Keith Williams

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Keith Williams,
a prisoner at HMP Dovegate,
on 12 July 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Keith Williams died on 11 July 2021 after he cut his neck in his cell at HMP Dovegate.
He was 46 was years old. I offer my condolences to his family and friends.
Mr Williams initially complained about an infected hair follicle, which progressed to bizarre
and distressing beliefs about an infection running through his body and excruciating pain.
Although there was no evidence of a physical health problem, Mr Williams was convinced
that something was wrong and cut himself on several occasions to stop the pain.
Staff monitored Mr Williams under suicide and self-harm prevention procedures, known as
ACCT, six times at Dovegate. While there was some good practice, I am concerned that
staff did not fully address his risks or consider the possibility of accidental death. It is not
the first time that I have identified deficiencies in Dovegate’s ACCT procedures.
The clinical reviewer concluded that although elements of Mr Williams’ clinical care at
Dovegate were satisfactory, his mental health care was not equivalent to that which he
could have expected in the community. Our investigation found that mental health staff
focussed too heavily on his reported physical health problems and apparent substance
misuse and missed several opportunities to arrange a follow-up psychiatric assessment.
I am also concerned that healthcare staff did not hold a complex case review, did not
inform Mr Williams of his hospital scan result and did not always complete the ACCT
document. We have previously made a recommendation about this and are disappointed
that we need to do so again.
I am also concerned that the prison did not inform Mr Williams’ next of kin of his death
promptly in line with Prison Service instructions.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman July 2022
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. In March 2017, Mr Keith Williams was sentenced to eight years in prison for robbery
and sent to HMP Birmingham. (He was subsequently sentenced to an additional
four years in prison in March 2019.) Mr Williams had a history of substance misuse
problems and was prescribed methadone to treat opioid dependence.
2. On 16 January 2020, Mr Williams was moved to HMP Dovegate. In August, a
prison GP recorded that Mr Williams had several sores on his scalp and prescribed
an antibiotic.
3. In December, a prison GP, a consultant psychiatrist and a mental health nurse
jointly reviewed Mr Williams after he made a cut to his neck. Mr Williams denied
hallucinations or substance misuse and the psychiatrist concluded that there was
no evidence of severe mental illness. That day, prison staff started ACCT
procedures.
4. Over the next seven months, Mr Williams frequently reported pain and various
sensations throughout his body that he felt were linked to an infected hair follicle.
He sometimes said he believed there were insects in his body. Prison staff started
ACCT procedures on four occasions, twice after Mr Williams cut himself to stop the
physical pain he said he felt.
5. On 8 July 2021, a Prison Custody Officer (PCO) found Mr Williams in his cell,
covered in blood, and radioed an emergency medical code. Prison and healthcare
staff attended to Mr Williams and noted that he presented as under the influence of
psychoactive substances (PS). Prison staff started ACCT procedures and removed
potentially dangerous items from his cell, such as razors.
6. On 9 July, Mr Williams told staff at an ACCT case review that he did not have any
suicidal thoughts but was still in agony and felt like cutting to stop the pain. They
reduced his ACCT observation requirement to two an hour but did not indicate
whether any items had been removed or were restricted.
7. At 11.38pm on 11 July, a night support officer (NSO) saw Mr Williams lying face
down on the floor of his cell, which was covered in blood. She radioed a medical
emergency code and a PCO arrived immediately. A Custodial Operations Manager
(COM) asked them by radio if Mr Williams was responsive and they said that they
had seen him breathing. She therefore told them not to enter the cell, unless
necessary.
8. At 11.40pm, the COM arrived with a PCO and a nurse and had to force entry to the
cell as Mr Williams had put a chair behind the door. Staff began cardiopulmonary
resuscitation (CPR), but at 12.05am on 12 July, the nurse asked them to stop CPR
as it was clear that Mr Williams had died. Paramedics arrived at 12.20am and at
12.24am, confirmed that Mr Williams was dead.
Findings
9. We cannot say if Mr Williams intended to kill himself when he cut his neck.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Risk management
10. Mr Williams repeatedly reported pain and bizarre and distressing beliefs about an
infection running through his body. We are satisfied that staff showed concern and
appropriately started ACCT procedures following incidents of self-harm and
associated thoughts.
11. While there was some good practice, we are concerned that staff failed to fully
consider Mr Williams’ risk factors as part of their ongoing assessment and placed
too much emphasis on the fact that he denied having suicidal thoughts.
12. We are particularly concerned that staff misinterpreted Mr Williams’ risk the day
before he died. They failed to consider his risk of accidental death and his access
to razors and inappropriately reduced his ACCT observations. We have raised
concerns about ACCT management at Dovegate before and urgent action is now
required.
Clinical care
13. The clinical reviewer concluded that although elements of Mr Williams’ clinical care
at Dovegate were satisfactory, his mental health care was not equivalent to that
which he could have expected in the community.
14. Mr Williams was referred to the mental health in reach team several times, but they
repeatedly declined to provide intervention and, particularly from March 2021
onwards, appeared to focus on his PS use and reports of physical pain. These
were missed opportunities to fully assess him and to request another psychiatric
review.
15. We are concerned that healthcare staff did not hold a complex case review and that
services often acted in isolation, with minimal communication. We are also
concerned that nobody informed Mr Williams of the result of his MRI scan and that
healthcare staff did not always complete ACCT records. We have previously made
a recommendation about this and are disappointed to need to do so again.
Emergency response
16. The two staff who saw Mr Williams bleeding on the floor on 11 July, did not
immediately enter the cell. They considered it was unsafe as Mr Williams might
have a blade. We cannot say their fears were unreasonable and we do not criticise
them. However, this caused a delay of around two minutes before CPR began. We
cannot say whether this affected the outcome for Mr Williams.
