Keith Gadd

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Independent investigation into
the death of Mr Keith Gadd,
a prisoner at HMP Bristol,
on 9 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 best to assist HMPPS in ensuring the standard of care received by those
within service remit is appropriate, then our recommendations should be focused
evidenced and viable. This is especially the case if there is evidence of systemic failure.
Mr Keith Gadd died on 9 March 2023 after being found hanged in his cell at HMP Bristol.
He was 60 years old. I offer my condolences to Mr Gadd’s family and friends.
Mr Gadd was serving a sentence of Imprisonment for Public Protection (IPP). His tariff
(minimum time to be served in prison) expired more than thirteen years before he died,
and he had never been released on licence. In September 2022, the Justice Select
Committee found that IPP sentences cause acute harm to those subject to them, with the
prospect of serving a sentence without an end date causing higher levels of self-harm as
well as a lack of trust in the system that is meant to rehabilitate them.
In September 2023, following a worrying increase in the self-inflicted deaths of IPP
prisoners in 2022, I issued a Learning Lessons bulletin on the subject. Mr Gadd had most
of the risk factors I identified in that bulletin as increasing the risk of suicide and self-harm
of IPP prisoners. I conclude that insufficient weight was given to those risk factors when Mr
Gadd’s behaviour changed in the days before he died. As a result of some commendable
local innovation, support for IPP prisoners has improved at Bristol since Mr Gadd died.
However, as a reception prison, it remains an inappropriate location for them and HMPPS
must deliver on its plans to ensure IPP prisoners’ needs can be met in more suitable
prisons.
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 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 16
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Summary
Events
1. In 2006, Mr Keith Gadd was sentenced to a sentence of Imprisonment for Public
Protection (IPP) for wounding with intent. In 2009, he successfully appealed the
minimum time he had to serve before he could be considered for release (tariff)
from over seven years to three years five months. His tariff expired in January 2010.
Despite this, Mr Gadd had not been released on licence.
2. In March 2021, Mr Gadd transferred to HMP Leyhill (an open prison). On 11 July
2022, staff started Prison Service suicide and self-harm monitoring procedures
(known as ACCT) after Mr Gadd said he felt depressed and helpless and had
suicidal thoughts. He had withdrawn from work, been rude to other prisoners and
stayed in his room.
3. On 19 July, Mr Gadd refused to comply with the terms of his escorted release on
temporary licence (RoTL). Another prisoner said he had overheard Mr Gadd
threaten to stab someone. A case conference on 25 July decided that Mr Gadd
could no longer be safely managed in an open prison, and he was transferred to
HMP Bristol the same day. Mr Gadd was frustrated and upset by his return to a
closed prison, which he felt was unjustified. He could no longer access risk
reduction groups or the same level of mental health support he had been able to at
Leyhill and must have felt that his release was even more of a distant prospect.
4. On 2 August, staff closed Mr Gadd’s ACCT as they no longer assessed him as a
risk to himself. On 20 December, the Parole Board recommended Mr Gadd be
returned to an open prison. The decision was sent to the Secretary of State for
Justice for approval. Mr Gadd did not receive a response before he died.
5. In early March, Mr Gadd stopped attending work, did not collect his meals and
stayed in his cell more. On 9 March 2023, an officer found Mr Gadd hanged in his
cell. Cardio-pulmonary resuscitation (CPR) was started but quickly stopped
because there were clear signs Mr Gadd had died.
Findings
6. Overall, more needs to be done to recognise a prisoner’s IPP status as a potential
risk factor for suicide and to identify the triggers for suicide and self-harm that are
associated with this status.
7. Mr Gadd had a number of risk factors that meant he was at risk of suicide or self-
harm including previous suicide attempts, personality disorder, anxiety and
depression. In the days leading to his death, Mr Gadd did not go to work, spent
more time in his cell and his behaviour to his friends was out of character. Prisoners
raised concerns about Mr Gadd, but staff did not give sufficient weight to them in
light of Mr Gadd’s IPP status.
8. As a reception prison, Bristol was an inappropriate location for Mr Gadd and was
unable to offer him risk-reduction work and the level of support he had at Leyhill.
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9. The decision to return any IPP prisoner to a reception prison must only be taken in
the most exceptional circumstances due to the difficulty of onward transfer, the
particular risks associated with that sentence and the lack of prison places
generally.
10. Leyhill did not provide Mr Gadd with a move-on plan or make sufficient effort to
ensure his return to a more appropriate prison. This remains an issue for transfers
of IPP and life-sentence prisoners to Bristol.
11. Mr Gadd had a single key work session at Bristol in over seven months. We
consider that IPP prisoners should be treated as a vulnerable group and be
prioritised for key work. This now happens at Bristol.
12. The clinical reviewer concluded that Mr Gadd’s healthcare was partially equivalent
to that he could have expected in the community. There was a lack of continuity and
equity in Mr Gadd’s mental health care between Leyhill and Bristol.
Recommendations
• The Governor and Head of the Offender Management Unit at HMP Bristol should
ensure that all staff are aware of the risks associated with IPP prisoners and
actively consider these when an IPP prisoner’s behaviour changes or they are
assessing their risk of suicide and self-harm.
• The Governor at HMP Leyhill should ensure that if they return prisoners to closed
conditions, they must provide a move-on plan and make determined, documented
efforts to return the prisoner to the sending prison.
