Jason McQuoid

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Independent investigation into
the death of Mr Jason McQuoid,
a prisoner at HMP Risley, on
2 March 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
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 Jason McQuoid died from hypoxic-ischaemic brain injury after he was found hanging in
his cell on 2 March 2021, in the Care and Separation Unit at HMP Risley. He was 37
years old. I offer my condolences to his family and friends.
Mr McQuoid had been in prison before. He had a history of substance misuse, but no
particular mental health concerns and no known history of suicide attempts or self-harm.
A few weeks after he moved to Risley, Mr McQuoid’s mental health deteriorated. Over the
space of five days, he displayed paranoid and bizarre behaviour, set a fire in his cell, was
restrained and segregated in the Care and Separation Unit, was monitored under suicide
and self-harm prevention procedures and, ultimately, died. Before he died, Mr McQuoid
said he had used psychoactive substances, but his behaviour seemed to have returned to
normal.
Clearly, some of the decisions made about Mr McQuoid in the days before his death were
finely balanced and staff were dealing with some conflicting information. However, I am
concerned that overall, there simply is not enough evidence to satisfy me that those
decisions were made on the basis of all of the available evidence. There were missed
opportunities for staff across various functions to assess Mr McQuoid’s risk and provide
him with appropriate support.
I am concerned that Mr McQuoid’s mental health was not assessed despite his concerning
behaviour, and that staff relied too much on his admission of illicit drug use and his
assurances that he had no thoughts of suicide. The clinical reviewer concluded that the
care Mr McQuoid received at Risley was of a mixed standard and not fully equivalent to
that which he could have expected to receive in the community.
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 August 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 12
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Summary
Events
1. On 27 November 2020, Mr Jason McQuoid was sentenced to 11 months in prison
for theft while subject to a supervision order. Mr McQuoid had a history of
substance misuse issues. He had been in prison several times before. Mr McQuoid
was initially held at HMP Altcourse, but on 20 January 2021, he was transferred to
HMP Risley.
2. In February, Mr McQuoid’s mental health started to deteriorate. Staff began suicide
and self-harm prevention procedures, known as ACCT, but stopped monitoring the
next day. Mr McQuoid denied any intent to harm himself or that his behaviour was
the result of illicit drug use. Prison staff referred him to the mental health team for
further assessment.
3. Mr McQuoid appeared paranoid and believed that other prisoners were going to
attack him. Staff tried to reassure him, but his behaviour remained unchanged.
Staff considered that he did not pose an increased risk to himself.
4. On 27 February, Mr McQuoid set fire to his cell. Staff tried to remove him from the
cell, but he resisted. They restrained him and moved him to the Care and
Separation Unit (CSU). Staff began ACCT monitoring again. The CSU was very
rowdy that night and so staff placed him under constant supervision on a different
wing overnight.
5. Mr McQuoid moved back to the CSU first thing the next morning. Some of the
paperwork explaining the decision to segregate him despite him being subject to
ACCT procedures was either missing from the investigation paperwork or
incorrectly completed.
6. During an ACCT review on 28 February, Mr McQuoid told staff that he had no
recollection of the events of the night before and that he had been under the
influence of a psychoactive substance (PS) at the time. He denied any thoughts or
intent to harm himself. Staff reduced his observations to hourly and planned to
discuss his care with the mental health team.
7. On 1 March, Mr McQuoid was found several times with his mattress placed behind
his cell door. On each occasion staff asked him to remove it, which he did.
8. At 12.55am on 2 March, during an ACCT check, an officer found Mr McQuoid
hanging from his cell window. The officer immediately radioed for assistance, but he
did not use a medical emergency code. The officer waited for other staff to arrive,
and they entered the cell and removed the ligature from around Mr McQuoid’s neck.
A nurse asked staff to call an ambulance. Staff began cardiopulmonary
resuscitation (CPR). Paramedics arrived at 1.10am and took over Mr McQuoid’s
care and treatment.
9. Mr McQuoid was taken to the intensive care unit at hospital, where he died later on
2 March.
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Findings
10. The clinical reviewer concluded that the care Mr McQuoid received at Risley was of
a mixed standard and not fully equivalent to that which he could have expected to
receive in the community.