Contact with Mr Williams’ family
17. We are concerned that the prison did not inform Mr Williams’ next of kin of his death
promptly in line with Prison Service instructions.
Recommendations
• The Director and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide and self-harm in line with national guidelines, including that staff:
• set effective caremap actions that are specific and meaningful, aimed at
reducing risk, and update them at each review;
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• encourage family engagement in the ACCT process, where appropriate, to
assist in managing and reducing the risk of prisoners who self-harm;
• consider all relevant information when identifying a prisoner’s risk factors and do
not rely solely on his behaviour and comments;
• remove or restrict prisoners’ access to items such as razors, when they present
a risk of harm by cutting;
• engage prisoners in meaningful conversation and record the outcome of the
discussion in the ACCT ongoing record; and
• complete all aspects of the ACCT document, including the daily supervisor
check in the ongoing record.
• The Director of Custodial contracts should write to the Ombudsman setting out what
is being done to ensure that ACCT procedures at Dovegate improve.
• The Head of Healthcare should:
• ensure that there is a robust system in place for conducting complex case
reviews and that the process is communicated effectively to all relevant
members of healthcare staff;
• improve communication between healthcare and mental health services and
ensure that feedback and advice on how to manage complex cases is
provided to those who make referrals;
• conduct a review of the mental health risk assessment process for identifying
prisoners at risk of death by self-harm to ensure that it is fit for purpose; and
• ensure that the results of hospital investigations are promptly communicated to
prisoners.
• The Head of Healthcare should ensure that all staff make an entry in the ACCT
record after intervention with a prisoner to ensure continuity of care.
• The Director should ensure that a member of Prison Service staff informs a
prisoner’s next of kin of their death promptly, in line with national guidance.
• The Director should ensure that a copy of this report is shared with the staff named
in this report and that a senior manager discusses the Ombudsman’s findings with
them.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
18. The investigator issued notices to staff and prisoners at HMP Dovegate informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
19. The investigator obtained copies of relevant extracts from Mr Williams’ prison and
medical records.
20. The investigator interviewed 12 members of staff from Dovegate by video-link
between 2 and 10 September. NHS England commissioned a clinical reviewer to
review Mr Williams’ clinical care at the prison. The investigator and clinical reviewer
jointly interviewed 11 members of staff.
21. We informed HM Coroner for Staffordshire South of the investigation. He gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
22. The Ombudsman’s family liaison officer contacted Mr Williams’ family to explain the
investigation and to ask if they had any matters they wanted us to consider. His
family wanted to know why no one told them that Mr Williams was subject to ACCT
monitoring.
23. Mr Williams’ family received a copy of the initial report. They did not raise any
further issues, or comment on the factual accuracy of the report.
24. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background information
25. HMP Dovegate is a Category B prison in Staffordshire, managed by Serco. The
main prison holds around 930 remanded and sentenced adult prisoners. There is
also a therapeutic community, separate to the main prison, which holds up to 220
prisoners. Practice Plus Group provides 24-hour healthcare services. South
Staffordshire and Shropshire Foundation Trust provides mental health services.
HM Inspectorate of Prisons
26. The most recent inspection of HMP Dovegate was in September/October 2019.
Inspectors found that despite recent staffing challenges, mental health practitioners
responded promptly to prisoners’ needs and the range of therapeutic options was
limited but growing. Inspectors also found that a comprehensive and joined-up
approach to combating the misuse of drugs was now in place, but that drug
availability remained a key concern.
Independent Monitoring Board
27. 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 September 2020, the IMB
reported that incidents of self-harm and the number of prisoners subject to ACCT
procedures had increased.
Previous deaths at HMP Dovegate
28. Mr Williams was the ninth prisoner to die at Dovegate since July 2019. Of the
previous deaths, one was self-inflicted, one was drug-related and six were from
natural causes. There have since been two deaths from natural causes.
29. In a previous investigation into a death at Dovegate in November 2019, we found
deficiencies in the operation of ACCT procedures. We also expressed concern
about staff not immediately entering cells in potentially life-threatening situations
and the importance of healthcare staff making entries in the ACCT record.
Assessment, Care in Custody and Teamwork
30. ACCT is the Prison Service procedure used to support prisoners at risk of self-harm
or suicide. The purpose of ACCT is to try to determine the level of risk, how to
reduce the risk and how best to monitor and supervise the prisoner. After an initial
assessment of the prisoner’s main concerns, levels of supervision and interactions
are set according to the perceived risk of harm. Checks should be irregular to
prevent the prisoner anticipating when they will occur. There should be regular
multi-disciplinary review meetings involving the prisoner.
31. Part of the ACCT process involves assessing immediate needs and drawing up a
caremap to identify the prisoner’s most urgent issues and how they will be met.
Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Psychoactive Substances (PS)
32. Psychoactive substances (formerly known as ‘new psychoactive substances’ or
‘legal highs’) are a significant problem across the prison estate. They are difficult to
detect and can affect people in a number of 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.
33. There are many types of PS, including synthetic cannabinoids, often referred to as
“Spice”.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
2017 to 2019
34. On 8 March 2017, Mr Keith Williams was sentenced to eight years in prison for
robbery and sent HMP Birmingham.
35. Mr Williams had a history of substance misuse problems and was prescribed
methadone to treat opioid dependence. He occasionally harmed himself in prison
and was referred to mental health services, but the consensus was that he did not
have a mental illness.
36. Mr Williams also suffered from recurring dry skin and folliculitis (an infection and
inflammation of the hair follicles), which healthcare staff treated with various creams
and antibiotics.