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The Investigation Process
13. HMMPS notified us of Mr Gadd’s death on 13 March 2023. The investigator issued
notices to staff and prisoners at HMP Bristol informing them of the investigation and
asking anyone with relevant information to contact her. No one responded.
14. The investigator obtained copies of relevant extracts from Mr Gadd’s prison and
medical records.
15. The investigator interviewed nine members of staff and three prisoners between
June and August 2023.
16. NHS England commissioned a clinical reviewer to review Mr Gadd’s clinical care at
the prison. She joined the investigator for the interviews with healthcare staff.
17. We informed HM Coroner for Bristol of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
18. We were informed by the prison that Mr Gadd had no next of kin. He was not in
contact with his family and had no friends listed on his prison telephone account.
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Background Information
HMP Bristol
19. HMP Bristol is a local prison serving the courts and holds up to 580 adult men.
Healthcare is provided by Oxleas NHS Foundation Trust.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Bristol was in July 2023. Following the
inspection, the Chief Inspector of Prisons invoked the Urgent Notification (UN)
process because he was so concerned about conditions there. He noted that the
UN process had been invoked after the last inspection in 2019 and many of the
failings highlighted then were also observed during the 2023 inspection. Despite
this, there were many excellent, dedicated staff in the prison who were doing their
best to support the men in their care. The issues highlighted included:
• Staffing across the prison was insufficient to ensure the delivery of a safe
and purposeful regime.
• The number of self-inflicted deaths and reported levels of self-harm were
much too high.
• Most prisoners spent 22 hours a day locked up, with half of them sharing
cramped cells designed for one.
• Wing staff did not develop effective relationships with prisoners. The prison
was not delivering key work, wing staff had little time to advocate for
prisoners who needed their help, and they lacked the capability and
confidence to manage behaviour more effectively.
The poor regime, ineffective relationships with wing staff and lack of support
contributed to a sense of hopelessness and despondency among many prisoners.
21. Inspectors reported that there were staff shortages on the mental health team,
which was struggling to meet increased demand. Referrals to the team had doubled
in the previous six months with patients in crisis prioritised.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 July 2023, the IMB reported
that there had been an increase in deaths, self-harm and violence and more
prisoners than the previous year were on ACCT and constant supervision. There
had been high levels of overcrowding (over 50% all year) with two prisoners in cells
built for one person. Staffing was below the required levels, which affected the
consistent delivery of a full daily regime, resulting in more prisoners spending time
in their cells. Activities were often cancelled on the day and key working had not yet
been re-established after the Covid-19 pandemic. The Board reported that there
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were insufficient staff in the mental health team to support the mental health needs
of all prisoners. Priority was given to the most unwell.
Previous deaths at HMP Bristol
23. Mr Gadd’s was the fifth self-inflicted death at Bristol since March 2020. There were
also two deaths from natural causes and one drug related death during that period.
Up to the end of 2023, there have been a further five self-inflicted deaths since,
including that of an IPP prisoner on the same wing as Mr Gadd. As a result of these
self-inflicted deaths and the Urgent Notification issued by HMIP, Bristol is receiving
additional support and monitoring from regional and national safety teams. One
prisoner has died from natural causes and there has also been a homicide. Apart
from the other IPP prisoner there were no similar issues between Mr Gadd’s death
and the other self-inflicted deaths.
Imprisonment for Public Protection (IPP) sentences
24. Imprisonment for Public Protection (IPP) sentences were introduced in 2005 and
abolished in 2012. They were intended to protect the public against offenders
whose crimes were not serious enough to merit a normal life sentence, but who
could only be released once they had served their minimum tariff and had
demonstrated to the satisfaction of the Parole Board that they had sufficiently
reduced their risk. The abolition was not applied retrospectively. There are about
3,000 IPP prisoners, of which half have never been released.
25. Since June 2022, the Secretary of State for Justice must approve all Parole Board
recommendations for the release or return to open conditions of prisoners serving
indeterminate sentences.
26. In September 2022, the Justice Select Committee (JSC) published a report of its
review of IPP sentences. The JSC found that the indefinite nature of the sentence
contributed to feelings of hopelessness and despair that had resulted in high levels
of self-harm and some suicides within the IPP population. They recommended that
all IPP prisoners be re-sentenced.
27. In February 2023, the Government announced that it would not re-sentence IPP
prisoners. In response to the JSC report, the Ministry of Justice (MOJ) and HMPPS
published a new IPP action plan in April 2023. The aim of the plan is to focus on
ensuring that HMPPS processes support IPP prisoners to “maximise their prospects
of achieving a safe and sustainable release”.
28. In September 2023, we issued a Learning Lessons Bulletin on the self-inflicted
deaths of IPP prisoners after 2022 saw the highest number of these deaths since
the sentence was introduced. We concluded that an IPP sentence should be
considered as a potential risk factor for suicide and self-harm. We also identified a
number of risk triggers associated with IPP prisoners including parole hearings,
prison transfers and change in security categorisation.
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The key worker scheme
29. The key worker scheme was introduced in the men’s prison estate in 2018. It
provides prisoners with an allocated officer that they can meet regularly to discuss
how they are and any day-to-day issues they would like to address. Improving
safety is a key aim of the scheme. All adult male prisoners should have around 45
minutes of key work each week, including a meaningful conversation with their
allocated officer.
30. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
31. At Bristol key worker duties are not allocated to specific prison officers due to staff
shortages.
Psychologically informed planned environment (PIPE)
32. PIPE units are designed to provide a supportive environment for high-risk prisoners
with personality disorders.
Returning prisoners from open to closed conditions
33. If a prisoner is deemed no longer suitable for an open prison (a prison with
minimum security that aims to reintegrate prisoners into the community) they should
be returned to their original sending establishment. However, if the move is deemed
urgent they will be sent to the nearest local prison as an interim measure. The open
prison retains responsibility for ensuring the prisoner then either goes back to their
original prison or moves to a lower category training prison. Prisoners that are
returned from open conditions should travel with a ‘move on plan’.
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Key Events
34. On 4 August 2006, Mr Keith Gadd was sentenced to a sentence of Imprisonment
for Public Protection (IPP) for wounding with intent. On 6 August 2009, he
successfully appealed his tariff (the minimum time he had to serve before he could
be considered for release) from over seven years to three years five months. His
tariff expired on 14 January 2010, but he had never been released on licence.
35. Mr Gadd was diagnosed with anti-social and avoidant personality disorders which
meant he had excessive social anxiety. He attempted suicide twice by overdose, in
1999 and 2013. His overdose in 2013 coincided with his removal from therapy. Mr
Gadd’s probation assessment showed he had spoken of “ending it all” in 2015 and
had told a previous Community Offender Manager (COM - probation officer) that he
could feel suicidal if he felt things were “not going right”.
36. In December 2018, he moved to the PIPE unit (psychologically informed planned
environment) at HMP Hull where he completed a number of offence-focused
interventions. On 17 September 2020, the Parole Board recommended his transfer
to an open prison to allow him to apply the skills he had learned there.
HMP Leyhill, March 2021 - July 2022
37. Mr Gadd transferred to HMP Leyhill open prison (a prison with minimum security
that aims to help prisoners reintegrate into the community) on 24 March 2021. His
Probation Service risk assessment from 2021 noted that Mr Gadd’s thoughts of
suicide and self-harm would need on-going monitoring, especially if he became
stressed about his situation.
38. Mr Gadd had regular appointments with the mental health in-reach team at Leyhill
and, as an IPP prisoner, came under the care of the prison psychology team. In
August 2021, he started escorted release on temporary licence (RoTL) visits to
Bristol. Mr Gadd completed several risk-reduction courses at Leyhill.
39. A senior probation officer said Mr Gadd always appeared quite frustrated although
he was polite and appreciative of her time. She thought that he felt ‘stuck’ which, in
her experience, was common among IPP prisoners. She said Mr Gadd liked being
able to discuss his situation and she felt that he needed an outlet to share his
frustrations.
40. In June 2022, Mr Gadd’s COM noted in a report to the Parole Board that Mr Gadd
withdrew from professionals and became socially avoidant when feeling stressed
and emotionally affected.
41. On 8 July, a Supervising Officer (SO) spoke to Mr Gadd after one of the Prison
Offender Managers (POMs) raised concerns about Mr Gadd’s state of mind. Mr
Gadd said he was fine but was obviously agitated. The same day another prisoner
told the SO that they were worried about Mr Gadd as for the previous two days he
had not gone to work and been alone in his room shouting and arguing with himself.
42. On 11 July, a member of the prison Wellbeing Team started Prison Service suicide
and self-harm monitoring procedures (known as ACCT) after Mr Gadd told her he
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felt “depressed and helpless”. He said nothing was going right for him and he had
spent the last three days in his room. He said he was having suicidal thoughts, his
appetite was poor and he was struggling to sleep.
43. At his first ACCT case review the same day, Mr Gadd said that he felt anxious
about his progression towards release. He said he had been unable to talk through
his concerns and everything had become too much, to the point that he felt
depressed and suicidal. He was not taking his antidepressants or eating properly
and had been using laxatives to control his weight.
44. The review agreed an ACCT care plan to support Mr Gadd which included
attending the prison’s weekly anxiety group, advice on healthy weight management,
an appointment with his new POM to discuss sentence progression and returning to
his prison job in the DHL workshop.
45. On 19 July, Mr Gadd refused to go on an escorted half-day release because he
wanted to get a passport photo for a driving licence application but was not allowed
to take cash to do so.
46. Mr Gadd attended a second ACCT review on 20 July. He had not yet attended
healthcare for weight management advice, or the anxiety group and it was agreed
these referrals would be followed up. He had returned to his prison job and had an
appointment with his POM for the following week.
47. On 25 July, the POM and prison managers held a case conference about Mr Gadd.
They noted that there had been an escalation in concern about his behaviour from
staff and prisoners. A prisoner had reported hearing Mr Gadd threaten to stab
someone. He had been verbally hostile to other prisoners, withdrawn from his
support networks and refused to engage with his temporary release programme.
The case conference panel concluded that Mr Gadd was no longer manageable in
open conditions and should return immediately to closed conditions in a category C
prison. Given the immediacy of their concerns they decided Mr Gadd should
urgently transfer to HMP Bristol, a category B local prison, as an interim measure.