11. When Mr McQuoid arrived at Risley, he asked staff to refer him to the mental health
team. There is no evidence that healthcare staff actioned this. When staff became
concerned about Mr McQuoid’s mental health, a duty mental health nurse failed to
conduct an urgent mental health assessment for Mr McQuoid. Instead, he told staff
to start ACCT procedures. This was not an appropriate response.
12. There were missed opportunities to consider Mr McQuoid’s risk in the round.
Instead, staff were too easily reassured by his admission that he had used illicit
drugs and had no thoughts of suicide or self-harm.
13. It is not clear that the decision to segregate Mr McQuoid under ACCT procedures
was appropriate and compliant under the relevant prison policy because relevant
paperwork was either not available to the PPO or incorrectly completed.
14. The substance misuse team should have been told that Mr McQuoid had used PS
given that they were already working with him. They should also have been
involved in the ACCT process.
15. The officer who found Mr McQuoid hanging in his cell, failed to use a medical
emergency code. As a result, there was a delay of four minutes in calling an
ambulance.
Recommendations
• The Governor and the Head of Healthcare should ensure that staff manage
prisoners at risk of suicide and self-harm in line with PSI 64/2011, including:
• that prison and healthcare staff share all information that affects risk
and do not rely solely on what a prisoner says or how he presents and
• consider whether the prisoner’s family should be involved in the ACCT
process, discuss this with the prisoner, and document the outcome of
any discussions.
• The Governor and Head of Healthcare should ensure that:
• All necessary paperwork explaining the decision to segregate is
appropriately completed, stored and made available in the event of a
PPO investigation.
• The Head of Healthcare and the Mental Health Team Manager should
ensure that:
• mental health referrals are actioned and recorded, and assessments
take place with appropriate urgency.
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• ACCT procedures are not used to substitute urgent mental health
assessments.
• The Governor and the Head of Healthcare should ensure that:
• any information suggesting a prisoner has or is at risk of substance
misuse is shared with the substance misuse service, and
• the substance misuse service are invited to ACCT reviews as
appropriate.
• The Governor should ensure that all staff use the medical emergency codes
as set out in PSI 03/2013.
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The Investigation Process
16. The investigator issued notices to staff and prisoners at HMP Risley informing them
of the investigation and asking anyone with relevant information to contact her. One
prisoner responded and provided information, which was considered as part of the
investigation.
17. The investigator obtained copies of relevant extracts from Mr McQuoid’s prison and
medical records.
18. The investigator interviewed 11 members of staff between 21 and 23 April 2021.
The interviews were completed by video link and telephone due to the restrictions
imposed as a result of the COVID-19 pandemic. The investigation was
subsequently transferred to one of the investigator’s colleagues, who completed the
investigation.
19. NHS England commissioned a clinical reviewer to review Mr McQuoid’s clinical care
at the prison. He completed joint interviews with the investigator.
20. We informed HM Coroner for Cheshire of the investigation. The Coroner gave us
the post-mortem report and toxicology reports. We have sent the Coroner a copy of
this report.
21. The Ombudsman’s family liaison officer contacted Mr McQuoid’s family, to explain
the investigation and to ask if they had any matters, they wanted us to consider.
The family asked the following questions:
• How long had Mr McQuoid lived on the rehabilitation wing?
• Was Mr McQuoid prevented from communicating with his family at any
point?
• On 26 February, his mother received a phone call from the prison asking her
if she was all right as Mr McQuoid was anxious. Why was Mr McQuoid not
allowed to make the call himself?
• Was Mr McQuoid under pressure from other prisoners?
• Did Mr McQuoid receive items sent to him by his family?
• What was Mr McQuoid’s mental health like and what care was he receiving?
• Why did it take the prison over 5 hours to notify them that Mr McQuoid had
tried to take his own life?
• Why did Mr McQuoid set fire to his cell on 27 February?
• What attempts were made to resuscitate Mr McQuoid and how long was it
before an ambulance was called?
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22. Mr McQuoid’s family asked some questions which were outside the remit of our
investigation. We have responded to the family about those questions in separate
correspondence.
23. Mr McQuoid’s family responded to our initial report and raised further questions in
relation to the findings. These have been answered in separate correspondence.
24. HMPPS responded to our initial report and highlighted one factual inaccuracy, in
relation to the healthcare provider, this has been amended. HMPPS also provided
an action plan in response to the recommendations made. This is attached as an
additional annex.