37. On 7 March 2019, Mr Williams was sentenced to an additional four years in prison
for robbery. Over the next nine months, he failed a mandatory drug test and was
found in possession of prison-brewed alcohol (known as hooch).
2020
38. On 16 January 2020, Mr Williams was moved to HMP Dovegate as part of his
sentence progression. A nurse conducted an initial health screen and made a
mental health referral as Mr Williams reported a history of self-harm and asked for
support. A substance misuse nurse reviewed Mr Williams and recorded that he
was prescribed several medications, including methadone and mirtazapine (an
antidepressant). The next day, a substance misuse worker visited Mr Williams and
agreed a care plan with him.
39. On 19 January, a mental health nurse conducted an initial assessment and
recorded that Mr Williams reported a history of substance misuse and depression
and said that he thought he had “something growing inside his head”. However, he
failed to elaborate further. The following day, the mental health team discussed Mr
Williams at a multidisciplinary team meeting (MDT), after which they discharged him
from their care as they concluded that there was no evidence of mental illness.
40. On 30 January, a Prison Custody Officer (PCO) introduced himself to Mr Williams
as his keyworker and recorded that they discussed the prospect of him attending
group education. Over the next seven months, officers conducted 12 keywork
sessions and records indicate that Mr Williams engaged well with the restricted
regime that was imposed in response to the COVID-19 pandemic.
41. On 27 August, a prison GP reviewed Mr Williams and noted that he had several
sores on his scalp that had not responded to treatment with flucloxacillin (an
antibiotic). He took a swab and prescribed doxycycline (another antibiotic). Over
the next three months, Mr Williams’ sores persisted, and healthcare staff prescribed
additional antibiotics and creams.
42. On 25 November, a nurse associate practitioner reviewed Mr Williams and noted
that he was very distressed about his sores and felt that he was breathing through
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
the wounds. She made a mental health referral and requested a hospital referral to
the dermatology team.
43. On 27 November, a mental health nurse visited Mr Williams to conduct an initial
assessment and recorded that his focus was on his physical wounds and that he
did not want to engage with mental health services.
44. On 29 November, Mr Williams was moved to the prison’s inpatient healthcare unit
for a period of assessment as he continued to display bizarre behaviour. A nurse
noted that he reported parasites in his wounds, trying to get out through his
stomach, and refused to have his wounds dressed for fear of not being able to
breath.
45. On 1 December, the mental health team discussed Mr Williams at a clinical team
meeting, and a consultant psychiatrist requested a full physical health check to rule
out an infection. Attendees agreed that, in the meantime, Mr Williams would be
added to a mental health nurse’s caseload.
46. On the morning of 8 December, prison staff noticed that Mr Williams had cut the
back of his neck using a pair of nail clippers and started ACCT procedures. A
medical team jointly reviewed Mr Williams who reported a tight feeling across the
skin on his back. A doctor recorded that there was no sign of infection, but he
would try a short course of prednisolone (a steroid). He noted that Mr Williams
denied hallucinating or taking illicit drugs and said, “It isn’t in my mind” several
times. He concluded that there was no evidence of psychotic or severe mental
illness and suggested a psychiatric assessment once Mr Williams’ physical health
issues had been resolved.
47. On 9 December, a Custodial Operations Manager (COM) chaired a first ACCT case
review which two members of prison staff and a mental health nurse attended. She
noted that healthcare staff had prescribed diazepam (a sedative) to help with Mr
Williams’ anxiety and that he said he did not want to harm himself but found the
pain from his sores too much to manage. Attendees assessed his risk of suicide or
self-harm as low and stopped ACCT monitoring.
48. On 15 December, a consultant dermatologist reviewed Mr Williams by video link
and noted that he had some inflammation on his scalp and sores on his back that
appeared to have been picked. The dermatologist concluded that there was no
clear diagnosis to go against a clinical diagnosis of recurrent bacterial sores with
excoriation (a disorder where a person cannot stop picking at their skin) and
suggested specialised shampoo and cream, with the addition of limacine (an
antibacterial medication) if his condition did not improve.
49. On 21 December, a multidisciplinary team meeting (MDT) agreed that Mr Williams’
presentation had improved and that he could return to the wing. Later that day, a
mental health nurse reviewed Mr Williams and noted that he displayed no evidence
of acute mental illness.
50. On 22 December, prison staff started ACCT procedures after Mr Williams made a
superficial cut to his neck using a razor. At a first case review the next day, Mr
Williams told attendees that he was struggling with his physical health and it was
impacting on his mental health.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
51. On 29 December, prison staff decided not to proceed with an ACCT case review as
Mr Williams appeared to be under the influence of an illicit substance. On 31
December, a COM chaired an ACCT case review and recorded that Mr Williams
had spoken to his father who was supportive and had encouraged him to engage
with the wing regime. Attendees assessed his risk of suicide or self-harm as low
and stopped ACCT monitoring.
2021
52. On 5 January 2021, a substance misuse worker visited Mr Williams on the wing for
a review. He recorded that before the meeting, prison staff told him that Mr
Williams had presented as under the influence of an illicit substance on several
occasions. Mr Williams told him that he felt stable on his current dose of
methadone and he provided harm minimisation advice about not mixing prescribed
and non-prescribed medication. However, Mr Williams denied that he had taken
any illicit substances.
53. On 20 January, prison staff started ACCT procedures after Mr Williams reported
thoughts of self-harm. On 21 January, a COM conducted a first ACCT case review
which prison and healthcare staff attended. Mr Williams refused to attend due to
pain in his back. The COM noted that healthcare staff said that Mr Williams
continued to complain about an infection although there was no evidence of
anything abnormal.
54. On 15 February, a COM chaired an ACCT case review, which prison and
healthcare staff attended. Mr Williams told attendees that he had been using
psychoactive substances (PS) but had since stopped and his mental health had
improved. He did not report any thoughts of suicide or self-harm and attendees
stopped ACCT monitoring.