HMP Bristol, 25 July 2022 – 8 March 2023
July and August 2022
48. Mr Gadd transferred to HMP Bristol the same day, 25 July. He attended an ACCT
review in reception with an SO and Mr Gadd’s new POM at Bristol. Mr Gadd said he
was not expecting to be moved from open conditions and was surprised to be in
Bristol. He said he was confused and felt he had been treated unfairly.
49. Mr Gadd wrote in the resident contribution section of his ACCT plan that he was in
a bad place, did not know what he had done to end up in closed conditions and
wanted to know why he was there.
50. The next day, a SO held an ACCT review with Mr Gadd, a duty POM, and a mental
health support worker. Mr Gadd said he was frustrated about his return to closed
conditions and still did not know the reasons behind it. He said he had no thoughts
of suicide or self-harm but was having a bad time due to his transfer. He said he
intended to work to pass the time and was focused on a Parole Board review of the
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decision to return him to a closed prison. The review team agreed Mr Gadd’s
observations could be reduced and decided to review him again a week later once
the reasons for his transfer had been explained to him.
51. A SO held another ACCT review on 2 August with Mr Gadd and a wing officer. A
nurse told the SO that the mental health team had no concerns about Mr Gadd and
would not be attending his review (even though they had not formally assessed his
mental health). The SO also spoke to the POM, who explained that he had re-
issued the reasons for his recall to closed conditions to Mr Gadd.
52. Mr Gadd said he had no current thoughts of suicide or self-harm. He had been
receiving support from his cellmate who was in a similar position having been
recalled to closed conditions. Mr Gadd said he would like to transfer to a prison
where he could receive help with his personality disorders and, ideally, wanted to
transfer to a PIPE unit that specialised in prisoners that had been returned from
open conditions. The review team concluded that ACCT monitoring could be
stopped.
53. On 3 August, a nurse reviewed Mr Gadd’s medication with him. She said Mr Gadd
was initially guarded and said he was frustrated about his transfer. He denied acting
aggressively at Leyhill and said he had been overheard venting his frustration in his
room. He said he felt stable in mood and was eating and sleeping well but was
worried about paranoia and rumination since being taken off chlorpromazine (an
anti-psychotic) at Leyhill. He was happy with his current dose of fluoxetine (an
antidepressant). Mr Gadd was keen to attend an anxiety support group as he had
done in Leyhill, but the nurse told him these were not currently running at Bristol.
54. On 5 August, the POM met Mr Gadd to properly introduce himself. They discussed
the possibility of Mr Gadd transferring to a lower security closed prison (a category
C prison). Mr Gadd asked if he could be considered for transfer to HMP Warren Hill
as it had a progressive regime and the POM said he would contact them. He said
Mr Gadd was polite and receptive throughout their conversation.
55. At his ACCT post-closure review on 9 August, Mr Gadd said he was feeling better
and had discussed his options for transfer with his POM.
September 2022
56. There were no entries on Mr Gadd’s electronic prison record (NOMIS) in September
2022. On 12 September, Mr Gadd applied to see someone from the mental health
team because of how he was feeling. Mr Gadd’s clinical record indicated that a task
had been sent to the mental health team but there is no record of Mr Gadd being
seen in response.
57. On 27 September, the POM met Mr Gadd to discuss his potential transfer to
Warren Hill. The POM said he had no news despite an initial exchange and a
chasing email. Mr Gadd said he did not belong in Bristol and should be somewhere
more suitable. The POM said he agreed with Mr Gadd but told him that arranging a
transfer was not as simple as he might think.
58. The POM told the investigator that Mr Gadd had not arrived with a move-on plan
from Leyhill as he should have. He said at the time there was an influx of
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indeterminate sentence prisoners being returned from open conditions due to
measures introduced by the then Secretary of State for Justice in June 2022. The
increase in numbers made it harder to move these prisoners out to lower category
closed prisons (category C prisons) that offered risk-reduction work and more
specialised support for indeterminate sentence prisoners. He said category C
prisons were often unwilling to take IPP prisoners because of the complexity of their
cases and the fact that they were often in a ‘parole window’. He said there was a lot
of kickback from these prisons at the time.
October 2022
59. On 3 October, the POM and Mr Gadd again discussed his transfer from Bristol. The
POM said he had chased a reply from Warren Hill but had not had a response. He
said Mr Gadd again appeared confused about the reason he was in Bristol, and he
reminded him of the reasons for his transfer from Leyhill and directed him to the
form he had previously provided to him which explained the reasons.
60. On 5 October, Mr Gadd began work in the prison’s print workshop and moved to a
cell on B wing.
61. On 23 October, Mr Gadd told an officer that two prisoners had called him a “nonce”
(prison slang for a sex offender). He said he did not want to move wings but wanted
to know why they had done that. The officer completed a challenge support and
intervention plan (CSIP – the process in prisons used to support perpetrators and
victims of bullying and/or violence) referral. The CSIP referrals meeting
subsequently decided that Mr Gadd could be supported outside the CSIP process.
There is no evidence that Mr Gadd received any additional support.
62. On 24 October, the POM spoke to Mr Gadd about a potential transfer to HMP
Erlestoke, a category C prison. He explained that he had still not heard back from
Warren Hill and that Erlestoke offered more opportunities to complete risk-reduction
work than Bristol did. Mr Gadd refused the transfer and said his solicitor had told
him that he had an oral Parole Board hearing on 20 December. The POM said he
had not been made aware that Mr Gadd had a hearing date. This meant that Mr
Gadd was in a ‘parole window’ and any potential transfers would be put on hold
until the outcome of the hearing was known. This hearing was to review the
decision to move Mr Gadd back to closed conditions and also review his potential
for a move back to open conditions or release.