25. Following an inquest into Mr McQuoid’s held on 7 October 2024, the assistant
Coroner for Cheshire concluded that:
‘… a lack of a robust handover procedure and the observations (ACCT) not carried
out irregularly to the stated frequency, on the balance of probability did contribute
more than minimally to Mr McQuoid’s death …’
‘… on reception assessment there was a failure to refer Mr McQuoid for mental
health team intervention, which possibly contributed to Mr McQuoid’s death …’
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Background Information
HMP Risley
26. HMP Risley is a medium security training prison which holds over 1,000 convicted
men. Greater Manchester Mental Health NHS Foundation Trust provides primary
healthcare and mental health care services in the prison. Change Grow Live
provide substance misuse services. There is 24-hour healthcare cover.
HM Inspectorate of Prisons
27. The most recent full inspection of HMP Risley was in June 2016. In November
2020, HMIP carried out a short scrutiny visit to review the conditions at Risley and
treatment of prisoners during the COVID-19 pandemic. They found that the amount
of violence and self-harm had reduced at the start of the restrictions. There had
been a subsequent rise in the number of incidents, but this remained below pre-
pandemic levels. This was in the context of improved prison safety and reducing
trends in both violence and self-harm in the year before the pandemic. Safety
meetings had continued throughout the pandemic and managerial oversight of this
area was good.
28. Inspectors found evidence of an appropriate level of support for prisoners at risk of
suicide or self-harm, supported by the ACCT case management process. They saw
staff engaging well with prisoners. Key work had been well embedded in the prison
before the pandemic, and weekly checks on the wellbeing of more vulnerable
prisoners and those coming up for release had continued during the COVID-19
pandemic.
Independent Monitoring Board
29. 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 March 2021, the IMB reported a
good level of support for prisoners.
Previous deaths at HMP Risley
30. Mr McQuoid was the sixth prisoner to take his own life at Risley since March 2018.
31. In a previous investigation into the death of a prisoner at Risley in August 2020, we
made recommendations about the substance misuse and mental health care. The
prison accepted our recommendation and said that to ensure a collaborative
approach, there would now be a fortnightly meeting between departments. It is
disappointing that we are raising this issue again in this report.
Assessment, Care in Custody and Teamwork
32. 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,
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how to reduce the risk and how best to monitor and supervise the prisoner. After an
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.
33. As part of the process, a caremap (plan of care, support, and intervention) is put in
place. The ACCT plan should not be closed until all the actions of the caremap
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.
Psychoactive substances
34. Psychoactive substances (PS), previously known as ‘legal highs’, are an increasing
problem across the prison estate. They are difficult to detect and can affect people
in several ways including increasing heart rate, raising blood pressure, reducing
blood supply to the heart and vomiting. Prisoners under the influence of PS can
present with marked levels of disinhibition, heightened energy levels, a high
tolerance of pain and a potential for violence. Besides emerging evidence of such
dangers to physical health, there is potential for precipitating or exacerbating the
deterioration of mental health with links to suicide or self-harm.
35. In July 2015, we published a Learning Lessons Bulletin about the use of PS and its
dangers, including its close association with debt, bullying and violence. The bulletin
identified the need for better awareness among staff and prisoners of the dangers
of PS; the need for more effective drug supply reduction strategies; better
monitoring by drug treatment services; and effective violence reduction strategies.
36. HMPPS now has in place provisions that enable prisoners to be tested for specified
non-controlled psychoactive substances as part of established mandatory drugs
testing arrangements. Testing has begun, and HMPPS continue to analyse data
about drug use in prison to ensure new versions of PS are included in the testing
process.
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Key Events
HMP Altcourse
37. On 27 November 2020, Mr Jason McQuoid was sentenced to 11 months in prison
for theft while subject to a supervision order and was sent to HMP Altcourse. This
was not his first time in prison. Mr McQuoid had a history of substance misuse in
prison and in the community. He sometimes reported having been diagnosed with
Attention Deficit Hyperactivity Disorder (ADHD) as a child but had not been
prescribed medication for some years. He generally reported no history of suicide
attempts or self-harm either in prison or the community.
38. During his health screen at Altcourse, Mr McQuoid tested positive for cocaine,
opiates, benzodiazepines, and cannabis. He told healthcare staff that he had spent
around £100 per day on drugs and had used two bags of heroin before he had been
taken into police custody two days earlier. Healthcare staff referred him for support
from the Integrated Drug Treatment Service (IDTS) and they started him on a
methadone programme. (Methadone is a drug commonly used for the treatment of
withdrawal associated with opiate addiction). Mr McQuoid denied having mental
health issues or thoughts of suicide or self-harm. There were no significant issues
during Mr McQuoid’s period at Altcourse.