55. On 19 February, an officer saw Mr Williams for a keywork session and recorded
that although he said he was fed up with the COVID-19 regime, he had regular
contact with his family and did not have any issues on the wing. Mr Williams had a
further eight keywork sessions before his death and officers recorded that he was
happy on the wing and mostly spoke about his physical health concerns.
56. On 23 March, a doctor visited Mr Williams to conduct a follow-up review with an
assistant psychologist. Mr Williams reported pains throughout his body that he felt
resulted from an infected hair follicle in his neck. The doctor noted that Mr Williams
had used PS within the last two weeks and had a history of mental health
assessments dating back to 2011 which found no evidence of mental illness. He
concluded that there was no evidence of a severe or enduring mental disorder and
requested a GP review to consider a neurology referral (a branch of medicine that
focuses on the nervous system). He also noted that he started ACCT procedures
as Mr Williams said that he would “hang himself” if his pain continued.
57. Later that day, the mental health team discussed Mr Williams at a clinical meeting
and discharged him from their care. However, they noted that staff could re-refer
him following his physical investigations, if necessary.
58. On 24 March, a COM chaired a first ACCT case review which prison and mental
health staff attended. She noted that Mr Williams reported a constant dripping
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
feeling in his back and said that his body was swelling up overnight. He said that
although the pain made him want to end his life, he did not act on it as he had his
father and sister for support. Attendees assessed his risk of suicide and self-harm
as low and added an action to the caremap for Mr Williams to have a GP review.
59. On 26 March, a prison GP reviewed Mr Williams and recorded that he reported a
headache and back pain. He noted the outcome of the mental health team’s recent
review and requested a Magnetic Resonance Imaging (MRI) scan of his head,
spine and hips. Later that day, a COM chaired an ACCT case review and noted
that Mr Williams said he was happy about being referred for an MRI scan and did
not report thoughts of self-harm or suicide. Attendees assessed his risk as low and
decided to stop ACCT monitoring.
60. On 29 March, a substance misuse worker visited Mr Williams to conduct a welfare
check and noted that he felt stable on his methadone dose but continued to report
pain in his back that he said was due to an infection that had spread through his
body. He also noted that Mr Williams said that he had not been taking illicit drugs
and was not imagining the pain.
61. On 2 April, a COM visited Mr Williams for an ACCT post-closure review and noted
that healthcare staff were looking into his physical health concerns and that he had
support from his father.
62. Between 12 and 20 April, Mr Williams’ sister contacted Dovegate on several
occasions to express concerns about the quality of the healthcare he was receiving.
On 29 April, the Head of Healthcare sent a written response to Mr Williams’ sister,
addressing her concerns in detail by referring to his medical record (with Mr
Williams’ consent).
63. At 6.00am on 12 May, prison staff called a medical emergency code red (which
indicates that a prisoner has serious blood loss or burns) after they found Mr
Williams with cuts to his neck. A nurse reviewed him and noted that he said the
holes in his back were causing him pain and “ripping him apart”. She made a
mental health referral as, on examination, she could only see scars.
64. Later that morning, a COM chaired an ACCT case review which prison and mental
health staff attended. He noted that Mr Williams said that he was in such pain that
he had to cut himself to stop it. Attendees assessed him as a low risk of suicide or
self-harm and added two actions to the caremap: for healthcare staff to conduct a
review and for an MRI scan to be arranged.
65. A mental health nurse then conducted a mental health assessment and recorded
that Mr Williams’ engagement was limited due to him reporting severe pain. She
noted that he had a long history of substance misuse but had poor insight into the
impact of his drug use. She concluded that although he potentially had delusional
beliefs about the patches on his skin, he did not display disordered or paranoid
thoughts and that no mental health follow-up was required. In the afternoon, mental
health staff discussed Mr Williams at a team meeting and decided not to add him to
their caseload.
66. On 14 May, a COM chaired an ACCT case review, which another COM attended.
He noted that although Mr Williams reported pain and difficulty walking, his
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
presentation on the wing did not reflect this and he became irate when questioned
about it. Attendees assessed his risk of suicide or self-harm as low and stopped
ACCT monitoring.
67. Later that day, the Head of Healthcare wrote another letter to Mr Williams’ sister to
assure her that staff were doing everything necessary to care for him. She said
healthcare staff would continue to monitor him frequently while he waited for a
hospital scan and that she would arrange for a member of staff to provide her with
monthly updates.
68. On 7 June, a COM completed an ACCT post-closure review and noted that
healthcare staff were aware of Mr Williams’ issues and that his appointments had
been completed. (The review should have taken place on or before 21 May.)
69. On 14 June, the prison received the result of Mr Williams’ MRI scan which did not
show any significant abnormalities. On 23 June, a substance misuse nurse
reviewed Mr Williams and recorded that he continued to report pain caused by a
skin infection. Mr Williams said he had not had the results of his MRI scan, so she
sent an electronic task to healthcare staff. On 25 June, a prison GP booked an
appointment to discuss the results with Mr Williams on 23 July.
Events of 8 July
70. At around 12.45am on 8 July, a PCO responded to a prisoner’s cell bell. At
interview, she told us that as she walked past Mr Williams’ cell, the light was on and
she saw what she thought was a red carpet through the gap in the door before
realising that it was blood. After responding to the cell bell, she returned to Mr
Williams’ cell, where she tried to look through the cell door observation panel but
found that it was covered from inside. She radioed a medical emergency code red
and the Night Security Officer (NSO), who was present on the wing, arrived straight
away. The PCO said that that they could hear Mr Williams groaning and could see
him moving his left arm so waited for additional staff to arrive.