63. On 25 October, an officer had a key worker session with Mr Gadd. Mr Gadd said he
was generally okay because he was busy in the print shop but sometimes got
frustrated with his situation and wanted time on his own. This was the only key
worker session Mr Gadd had during his time at Bristol.
November 2022
64. On 7 November, the Parole Board formally notified both POMs of Mr Gadd’s oral
parole hearing via video-link on 20 December. They requested a report from the
first POM, with details of why Mr Gadd had been returned to a closed prison and a
report from the second POM on Mr Gadd’s conduct and progress at Bristol.
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65. There was only one entry on Mr Gadd’s NOMIS record in November – on 8
November his workshop instructor recorded that he had handed in a Stanley knife
blade and always worked hard and “keeps busy with cleaning”.
66. On 29 November, the first POM spoke to Mr Gadd via video-link for his report to the
Parole Board. Mr Gadd told him he had settled at Bristol but that he resented being
back in a closed prison and the rationale for the decision. He denied threatening to
stab someone and said this was a malicious accusation made by another prisoner
who he suggested had bullied him. He said he had talked out loud in his room to
work through his negative emotions and this had been overheard and spread about
by prisoners. He said prisoners had spread rumours about his offending history
which had resulted in some hostility towards him. He had therefore distanced
himself and focused on his work while at Leyhill.
67. The POM said that during their conversation, Mr Gadd told him that he had “looked
at some ceiling pipework and considered that he could hang himself”. He added this
to a minute on Mr Gadd’s case notes but did not directly bring it to the attention of
the other POM or suggest that that POM begin ACCT procedures. The second
POM said he had not noticed this reference in the case notes. He said at the time
he had an extremely high case load due to staff shortages.
December 2022
68. There are three entries on Mr Gadd’s NOMIS record in December. Two alerts
indicating he was on parole hold and unable to transfer and a negative entry for
refusing to work in the kitchens on 12 December. The alert on 30 December 2022
was the last entry on Mr Gadd’s NOMIS before he died.
69. On 12 December, the POM assessed Mr Gadd for his report to the Parole Board.
They discussed Mr Gadd’s transfer from Leyhill and Mr Gadd said he remained
upset over his treatment there.
70. In his report, the POM noted Mr Gadd had positive reports from wing staff however,
he tended to isolate and not engage with others. Mr Gadd said he deliberately kept
his distance from some prisoners as he thought they were curious about his
offending history. He noted that Mr Gadd had been unable to undertake any core
risk-reduction work at Bristol because the prison did not offer any accredited
programmes or group work and he had not had capacity due to his high workload to
undertake one to one offending behaviour work with him. Mr Gadd had been unable
to continue with his programme of temporary release into the community because
Bristol did not facilitate temporary release.
71. On 13 December, Mr Gadd applied to see the mental health team because he was
low in mood. A healthcare assistant noted on his clinical record that she had
attempted to see Mr Gadd three times during the day but that there had been too
few officers to facilitate the appointment.
72. The next day, a mental health practitioner saw Mr Gadd on B wing. He showed her
a diary he had kept of how he was feeling. He said he spent a lot of time in his cell
and used the diary as a coping mechanism. He said he ruminated on everything
and was very low in mood. Mr Gadd said he had been in prison for 17 years and
was worried about the outcome of his upcoming parole hearing. He asked her
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whether it was possible for someone from the mental health team to support him
during his video-link hearing. She told him this was unlikely but said it might be
possible for someone to see him afterwards to check how he was. Mr Gadd said he
would be very grateful if that was possible.
73. Mr Gadd told the mental health practitioner that it had helped to offload how he was
feeling to someone as he had a lot of things bottled up in his head. She noted in his
clinical record that his mood was very low and booked a crisis visit for him on 21
December, the day after his parole hearing.
74. On 20 December, Mr Gadd attended his oral parole hearing via video-link. His POM
had annual leave booked before he learned of the date of the hearing.
75. On 21 December, a member of the mental health crisis team saw Mr Gadd briefly
for his pre-booked visit. She said she had been unable to see him for longer as she
had been assigned to escort another prisoner to hospital that day. Mr Gadd said he
had had a bad night as he had been ruminating on his parole hearing. They agreed
she would come and see him at 8.30am the next morning.
76. The member of the mental health crisis team visited Mr Gadd the next day as
planned. Mr Gadd said his parole hearing had lasted about four hours. He told her
about his POM not having accepted his explanation for his behaviour at Leyhill and
his transfer to Bristol. He said he tended to ruminate due to his personality disorder
but had learned some “avoidance and distraction techniques” that helped him cope.
Mr Gadd said his mental health was currently stable and he had no thoughts of
harming himself or others.
77. The member of the mental health crisis team said that the mental health team was
not able to offer Mr Gadd a regular appointment. She said he would have benefitted
from attending an anxiety management group, but none were running. She said she
would make another appointment for Mr Gadd once he had received his parole
decision and Mr Gadd agreed to let clinical staff know when this had happened. The
mental health team leader told the investigator that Mr Gadd did not require crisis
support. Due to staff shortages as a result of the change of healthcare provider in
October, there was no capacity to offer primary mental health support and none of
the groups such as anxiety management were running.