HMP Risley
39. On 20 January 2021, Mr McQuoid was transferred to Risley. When he arrived, a
nurse completed his health screen. He noted that Mr McQuoid was on a methadone
programme. Mr McQuoid asked to be referred to the mental health team and to see
a GP. He told the nurse that he had seen his friend being killed during a fight in the
community and that he had ‘flashbacks and nightmares’. There is no evidence that
a nurse made the referrals, and he did not record any other issues about Mr
McQuoid’s mental or physical health.
40. An officer completed Mr McQuoid’s first night interview. He noted that Mr McQuoid
was polite, cheerful, and denied thoughts of harming himself. Mr McQuoid
completed his period of COVID-19 quarantine in B wing on 4 February and
remained there because he was under the care of the substance misuse service.
41. On 8 February, Mr McQuoid met his prison offender manager. He recorded that Mr
McQuoid appeared happy to be at Risley and was due to be released in June but
was unsure where he would live after his release. He told him that he would see
him again to discuss his concerns about his release.
42. On 25 February, an officer recorded that Mr McQuoid was self-isolating because
other prisoners were calling him a ‘nonce’. (Nonce is a derogatory term used to
describe anyone convicted of sexual offences.) Mr McQuoid believed that staff were
leaving his door unlocked so that other prisoners could enter his cell and attack him.
Staff considered that Mr McQuoid was behaving bizarrely, and they referred him to
the mental health team for assessment. Mr McQuoid’s strange behaviour continued
that day. He shouted at other prisoners through his cell door, telling them that he
was not a ‘nonce’ but they were.
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43. On the morning of 26 February, prison and healthcare staff attended a Safety and
Intervention Meeting (SIM – a joint meeting between custodial and healthcare staff)
to discuss prisoners of concern, including Mr McQuoid. Staff said that his behaviour
was now affecting other prisoners.
44. That afternoon, an officer spoke to mental health nurse about Mr McQuoid. She
asked for someone from the mental health team to see him. The nurse
documented in Mr McQuoid’s medical record that he had told the officer that mental
health staff “don’t just come and see prisoners” and that even though there was a
mental health duty worker who completed urgent reviews, prison staff should start
suicide and self-harm prevention procedures, known as ACCT, if they were
concerned. He said that a member of the mental health team would attend the first
ACCT case review and have a multidisciplinary meeting to address Mr McQuoid’s
issues. He also noted that he had told the officer to refer Mr McQuoid to the mental
health team for discussion at the weekly Single Point of Referral meeting (a mental
health team meeting to discuss those prisoners who have been referred to the
service).
45. Later that afternoon, prison staff started ACCT monitoring because Mr McQuoid
was behaving erratically (although he had not harmed himself or expressed any
intention to do so). A Supervising Officer (SO) completed the immediate action plan.
He told the investigator that he knew Mr McQuoid from previous periods at Risley,
but he had not seen him display paranoid behaviour before. He said that in the past,
Mr McQuoid had been known to use PS and he initially thought that Mr McQuoid’s
behaviour was drug related.
46. Staff completed an assessment interview shortly afterwards. This was immediately
followed by a case review, chaired by a SO. A mental health nurse, and a member
of the chaplaincy team also attended. They agreed that ACCT monitoring should
stop because Mr McQuoid did not pose an immediate risk to himself and had said
that he had no thoughts of self-harm. The SO said that although ACCT monitoring
ended, Mr McQuoid remained in the post-closure phase for seven days and wing
staff were aware of his behaviour and issues. The nurse questioned whether Mr
McQuoid’s presentation was the result of PS use. The SO said that he did not
believe that it was. There is no evidence that the nurse considered that Mr McQuoid
needed any mental health support.
47. A SO telephoned Mr McQuoid’s mother on his behalf while the review was taking
place to reduce Mr McQuoid’s anxiety. She asked the SO to ask Mr McQuoid to
contact his grandmother, which he did. There is no evidence that the staff at the
ACCT case review considered involving Mr McQuoid’s family in the process.
48. The SO spoke to wing staff to find out if they had observed anything to confirm Mr
McQuoid’s perception that he was under threat. Wing staff told him that they were
not aware of any incidents or threats directed toward Mr McQuoid and that staff had
not seen any prisoners going to his cell.