71. A COM and a mental health nurse arrived shortly afterwards and entered the cell.
The nurse noted that Mr Williams had cut one arm and that his cell and body were
smeared with blood. He took his clinical observations and gave him oxygen, but Mr
Williams refused to comply with treatment. He recorded that Mr Williams presented
as under the influence and that officers found evidence of PS use in his cell
(modified vapes). He noted that he washed most of the blood off Mr Williams’ body
but there were no other cells available to which to move him. He also made a
mental health referral.
72. The PCO started ACCT procedures and the COM completed an immediate action
plan. (The ACCT document started was the newer version six, known as “ACCT
v6,” which Dovegate began using on 5 July.) The COM set Mr Williams’
observation requirement at four an hour, with three quality conversations. She also
noted that staff removed items such as plastics, razors and hair clippers from Mr
Williams’ cell for his own safety.
73. At 5.15am, the PCO noted that Mr Williams spent the night awake, crying out in
pain and picking at his cuts. She recorded that his property and cell chair were on
the landing and that his bedding and clothes appeared to have blood on them. She
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
added that Mr Williams had not tried to clean his cell and that blood had spread out
onto the landing.
74. At 7.50am, a PCO completed an ACCT assessment and recorded that Mr Williams
said that he had had conflicting opinions about the pains in his body from mental
and physical healthcare staff. He noted that Mr Williams showed signs of
helplessness and anxiety and said that he had harmed himself to mask his physical
pain as his prescribed medication was not working. He said that he had previously
used illicit substances but would be willing to have a drug test to convince staff that
he was self-harming because of physical pain not drugs.
75. At 10.00am, a COM chaired a first ACCT case review which several members of
prison staff and a mental health nurse attended. She recorded that Mr Williams
said that he had an infection running through his body that was causing him severe
pain and that he was under threat from prisoners on the wing. He said that he was
intent on killing himself because he wanted the pain to stop but had no razors or
other plans on how he would kill himself. Attendees agreed that his observations
should remain the same and two support actions were added to the care plan: for
physical healthcare staff to attend the next ACCT review and for prison staff to find
out who was said to be threatening Mr Williams. They also indicated that a safety
intervention meeting (a multidisciplinary, safety risk management meeting chaired
by the senior management team) was required but there is no record that this took
place.
76. At 10.30am, the mental health nurse recorded that she had attended an ACCT case
review and conducted a mental health assessment. She noted that although Mr
Williams continued to report pain, recent tests and scans had not identified an
underlying cause. She concluded that his presentation was most likely due to his
PS use. That afternoon, the mental health team discussed Mr Williams and
decided that no further input was required.
77. A substance misuse worker reviewed Mr Williams and asked him about his use of
PS. Mr Williams denied taking illicit substances and said that another prisoner had
broken one of his vapes and left it in his cell.
Events between 9 and 10 July
78. At 1.30am on 9 July, a NSO recorded that she had responded to Mr Williams’ cell
bell and that he reported burning everywhere. She contacted a nurse, who
informed her that all of Mr Williams’ recent tests had come back negative and that a
doctor had said there was nothing wrong with him.
79. In the morning, a nurse visited Mr Williams to change his dressings, but he refused.
The nurse noted that Mr Williams displayed bizarre behaviour throughout the
appointment and said that he was being treated for an infected hair follicle in his
head, but the infection had travelled down his back and was trying to reunite with a
‘worm’ behind his ear. He made a mental health referral but did not record this
contact in the ACCT document.
80. In the afternoon, a COM chaired an ACCT case review, which a nurse and a
substance misuse worker attended. She noted that she invited physical healthcare
staff, but they did not attend. She told the investigator that she phoned the
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
healthcare team and was informed that Mr Williams’ tests had come back negative.
She said that he presented ‘brighter’ but did not take the news well and remained
convinced that something was wrong. Mr Williams told attendees that he was still in
absolute agony and felt like cutting to stop the pain but did not have any suicidal
thoughts. The ACCT record shows that they did not consider that he presented a
high risk of suicide or that any items, such as razors, needed removing. It also
shows that they decided to reduce his ACCT observation requirement to two an
hour.
81. Mental health staff discussed Mr Williams at a team meeting that afternoon and
noted that prison staff had reduced his ACCT observations. However, there is no
recorded outcome in response to the mental health referral.
82. On 10 July, a PCO made two entries in Mr Williams’ ACCT record, one at 12.00pm,
and one at 17.15pm. Both entries indicate that he had spoken to Mr Williams and
that he seemed OK.
Events between 11 and 12 July
83. At midday on 11 July, PCO A noted in the ACCT record that Mr Williams had asked
to see a nurse at medication time. That afternoon, a pharmacy technician gave Mr
Williams paracetamol. At 5.00pm, PCO A made an entry in the ACCT record that
Mr Williams seemed OK and had engaged in the regime.
84. At 7.08pm, PCO B looked through the observation panel on Mr Williams’ cell door
to conduct an ACCT check and recorded that she did not see any sign of self-harm
or distress. At 11.00pm, a NSO looked through the cell door observation panel to
conduct an ACCT check, and saw Mr Williams standing by his TV. She told the
investigator that she asked Mr Williams if he was OK and that he nodded.
85. At 11.38pm, the NSO looked through Mr Williams’ cell observation panel to conduct
an ACCT check and saw that he was lying face down behind the door and that the
floor was covered in blood. She immediately radioed a medical emergency code
red and tried to get a response from Mr Williams. PCO C arrived shortly afterwards
and looked through the observation panel. In her prison statement, she said that
the colour of the blood was a much deeper red than it was on 9 July and that she
nervously said, “I’m not going in again and getting blood on my shoes for a second
time this week”. She then looked to see if Mr Williams was breathing, thought that
she saw movement on the right side of his back and tried to get a response from
him by calling out his name and kicking the cell door.
