr Jefferies was seen daily by healthcare
staff to record decisions around any future interventions.
96. The clinical reviewer notes that risk formulations should be used by healthcare staff
working in the CSU and for IPP prisoners. The Head of Healthcare will want to
consider the use of risk formulations.
Governor to note
Body worn video cameras (BWVC)
97. Staff responded to the emergency response at Mr Jefferies’ cell swifty. However,
despite it being a mandatory requirement, staff did not switch on their body worn
video cameras to record the incident. When used effectively a BWVC allows first
person audio and visual images to be captured to provide a clear and irrefutable
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record of events. One member of staff told us that she forgot to switch her camera
on. The Governor may wish to consider this.
Inquest
98. An inquest was concluded on 29 November 2024, that the cause of Mr Jefferies’
death was from hypoxic brain injury and pneumonia, as a result of tying a ligature
around his neck. It was not possible to determine his intention.
99. The coroner concluded that the following are facts, on the balance of probabilities,
were found to have happened and made a material contribution to Mr Jefferies’
death: Between the 18 February 2023 and 1 March 2023, Mr Jefferies was suffering
from psychosis as referenced by the expert psychiatrist. The fact that Mr Jefferies
was an IPP prisoner and that his parole hearing was delayed more than minimally
contributed to the development of this psychosis due to the psychological stress. ln
February 2023, during Mr Jefferies’ detainment at HMP Coldingley, there was a
serious failure by the custodial staff to record risk relevant information in regard to
his presentation. Specifically, concerns raised by his family through numerous
telephone calls and concerning comments made by Mr Jefferies to custodial staff.
There was an additional failure to ensure that risk relevant information was shared
with prison officers and clinical staff. Between the 18 and 27 February 2023, there
was a serious failure to refer Mr Jefferies to the Mental Health team. This was
despite evidence showing acknowledgement and intent to make a mental health
referral on more than one occasion. By 5.30pm on 28 of February 2023, Mr
Jefferies was floridly psychotic as evidenced by the expert psychiatrist. The proper
response would have been to ensure his immediate safety by putting him on
constant supervision and taken him to an external place of safety due to
Coldingley's unsuitable provision of safer cells. That none of this was done
represents a serious failure by HMP Coldingley custodial staff. There was a failure
to undertake a substantive mental health assessment on the 28 February 2023
following the morning referral from custodial staff and the subsequent CSU review.
A mental health review was booked in for the following day' which was inadequate.
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