49. At 4.50pm on 27 February, Mr McQuoid started a fire in his cell. Staff tried to get
him to leave the cell, but he resisted. They restrained him and took him to the Care
and Separation Unit (CSU). Mr McQuoid began to shout about an offence that he
had previously committed and said that it was not a sexual offence. Staff
considered that he was displaying paranoid behaviour again. The Head of Safer
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Custody agreed that Mr McQuoid should be subject to constant supervision
because he had set a fire in his cell. She said that the CSU was very rowdy that
evening and so she agreed he could be placed in a constant supervision cell on E
wing and return to the CSU the following morning. (A constant supervision cell has
a gate covered in Perspex, rather than a solid door, so that staff can watch over the
prisoner. A member of staff is positioned at the gate at all times to observe the
prisoner.)
50. As Mr McQuoid was in the post-closure phase of his ACCT, staff restarted ACCT
procedures. On the morning of 28 February, Ms Matthews authorised Mr McQuoid
to be held in the Care and Separation Unit while subject to ACCT procedures. She
told us that he was to be held under Prison Rule 53 (where a prisoner is to be
charged with an offence against discipline at an adjudication hearing) because he
had endangered the lives of staff, other prisoners and himself by setting fire to his
cell. He had also resisted staff attempts to remove him from the cell for his own
safety. We have not seen the decision log the head of safer custody said she
completed to record why she thought he should be segregated.
51. At 9.10am on 28 February, a mental health nurse completed a health screen to
assess whether Mr McQuoid had any mental or physical health concerns that
meant he should not be segregated in the CSU. The nurse incorrectly recorded that
Mr McQuoid was not subject to ACCT procedures. The nurse recorded that Mr
McQuoid was fit to be segregated.
52. At 9.15am on 28 February, the head of safer custody chaired an ACCT case
review. A nurse and a member of staff from the chaplaincy team attended. She
asked Mr McQuoid about starting the fire in his cell. Mr McQuoid said that as soon
as he arrived on B wing, someone gave him spice (PS) which had made him ‘lose
his head’. Mr McQuoid also said that he could not remember anything about what
happened the day before. She told the investigator that Mr McQuoid presented as
settled, he was talking coherently and did not report hearing voices. she asked
whether he had thoughts or intent to harm himself and Mr McQuoid said, ‘Definitely
no’. He said that he was due to be released in June and had two children so would
never do that.
53. The meeting considered that Mr McQuoid had an issue with PS. He told the
reviewers that he was happy to be in the CSU and away from drugs. The Head of
Safer custody said that she knew that Mr McQuoid was engaging with the
substance misuse team. She asked him if being away from PS would cause him
any negative issues such as detoxification symptoms. Mr McQuoid said no and that
he never had issues like that.
54. The Head of Safer Custody said that Mr McQuoid’s presentation was the opposite
of how he had presented the day before, and it was not in keeping with the
comments made in the ACCT document overnight, which said that Mr McQuoid had
displayed bizarre behaviour. The case review team asked Mr McQuoid several
times if he had thoughts of self-harm, which he continually denied. He talked about
his children who were protective factors. The attendees at the meeting believed that
the effects of whatever he had taken had worn off. She said that Mr McQuoid was
rational and that they had no concerns about his presentation. Mr McQuoid asked
whether being convicted of slapping a girl’s bottom would class him as a sex
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offender. She told him that he was not in prison for sexual offences so was not a
sex offender. The case review team reassured him that he was safe.
55. She asked a nurse what level of observations he felt were appropriate based on
what they had discussed and Mr McQuoid’s presentation during the meeting. The
nurse said that hourly observations would be appropriate. A member of staff from
the chaplaincy team and the head of safety custody agreed. The case review team
decided that Mr McQuoid would be reviewed on 3 March as the mental health team
were due to discuss him that day at their weekly meeting and this would also allow
a member of the substance misuse team to attend.
Events of 1 and 2 March
56. At 2.55pm on 1 March, a nurse completed another segregation health screen. She
noted that Mr McQuoid was subject to ACCT procedures but did not think his
mental health would deteriorate if he remained segregated. She concluded that he
was safe to remain in the CSU.