78. Mr Gadd received the Parole Board’s decision letter on 23 December. The panel
decided that the evidence put before it did not indicate that Mr Gadd’s risk had
increased. They agreed with the psychologist’s assessment that Mr Gadd should be
tested in the community via a gradual and staged process of escorted releases on
temporary licence. They therefore recommended to the Secretary of State for
Justice that Mr Gadd should be returned to an open prison to allow this to happen.
There is no evidence that staff spoke to him about this decision, nor that Mr Gadd
asked to see the mental health team, as he had agreed with the member of the
mental health crisis team before the hearing.
January 2023
79. There is very little information in Mr Gadd’s records during this period. There are no
entries on his NOMIS record. The mental health team leader said she had moved
from Leyhill to Bristol in October 2022 to take up a role as manager in the offender
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management unit (OMU). She had started a monthly forum for IPP and life
sentence prisoners, but this had been slow to get off the ground as staff shortages
meant there was no one to escort the prisoners to the group. As a result, in January
2023, she decided to hold the group on B wing as this was the wing with the most
IPP and life sentence prisoners. She said Mr Gadd attended the group and was
very open about his frustration at having to wait for Secretary of State approval of
his return to an open prison. Mr Gadd said he was struggling and at times
wondered what was the point. She said other prisoners in the group would try to
cheer him up, but she thought it was harder for Mr Gadd because he had no family
or friends supporting him outside prison.
80. She told us that the team at Bristol responsible for organising transfers stopped
looking for a category C prison for Mr Gadd because he was waiting for the
Secretary of State’s approval of his return to open conditions. Mr Gadd did not
receive the Secretary of State’s response before he died.
February – March 2023
81. On 9 February, the POM told Mr Gadd that the Government had rejected the
Justice Committee’s recommendation that all IPP prisoners be resentenced. He
also gave Mr Gadd a copy of a letter to all IPP prisoners from the Governor
explaining what the decision meant and offering support. He said Mr Gadd was
aware of the decision and had not been expecting the recommendation to be
accepted. He said Mr Gadd did not appear disappointed and showed insight into
the issue.
82. The POM also explained to Mr Gadd that it might take some time for the Secretary
of State’s approval of the Parole Board’s recommendation that he return to an open
prison to be received. Mr Gadd said he was aware of the process and, although he
was keen to receive an answer, he knew he had to be patient. He said Mr Gadd
was calm and polite throughout their conversation and he was not concerned about
Mr Gadd’s well-being.
83. Mr Gadd’s Probation Service record showed he telephoned his community offender
manager on 1 March, but she was not there, and he declined to leave a message.
He was advised to ring back on 10 March.
84. Three prisoners who all lived in cells on Mr Gadd’s landing, told the investigator that
Mr Gadd’s behaviour changed in the days before he died. They said he did not go
to work, and they were worried that he was not eating. He stayed in his room and
was verbally abusive to Mr Walker when he brought him some food. All three
prisoners said this was out of character for Mr Gadd. One prisoner said he
remembered that the prison newspaper Inside Time had a lot of articles about IPP
prisoners and delays in returning them to open prisons at about this time. All three
prisoners said they told wing staff that they had been worried about Mr Gadd.
85. During the HMPPS Early Learning Review after Mr Gadd’s death, catering staff
confirmed to the Area Safety Lead that Mr Gadd had not attended his job in the
kitchens for three or four days before 9 March. The Lead said an officer told him
that concerns had been raised at the wing briefing on 7 March that Mr Gadd was
behaving out of character. The officer was tasked with completing a welfare check.
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86. The officer told the investigator that Mr Gadd’s behaviour had not changed at all in
the days leading to his death. He thought Mr Gadd had an arrangement with the
kitchen that he did not have to work every day, so he was not concerned when Mr
Gadd did not go to work. He said he was not aware Mr Gadd was not eating but he
did remember completing a welfare check on Mr Gadd after he had been rude to a
prisoner who had taken him some food. He said Mr Gadd told him he was fine and
seemed to be his usual self.
87. A SO said she did not remember a wing briefing in which concerns for Mr Gadd’s
behaviour were raised. She said she had been on duty on 8 March, and no one had
raised any concerns about him with her. An officer said he regularly worked on Mr
Gadd’s landing. He had been away for a few days, returning to work on 8 March but
no one had raised any concerns about Mr Gadd’s behaviour.
Events of 9 March 2023
88. Unknown to staff, a prisoner had smeared a clear substance on to the lens of the
CCTV camera on Mr Gadd’s landing obscuring the view from it. It is especially
difficult to see exactly what happened before the landing light is turned on. (The
prison investigated and identified the prisoner responsible – it was not Mr Gadd.)
89. At 5.35am, an Operational Support Grade (OSG) checked the prisoners on Mr
Gadd’s landing for the morning routine check. CCTV showed the OSG used his
torch to look through the observation panels on the cell doors. The substance on
the camera lens and the angle due to the location of Mr Gadd’s cell meant it was
not possible to see how long he remained outside Mr Gadd’s cell.
90. The OSG said that he could not remember checking Mr Gadd that morning. He said
prisoners on B Wing often obscured their observation panels and this was a regular
issue that had been raised with prison managers. He said that when he came
across a covered observation panel, he knocked on the door until the prisoner
responded. If he failed to get a response, he would radio the orderly officer for
assistance. He said the fact that he had not used his radio that morning indicated
he had either seen Mr Gadd in his cell alive and well or had obtained a verbal
response from him.