86. In the meantime, a COM radioed PCO C and the NSO in response to the code red
and asked if Mr Williams was responsive. They told the COM that they had seen
Mr Williams breathing and she advised them not to enter the cell, unless necessary.
87. At 11.40pm, staff arrived at the cell. The COM looked through the observation
panel and unlocked the door but had difficulty getting into the cell due to Mr
Williams’ position and the fact that he had placed a chair behind the door. She and
a PCO forced entry into the cell. The COM checked Mr Williams for a pulse and
moved him onto his back in the centre of the cell. A nurse assessed Mr Williams
and found that he had fixed pupils, blue lips and a clammy body.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
88. At 11.43pm, the COM radioed the control room to advise that the medical
emergency code red had changed to a medical emergency code blue (which
indicates that a prisoner is unconscious or has breathing problems). She started
cardiopulmonary resuscitation (CPR) while the nurse attached a defibrillator, but no
shock was advised.
89. At 12.05am on 12 July, the nurse asked staff to stop CPR as it was clear that Mr
Williams had died. The first paramedics arrived at the prison at 12.12am and at the
cell at 12.20am. They conducted an assessment and pronounced at 12.24am that
Mr Williams had died.
Contact with Mr Williams’ family
90. At 7.40am on 12 July, an assistant Director phoned Mr Williams’ father, his named
next of kin, to break the news of his son’s death. At 8.00am, the prison appointed a
family liaison officer (FLO) and a PCO as her deputy. At 10.00am, the FLO phoned
Mr Williams’ father to introduce herself and to offer support. She also offered to
visit him at home, but he declined.
91. Over the next seven days, the FLO made several calls to Mr Williams’ father and
spoke to him once. On 20 July, she phoned Mr Williams’ father, and he told her
that Mr Williams’ mother was taking over as the main point of contact. Later that
day, she contacted his mother by phone to introduce herself and explain her role.
92. The FLO continued to provide ongoing support to Mr Williams’ mother and father
until his funeral, which took place on 12 August. The prison offered a contribution
towards the cost, in line with national policy.
Support for prisoners and staff
93. After Mr Williams’ death, an assistant Director debriefed the staff involved in the
emergency response to ensure that they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
94. The prison posted notices informing other prisoners of Mr Williams’ 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 Williams’ death.
Post-mortem report
95. The post-mortem report established that Mr Williams died from an incised wound (a
cut) to the neck. Toxicology tests detected a type of PS in his blood and urine,
which suggested recent drug use. The pathologist did not consider the PS was the
cause of Mr Williams’ death.
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Management of Mr Williams’ risk of suicide and self-harm
96. Mr Williams’ presented with unusual and challenging issues. Although he strongly
believed that he had physical health problems, it gradually became clear that this
was unlikely to be the case and that something else was going on. Whatever the
cause, it is clear that Mr Williams experienced real and severe distress which led
him to self-harm, although we cannot say if he intended to kill himself on 12 July.
97. Prison staff responded appropriately to Mr Williams’ self-harm and monitored him
under ACCT procedures on six occasions at Dovegate. There was some good
practice. Case reviews indicate that staff were aware of his physical health
concerns and how these impacted on his risk of suicide or self-harm. They
demonstrated understanding and healthcare staff were frequently involved in the
process. However, we had some concerns about the management of the ACCT
process.
Caremaps and care plans
98. Prison Service Instruction (PSI) 64/2011 on safer custody states that completing a
caremap is an integral part of the ACCT process and that it must reflect the
prisoner’s needs, level of risk and the triggers of their distress. The caremap should
set time-bounded actions and be aimed at reducing the risk prisoners present to
themselves. The policy guidance annex to PSI 64/2011, which covers the changes
introduced by ACCT v6, states that support actions should be set to mitigate and
lower risks.
99. All the caremap actions set at ACCT case reviews between 8 December and 15
May were for healthcare staff. There was one care plan support action for prison
staff on 8 July relating to potential threats from prisoners but the other was for
healthcare staff. While we appreciate that Mr Williams told staff that his self-harm
was due to an inability to cope with physical pain, we consider that prison staff
could have done more to mitigate and lower his risk by setting out how they planned
to support him.
100. For example, prison staff did not consider a caremap or support action to involve Mr
Williams’ family in the ACCT process. The annex to PSI 64/2011 states that case
coordinators should identify and discuss potential sources of support for the
prisoner at case reviews. Mr Williams told staff that he had a supportive family on
several occasions and his sister wrote to the Head of Healthcare with concerns
about his wellbeing. However, there is no record that ACCT case coordinators
knew about his sister’s communication with the healthcare team or discussed the
possibility of involving his family in the ACCT process. We consider that family
involvement, which would have required Mr Williams’ consent, may have added an
extra layer of support for Mr Williams and should have at least been explored.
Assessing the level of risk and setting observations
101. PSI 64/2011 requires all staff who have contact with prisoners to be aware of the
triggers and risk factors that might increase the risk of suicide and self-harm and
Prisons and Probation Ombudsman 15
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
take appropriate action. Staff judgement is fundamental to the ACCT system. The
system relies on staff using their experience and skills, as well as local and national
assessment tools, to determine risk. While a prisoner’s presentation is obviously
important and reveals something of their level of risk, it is only one piece of
evidence in assessing risk. Staff should make a considered, objective evaluation of
all risk factors when assessing the risk of suicide and self-harm.