57. On 1 and 2 March, an officer was on night duties in the CSU. CSU staff had told
him about Mr McQuoid and his belief that he was at risk from other prisoners. They
also told him that during the day, Mr McQuoid had moved his mattress several
times from his bed and placed it behind his door. We have no information about
whether staff tried to discuss this with Mr McQuoid or understand his behaviour.
58. The officer completed hourly observations in line with the ACCT document. On
some occasions when he checked on Mr McQuoid, he had moved his mattress
from his bed and placed it behind his cell door. When he asked him to move it back,
he did so straight away and raised no concerns. The officer said that he did not
have any significant conversations with Mr McQuoid but on some occasions when
he completed his checks, Mr McQuoid acknowledged him by saying, ‘Alright boss,’
and on other occasions, he gave a ‘thumbs up’ gesture. The officer described Mr
McQuoid’s presentation as normal.
59. At 11.00pm on 1 March, the officer recorded in Mr McQuoid’s ACCT document that
he had been standing at his sink, washing his face and he did not report any
concerns. At 11.59am, the officer completed another check and saw Mr McQuoid
sitting on his mattress behind his door. The officer asked him to put it back on his
bed and Mr McQuoid did so.
60. At 12.55am on 2 March, the officer checked on Mr McQuoid again. He looked
through the observation panel of his cell and saw him hanging with a ligature
around his neck, tied to the window. The officer radioed for assistance, but he did
not use a medical emergency code. The officer said that because he was on his
own, he did not enter the cell immediately.
61. A Custodial Manager (CM), and a nurse and other prison staff responded. When
they arrived at the cell, the officer opened the door and went in. He released the
ligature from around Mr McQuoid’s neck and placed him on the floor. The nurse
checked for a pulse and any signs of breathing and asked the staff to call an
ambulance immediately, this was four minutes after the officer had discovered Mr
McQuoid hanging. Staff attached a defibrillator to Mr McQuoid and started CPR
until paramedics arrived at 1.10am, took over his care and took him to hospital.
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62. A CT scan showed that Mr McQuoid had no brain activity. He was placed on life
support in the Intensive Care Unit (ICU), where he died at 4.15pm on 2 March.
Contact with Mr McQuoid’s family.
63. At 2.35am on 2 March, a CM tried to telephone Mr McQuoid’s mother to let her
know that her that her son had been taken to hospital, but she did not answer the
phone. He left a message asking her to contact the prison.
64. Address details were provided by the prison to police at around 4.10am, and police
visited the family home and informed them that they should attend the hospital.
65. The prison appointed an officer as the prison family liaison officer (FLO). At 9.30am
on 2 March, he went to the hospital, where he met Mr McQuoid’s parents. After Mr
McQuoid died, the FLO spoke to the family and provided ongoing support.
66. The prison offered a financial contribution towards the cost of the funeral in line with
national policy.
Support for prisoners and staff.
67. After Mr McQuoid’s death, the CM 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.
68. The prison posted notices informing other prisoners of Mr McQuoid’s death and
offered support to those who might need it. Staff reviewed all prisoners assessed as
at risk of suicide or self-harm in case Mr McQuoid’s death had adversely affected
them.
Post-mortem report
69. The Coroner concluded in the post-mortem that Mr McQuoid died of hypoxic-
ischaemic brain injury caused by cardiac arrest and hanging. Post-mortem
toxicology samples found no illicit substances in Mr McQuoid’s system.
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Findings
Identification and management of Mr McQuoid’s risk of suicide and self-
harm.
70. Mr McQuoid had been in prison since November 2020, without raising any
significant concerns about his mental health or risk of suicide and self-harm. Within
the space of five days, his mental health had deteriorated, he had set a fire in his
cell, been restrained, and moved to the Care and Separation Unit, been monitored
under ACCT procedures, including in a constant supervision cell, had admitted
using PS and, ultimately, had apparently taken his life. We have considered
whether staff at Risley appropriately identified and managed his risk of suicide and
self-harm.
71. PSI 64/2011 lists a number of risk factors and potential triggers for suicide and self-
harm. It says all staff should be alert to the increased risk of suicide and self-harm
posed by prisoners with these risk factors and should act appropriately to address
any concerns. Mr McQuoid had some risk factors, including a history of substance
misuse, and the current context of anxiety, paranoia, and bizarre behaviour.