91. Just before 8.00am, Officer A opened Mr Gadd’s cell door to give him his breakfast
pack. He saw Mr Gadd suspended from the window frame by a belt. He radioed a
code blue emergency (indicating a prisoner is not breathing or having difficulty
breathing), cut the belt from the window frame and released the buckle from Mr
Gadd’s neck. The control room log recorded the code blue at 7.58am. Ambulance
records showed the control room officer called an ambulance at 8.00am and an
ambulance was dispatched with the highest priority.
92. Officer B helped Officer A lay Mr Gadd on the floor and Officer B started cardio-
pulmonary resuscitation (CPR). A SO attached a defibrillator. The defibrillator did
not detect a shockable heart rhythm and advised CPR to continue. A nurse arrived
and asked for Mr Gadd to be moved to the landing where there was more space to
work on him.
93. The nurse said she was unable to insert an airway into Mr Gadd’s mouth because
his jaw was too stiff. She inserted an airway into Mr Gadd’s nostril instead. She said
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there was evidence of blood pooling in Mr Gadd’s lower abdomen (hypostasis -
indicating a lack of circulation), his lips were blue, and his pupils were fixed with no
reaction to light. She told the investigator that she had not received any guidance or
undertaken any training about the circumstances in which CPR should not be given.
94. The Head of Healthcare arrived two minutes after Mr Gadd was moved to the
landing and told the nurse to stop resuscitation, as there were clear signs that Mr
Gadd had died. At 8.14am, paramedics confirmed Mr Gadd had died.
Contact with Mr Gadd’s family
95. The prison was unable to identify a next of kin. Mr Gadd was estranged from his
family and his previous partner had died.
Support for prisoners and staff
96. After Mr Gadd’s death, the Governor 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 and also offered support.
97. The prison posted notices informing other prisoners of Mr Gadd’s death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr Gadd’s death.
Post-mortem report
98. The Coroner gave the cause of death as suspension by ligature around the neck
(hanging).
Inquest
99. On 28 July 2025, a Coroner’s inquest found Mr Gadd had died by suicide.
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Findings
Assessment of risk
100. In our Learning Lessons Bulletin issued in September 2023, we concluded that
more needs to be done to recognise a prisoner’s IPP status as a potential risk factor
for suicide and to identify the triggers for suicide and self-harm that are associated
with this status. These include parole hearings, prison transfers and change in
security categorisation. The regularity with which IPP prisoners are subject to parole
review means that these triggers are often relevant. We also concluded that
insufficient opportunities to participate in offending behaviour programmes can
increase frustration and create a sense of hopelessness. Additionally, 2022-2023
was a significant year for IPP prisoners. In June 2022, the Secretary of State for
Justice tightened the criteria for transfer to open prisons and introduced ministerial
approval of Parole Board recommendations for these transfers. In February 2023,
the Government announced they would not accept the JSC recommendation to re-
sentence IPP prisoners.
101. Mr Gadd had a number of risk factors that meant he was at risk of suicide or self-
harm including previous suicide attempts, personality disorder, anxiety and
depression. A risk assessment in 2021 noted Mr Gadd’s thoughts of suicide and
self-harm would need on-going monitoring, especially if he became stressed about
his situation. His records showed that he experienced suicidal thoughts when he felt
things were not going right for him and withdrew from professionals and became
socially avoidant when feeling stressed and emotionally affected.
102. There is evidence that in the days leading to his death Mr Gadd displayed many of
the signs noted above. He did not go to work, spent more time in his cell and his
behaviour to his friends was out of character. It is clear from the HMPPS Early
Learning Review that concerns were raised to staff about Mr Gadd in this period.
We consider that staff should have given more weight to these concerns in the light
of Mr Gadd’s IPP status.
103. Mr Gadd had been waiting for Secretary of State approval of his return to an open
prison for the best part of three months and this would have been a source of
anxiety and frustration. The stricter criteria introduced in June 2022 meant approval
was by no means guaranteed. He was in a reception prison that was not set up to
support and manage IPP prisoners. He did not have the outlet of group work and
regular mental health support as he had at Leyhill. He was unable to complete risk
reduction work and his transfer to a category C prison had been put on hold
pending the Secretary of State’s decision. We consider that all these factors should
have been considered when determining Mr Gadd’s risk of suicide and self-harm.
We recommend that:
The Governor and Head of the Offender Management Unit at HMP Bristol
should ensure that all staff are aware of the risks associated with IPP
prisoners and actively consider these when an IPP prisoner’s behaviour
changes or they are assessing their risk of suicide and self-harm.
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Transfer to HMP Bristol
104. Mr Gadd’s transfer to Bristol was intended to be a temporary measure pending a
return to his original sending establishment or to a category C prison that could offer
him risk-reduction work and more specialist support. The Secretary of State’s
tightening of the criteria for open conditions in June 2022 was in response to the
high profile abscondence of a sex offender from Leyhill. It was perhaps natural that
this would result in Leyhill being more cautious when assessing prisoners’ risk.