102. Staff appropriately assessed Mr Williams as a high risk of suicide on 8 July and
asked for his case to be escalated to a senior manager for consideration at a safety
intervention meeting. However, we are concerned that there is no evidence that a
safety intervention meeting took place and that at the case review on 9 July,
attendees recorded that such a meeting was not required as Mr Williams did not
present a high risk of suicide or self-harm. We consider that there was no
significant change to suggest that Mr Williams’ level of risk had changed and that
therefore, a safety intervention meeting should have been arranged.
103. We are concerned that despite Mr Williams telling staff on 9 July that he was in
absolute agony and felt like cutting to stop the pain, they did not place more
emphasis on restricting his access to razors. A COM told us that when she asked
Mr Williams what he would do if he was to end his life, he said that in the past, it
had always been cutting. She said that she spoke to wing staff about not allowing
Mr Williams access to razors but that there was no formal restriction. With
hindsight, she said that she should have recorded it in the ACCT document and
wing observation book.
104. We consider that access to razors was a significant risk factor and that staff should
have put more stringent measures in place to restrict his access to them. While we
cannot say whether it would have prevented Mr Williams’ death, it would have made
it more difficult for him to self-harm.
105. The COM told us that they decided to reduce Mr Williams’ observations on 9 July as
he was engaging in the regime, seemed much calmer and had spoken to his father.
We consider that staff placed too much emphasis on Mr Williams’ improved
presentation and assurances that he had no thoughts of suicide. Mr Williams had
been displaying bizarre behaviour for several months and was convinced that there
was something physically wrong with him. He continued to report considerable pain
and said that he still might harm himself. However, there is no record that staff took
account of this, or the possibility of accidental death, when assessing his risk. We
are concerned that staff did not fully consider all Mr Williams’ risk factors and,
consequently, underestimated his risk of serious injury or death.
Recording conversations
106. PSI 64/2011 states that staff must follow the level of conversations stated on the
ACCT document and must record these immediately or as soon as is practical. The
ACCT annex to PSI 64/2011 states that conversations with prisoners should be
meaningful and that staff must be aware of what is on a prisoner’s care plan in
order to understand the context of any conversation. It also notes that the written
summaries also need to be meaningful and sufficiently detailed to convey the key
details of what was discussed.
16 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
107. There is no evidence that staff held good quality conversations with Mr Williams,
and most of their recorded interactions with him were brief. PCO A told the
investigator that on 10 and 11 July, he was redeployed from his normal position in
the security department to work on a wing due to low staffing levels. He said that
Mr Williams did not say much to him and that he felt it was because security staff
wear an all-black uniform, and that Mr Williams might have worried that it would
look to other prisoners as though he was providing information. We are also
concerned that the supervisor daily check section of the ACCT was never
completed.
108. While we appreciate that there may be challenges in engaging prisoners in
meaningful conversations, it is an essential part of the ACCT process and will help
staff to better understand and mitigate a prisoner’s risk. We also consider that
supervisor daily checks are vital in assuring that ACCT records are properly
completed and must be undertaken.
109. We make the following recommendations:
The Director and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide and self-harm in line with national guidelines,
including that staff:
• set effective caremap actions that are specific and meaningful, aimed at
reducing risk, and update them at each review;
• encourage family engagement in the ACCT process, where appropriate, to
assist in managing and reducing the risk of prisoners who self-harm;
• consider all relevant information when identifying a prisoner’s risk factors
and not rely solely on his behaviour and comments;
• remove or restrict prisoners’ access to items such as razors, when they
present a risk of harm by cutting;
• engage prisoners in meaningful conversation and record the outcome of
the discussion in the ACCT ongoing record; and
• complete all aspects of the ACCT document, including the daily
supervisor check in the ongoing record.
110. Dovegate have accepted our previous recommendations intended to address the
quality of ACCT procedures. In response to a previous investigation, the prison told
us in March 2021 that over 90% of operational staff had received suicide and self-
harm training and that prompt sheets had been sent to all ACCT case managers as
a reminder of risk factors to consider when setting actions and observation
requirements. They also said that quality assurance checks would be carried out
monthly.
111. While we recognise that Dovegate has made positive steps to improve ACCT
management, we are concerned that despite having implemented these changes,
our investigation of Mr Williams’ death shows that assessment of risk and setting of
observation requirements continued to be inadequate. We therefore consider that
urgent action is now required to ensure that ACCT procedures improve. We make
the following recommendation:
Prisons and Probation Ombudsman 17
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Director of Custodial contracts should write to the Ombudsman setting
out what is being done to ensure that ACCT procedures at Dovegate improve.
Clinical care
112. The clinical reviewer concluded that although elements of Mr Williams’ clinical care
at Dovegate were of a satisfactory standard, some fell below expectations and his
mental health care was not equivalent to that which he could have expected to have
received in the community.
Mental health care
113. Mr Williams was referred to the mental health team seven times but was only
accepted onto their caseload once, in November 2020. A doctor told the
investigator that on the two occasions he assessed Mr Williams, there was no
evidence of acute mental illness or delusional parasitosis (a mistaken belief that
parasites have entered the body). He said that he concluded that Mr Williams’
unmet physical needs required investigating further on 23 March, as he had active
dermatological lesions with associated pain, and no signs of mental illness.
114. Mental health staff did not re-refer Mr Williams to the doctor or accept him onto their
caseload despite an escalation of his belief that there was something wrong with
him and the fact that physical investigations failed to identify an underlying
condition. The doctor told us that he was not involved in clinical discussion about
Mr Williams beyond 23 March but would have reviewed him again based on the
neurological investigations.
115. The clinical reviewer considered that the focus of mental health staff appeared to be
based on a belief that Mr Williams’ bizarre behaviour and fixed ideas about an
infection running through his body could be attributed to his PS use, which is
something he denied, even when he was seen under the influence. However, a
doctor told us that although Mr Williams did not appear under the influence at any of
his reviews, he continued to present as delusional and report things crawling inside
him. We therefore agree with the clinical reviewer that there was clearly something
happening to Mr Williams that could not be fully explained by his use of PS.