72. On 26 February, staff began ACCT monitoring after they became concerned that Mr
McQuoid was behaving bizarrely and displaying paranoid behaviour. They did not,
in fact, consider that he posed a particular risk of suicide and self-harm but had
received little support from the mental health team (discussed in more detail in a
separate section). Mr McQuoid assured them that he had no thoughts of suicide or
self-harm and so staff ended ACCT monitoring later that day.
73. On 27 February, Mr McQuoid set fire to his cell and would not leave the cell when
instructed to do so, so staff began ACCT monitoring again. In response to this
escalation in his erratic behaviour, staff constantly supervised him.
74. At all times, Mr McQuoid maintained that he had no thoughts of suicide or self-
harm. He claimed to have taken PS and have no memory of his actions. He
described his children as important reasons to stay alive. On 28 February, staff
concluded that his level of risk could be sufficiently managed by one check an hour.
75. We consider that staff were correct to begin ACCT monitoring when they became
concerned about Mr McQuoid’s mental health and in response to his strange and
risky behaviour. However, we are concerned that they were too quickly reassured
(both by what he told them and because his behaviour seemed more normal) and
reduced levels of observations by too much, too soon. In fact, they still had
relatively little insight into what had caused Mr McQuoid’s bizarre presentation: he
said he had taken PS, but he had not been fully assessed by the mental health
team.
76. Mr McQuoid continued to display concerning behaviour on 1 March, when he
placed his mattress behind his cell door several times throughout the day and night,
despite staff telling him not to. There is no evidence that staff tried to talk to Mr
McQuoid about why he was doing this, or that they considered whether it indicated
his level of risk had increased. We consider that this was a relatively finely balanced
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decision but concluded that staff could have viewed his risk more holistically and
relied less on his presentation and reassurances that he was fine.
77. On 26 February, the SO chairing Mr McQuoid’s ACCT case review telephoned Mr
McQuoid’s mother to help to ease his anxiety. Mr McQuoid had expressed concerns
about the safety of members of his family and we consider that staff should have
asked Mr McQuoid if he would have liked his family to be involved in the ACCT
process, as directed by PSI 64/2011. It is possible that they could have helped staff
to understand Mr McQuoid’s presentation and level of risk. We recommend:
The Governor and the Head of Healthcare should ensure that staff manage
prisoners at risk of suicide and self-harm in line with PSI 64/2011, including:
• that prison and healthcare staff share all information that affects risk and
do not rely solely on what a prisoner says or how he presents, and
• consider whether the prisoner’s family should be involved in the ACCT
process, discuss this with the prisoner, and document the outcome of
any discussions.
Mr McQuoid’s location in the CSU
78. Prison Service Order (PSO) 1700, Segregation, sets out the process that must be
followed and actions that should be taken when a prisoner is located in segregation.
In relation to those prisoners subject to ACCT monitoring, PSO 1700 says:
‘…A prisoner on an open ACCT must only be kept in segregation under exceptional
circumstances whereby they are such a risk to others that no other suitable location
is appropriate and where all other options have been tried or are considered
inappropriate…’
79. On 27 February, Mr McQuoid started a fire in his cell. It is not clear that staff
established why he had done so and whether, for example, he intended to harm
himself in the process. For obvious reasons, setting fires in prison is punishable
through the adjudications process and Mr McQuoid was taken to the CSU pending
an adjudication. Soon after Mr McQuoid was moved to a constant supervision cell
on E wing, but it seems that staff always intended to move him back to the CSU as
soon as possible. We have considered whether the decision to segregate him while
on an ACCT was appropriate.
80. The head of safety custody said that she completed a justifiable decision log to
record her reasons for segregating Mr McQuoid. Despite asking for a copy of this,
we did not receive one. Almost as soon as he moved back to the CSU from E wing
on 28 February, the staff at the ACCT case review concluded that his risk to self-
had reduced and he was behaving quite normally. We understand that Mr McQuoid
was considered a risk to staff and prisoners having set a fire in his cell. She told us
that she considered the CSU was the most appropriate place to hold Mr McQuoid
until staff had been able to speak to him and identify his needs. However, there is
no evidence that those present at the ACCT case review (including the Head of
Safety Custody) reconsidered his location after the ACCT review.
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81. A nurse completed the first segregation health screen on 28 February, but
incorrectly noted that Mr McQuoid was not subject to ACCT procedures. A second
health screen completed on 1 March concluded that Mr McQuoid could be safely
segregated.