105. We note that Mr Gadd was transferred on the hearsay evidence of a fellow prisoner
and after he refused to engage with his programme of release on temporary
licence. We have not seen any evidence that Mr Gadd’s explanations were
explored, or alternatives considered. His new POM had not met him at this point
and did not speak to him personally. Additionally, Mr Gadd was subject to ACCT
monitoring and the actions on his care plan deemed necessary to reduce his risk
had not been completed and one of them, that he attend an anxiety management
group, could not be completed at Bristol.
106. A senior probation officer told the investigator that she was frustrated to see so
many IPP and life sentence prisoners at Bristol that she remembered from Leyhill.
She said Bristol was not a suitable environment for these prisoners. She provided
the investigator with email correspondence from 11 January 2023 that showed
there were 26 prisoners at Bristol who had been returned from Leyhill since October
2020. Of these, 22 were IPP or life sentence prisoners and 18 had been returned
after the Secretary of State for Justice brought in the new measures in June 2022.
107. The manager in charge of the Offender Management Unit subsequently had a
meeting with his counterpart at Leyhill, after which the senior probation officer said
the situation improved.
108. We consider that the decision to return any IPP prisoner to a reception prison must
only be taken in the most exceptional circumstances due to the particular difficulty
of onward transfer, the risks associated with that sentence and the lack of prison
places generally. As a minimum, the returning prison must provide a move-on plan
and make proper efforts to return the prisoner to their original sending prison.
Clearly there was an influx of IPP and other indeterminate sentence prisoners to
Bristol from Leyhill after June 2022 and this was sufficient for Bristol to initiate a
meeting to try to resolve the issue.
The Governor at HMP Leyhill should ensure that if they return prisoners to
closed conditions, they must provide a move-on plan and make determined,
documented efforts to return the prisoner to the sending prison.
109. We understand that the lack of move-on plan and the exploration of alternatives
continues to be a problem for Bristol, albeit there is now more national scrutiny of
the location of IPP prisoners and Bristol is now receiving more help moving IPP
prisoners on. We think that this investigation very clearly demonstrates both the
particular vulnerabilities of IPP prisoners and the lack of wider staff understanding
of them. We recommend that:
110. In its report on IPP sentences published in September 2022, the Justice Select
Committee (JSC) found that “the psychological harm caused by IPP sentences is a
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considerable barrier to progression for some IPP prisoners. The indefinite nature of
the sentence has contributed to feelings of hopelessness and despair that has
resulted in high levels of self-harm and some suicides within the IPP population. In
addition to this, IPP prisoners distrust the people and services that are necessary to
support their progression.”
111. The Government responded to the review in February 2023, when they announced
that they would not be resentencing those currently subject to an IPP sentence. In
response to the JSC report, the Ministry of Justice (MOJ) and HMPPS published a
new IPP Action Plan in April 2023. The aim of the plan is to focus on ensuring that
HMPPS processes support IPP prisoners to “maximise their prospects of achieving
a safe and sustainable release”. It includes measures to support those serving IPP
sentences and to reduce the risk of suicide and self-harm.
112. The IPP Action Plan includes a requirement for Executive Directors to introduce IPP
Delivery Plans for the prisons in their regions by the end of April 2024. It is
important that these plans contain meaningful actions to support IPP prisoners
through to release and that staff have an awareness of the specific risks that IPP
prisoners present in regard to self-harm and suicide if we are to stop seeing more
IPP prisoners from taking their own lives.
Key work at Bristol
113. In common with some other prisons, the key work scheme has not been operating
as it should at Bristol due to staff shortages. One of HMIP’s key concerns during
their recent inspection was that wing staff did not develop effective relationships
with prisoners. Mr Gadd had just a single key work session in over seven months.
Mr Gadd’s records showed he welcomed the opportunity to talk about his situation.
Regular key work sessions might have allowed staff to build a more accurate
picture of his risk to himself and others.
114. Some prisons prioritise the most vulnerable prisoners for key work. Our Learning
Lessons Bulletin concluded that IPP prisoners should be considered vulnerable and
prioritised for key work. Since Mr Gadd’s death and the death of another IPP
prisoner at Bristol, all IPP prisoners are prioritised for fortnightly key work sessions.
We therefore make no recommendation.
Clinical care
115. The clinical reviewer concluded that Mr Gadd’s healthcare was partially equivalent
to that he could have expected in the community. There was a lack of continuity and
equity in Mr Gadd’s mental health care between Leyhill and Bristol. In particular, Mr
Gadd was well supported by the mental health team at Leyhill but there was no
capacity to offer him individual support or group work at Bristol. The clinical
reviewer has made several recommendations which the Head of Healthcare will
wish to consider.
Emergency Response
116. We note that prison staff and the emergency response nurse initially gave Mr Gadd
CPR despite signs unequivocally associated with death. Once the Head of
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Healthcare arrived, he directed that CPR should stop. The nurse concerned said
she had not received guidance on this and was unaware that she did not need to
perform CPR when someone had clearly died. We note that this training need was
recognised by the Head of Healthcare who subsequently issued a Learning
Lessons Bulletin to all staff with appropriate guidance. Simulation training to
improve staff competence and confidence on when to perform CPR is planned for
February 2024. We make no recommendation.
Good practice
117. The senior probation officer’s introduction of an IPP/Lifer forum to support these
prisoners at Bristol is an example of good practice. We consider that this initiative
should be fully recognised and supported by senior managers at Bristol.
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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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