82. Mr McQuoid said he was quite happy to be in the CSU and raised no particular
concerns with CSU staff or healthcare and chaplaincy staff who made routine visits
to the unit while he was there.
83. However, we are unable to say that the decision to segregate Mr McQuoid was
wholly reasonable and in line with PSO 1700. There is insufficient documentary
evidence that staff properly considered whether there were any alternatives, and we
are not satisfied that the original health assessment was appropriate. We make the
following recommendation:
The Governor and Head of Healthcare should ensure that:
• All necessary paperwork explaining the decision to segregate is
appropriately completed, stored, and made available in the event of a
PPO investigation.
Mr McQuoid’s mental healthcare
84. The clinical reviewer concluded that the mental healthcare Mr McQuoid received at
Risley was of a mixed standard and not fully equivalent to that which he could have
expected to receive in the community. According to his prison medical record, Mr
McQuoid had no significant mental health needs and had not needed support from
mental health teams during previous prison stays.
85. However, when Mr McQuoid arrived at Risley on 20 January 2021, he asked to be
referred to the prison’s mental health team. The clinical reviewer found no evidence
that a referral was made and considers that this was a missed opportunity to
identify any mental health concerns that Mr McQuoid might have had at an early
stage.
86. On 25 February, prison staff referred Mr McQuoid to the mental health team
because they were concerned about his strange behaviour. On 26 February, they
asked a mental health nurse to come and see Mr McQuoid. That nurse told them to
begin ACCT monitoring instead and that a mental health nurse would attend the
first ACCT case review. This was an inappropriate and unhelpful response. The
clinical reviewer highlighted that this was another missed opportunity to conduct an
urgent mental health assessment, which should have fed into the ACCT process.
We recommend:
The Head of Healthcare and the Mental Health Team Manager should ensure
that:
• mental health referrals are actioned and recorded, and assessments take
place with appropriate urgency.
• ACCT procedures are not used to substitute urgent mental health
assessments.
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Mr McQuoid’s substance misuse care
87. Mr McQuoid had a history of substance misuse and was engaged with the
substance misuse service at Risley. On 26 February, when his behaviour became
erratic, staff noted that he might be under the influence of PS. The following day, Mr
McQuoid told staff that he had indeed taken PS and could not remember anything
about the previous day’s events.
88. Despite these concerns, prison staff did not consider inviting a representative from
the substance misuse service to the ACCT case reviews, or even to alert them to
Mr McQuoid’s possible illicit drug use. This was a missed opportunity to ensure Mr
McQuoid received appropriate support. We recommend:
The Governor and the Head of Healthcare should ensure that:
• any information suggesting a prisoner has or is at risk of substance
misuse is shared with the substance misuse service, and
• the substance misuse service are invited to ACCT reviews as
appropriate.
Joint care planning
89. The clinical reviewer identified little joined up working between the mental health
team and the substance misuse service at Risley in respect of Mr McQuoid’s care.
90. In our previous investigation into the death of a prisoner at Risley in May 2021, we
recommended that the mental health and substance misuse teams took a more
collaborative approach to prisoners’ care, treatment, and support. The prison
accepted our recommendation and said:
‘… The Dual Diagnosis meeting would be reviewed. To ensure a collaborative
approach, there would be fortnightly meetings between departments. Identifying
those prisoners who appear on both teams with both departments highlighting their
case worker for each prisoner, and holding a joint meeting to identify the correct
pathway or arrange joint care planning if required ...’
91. This action was due to be completed in April 2021, which was after Mr McQuoid’s
death. We therefore do not repeat the recommendation but would expect the
Governor to reassure herself that appropriate action has been taken to implement
this fully.
Emergency response
92. Prison Service Instruction (PSI) 03/2013 requires Governors to have a medical
emergency response code protocol, which instructs staff how to communicate the
nature of a medical emergency using agreed emergency codes and ensure that the
control room calls an ambulance immediately as soon as an emergency code is
called.
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93. When the officer found Mr McQuoid hanging in his cell, he immediately used his
radio and asked for assistance from other staff. Although staff responded quickly,
the officer did not radio a code blue as he should have done. As a result, an
ambulance was not called immediately. Although it is unlikely the delay of four
minutes affected the outcome for Mr McQuoid, failure to call a medical emergency
code could be critical in other cases. We make the following recommendation:
The Governor should ensure that all staff use the medical emergency codes
as set out in PSI 03/2013.
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