116. The primary care team appear to have been frustrated by what they perceived to be
inaction by the mental health team. A doctor told us his impression of Mr Williams
based on the results of investigations, including blood tests, was significant anxiety
issues manifesting themselves in physical health symptoms. He said that the
primary care team’s concerns centred on Mr Williams’ mental health and that he
was not sure they would have referred him for an MRI had he not requested it.
117. We are concerned that the mental health team did not accept Mr Williams onto their
caseload or consider that they should have referred him for another psychiatric
assessment.
118. The clinical reviewer also considered that as Mr Williams repeatedly harmed himself
by cutting, his risk of accidental death was increased. She noted that although staff
recognised the risk posed by Mr Williams’ actions, the mental health team’s risk
assessment process for identifying prisoners at risk of accidental death due to
persistent self-harm required improvement.
18 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Communication and multi-disciplinary meetings
119. Although mental health staff discussed Mr Williams at MDTs, the clinical reviewer
considered that these meetings were not truly multidisciplinary as input from
primary care and substance misuse staff was minimal. The mental health team
leader told the clinical reviewer that every mental health referral resulted in a face-to
face assessment and discussion at the daily team meeting. However, there was no
process in place for providing feedback to those making referrals or for explaining
the reason for their decisions. A doctor told us that primary care staff discussed
cases at a daily ‘buzz meeting’, but again, these meetings do not appear to have
been multidisciplinary.
120. The Head of Healthcare told us that there was a process for facilitating
multidisciplinary complex case reviews at Dovegate and that arranging it would
have been the responsibility of the mental health team. However, a doctor told us
that there was no such process in place.
121. The clinical reviewer found that the lack of communication between services was a
significant issue and that by acting in isolation, staff missed the opportunity to
formulate a multidisciplinary plan for Mr Williams. We therefore consider that urgent
action is required to ensure that there is a process in place for holding multi-agency
complex case reviews and that all staff are aware of the process and their individual
responsibilities.
Informing prisoners of hospital test results
122. The clinical reviewer considered that healthcare staff should have prioritised
discussing the result of Mr Williams’ MRI scan with him in an attempt to reduce his
anxiety. The prison received the scan result on 14 June, but there is no record that
anyone spoke to him about it. While we are satisfied that a doctor responded
appropriately to the task sent by a nurse on 25 June, we are concerned that the
appointment he booked to speak to Mr Williams was four weeks away. We
consider that as Mr Williams appeared fixated by the idea that there was something
physically wrong with him, he should have received the results sooner. As it was,
prison staff had to tell him, which we consider was inappropriate.
Recording healthcare interventions in ACCT records
123. The ACCT v6 record states that it is mandatory for staff other than prison officers,
such as those from healthcare and education, to complete the relevant summary
section of the ACCT document if they have engaged with a prisoner.
124. When a nurse saw Mr Williams on 9 July, he did not record his interaction in his
ACCT record. This meant there was no record of the bizarre behaviour that Mr
Williams showed throughout the review, that Mr Williams said his infection was
trying to reunite with a ‘worm’, or that the nurse had made a mental health referral.
We consider it crucial that such information is recorded as it may help staff at the
case review to better assess and manage any associated risks. We make the
following recommendation:
The Head of Healthcare should:
Prisons and Probation Ombudsman 19
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• ensure there is a robust system in place for completing complex case
reviews and that the process is communicated effectively to all relevant
members of healthcare staff;
• improve communication between healthcare and mental health services
and ensure that feedback and advice on how to manage complex cases is
provided to those who make referrals;
• conduct a review of the mental health risk assessment process for
identifying prisoners at risk of death by self-harm to ensure that it is fit for
purpose; and
• ensure that the results of hospital investigations are promptly
communicated to prisoners.
125. Dovegate has previously accepted a recommendation intended to address the lack
of healthcare entries in ACCT records. In response to the investigation published in
March 2021, the prison told us that the Head of Healthcare had advised all
healthcare staff by daily meetings and email of the requirement to document entries
in a prisoner ACCT record following intervention. However, we are concerned that
this does not appear to have resulted in any improvement. We therefore consider
that further action is required to ensure that ACCT records are updated. We make
the following recommendation:
The Head of Healthcare should ensure that all staff make an entry in the ACCT
record after intervention with a prisoner to ensure continuity of care.
Emergency response
126. Prison Service Instruction (PSI) 03/2013 on medical response codes requires
prisons to have a two-code medical emergency response system. Dovegate’s local
policy instructs staff to use a medical code blue to indicate an emergency when a
prisoner is unconscious or has breathing difficulties, and a code red when a
prisoner is bleeding or has severe burn injuries. Calling an emergency medical
code should automatically trigger the control room to call an ambulance, and for
healthcare staff to attend with the appropriate equipment.
127. PSI 24/2011 on the management and security of nights states that staff have a duty
of care to prisoners, to themselves, and to other staff, and that preservation of life
must take precedence over usual arrangements for opening cells. It says that
where there is or appears to be immediate danger to life, a single member of staff
can enter the cell alone, after performing a rapid dynamic risk assessment.
128. The NSO responded promptly when she found Mr Williams collapsed on the floor of
his cell, having lost a lot of blood, and called the correct medical code.
129. However, the NSO and PCO C did not enter the cell and waited for other staff to
arrive. The COM said that from the information they provided, she believed that Mr
Williams was alive and could wait for her to arrive with a nurse.
130. PCO C told the investigator that she did not enter the cell with the NSO because
she was concerned that Mr Williams could have had a blade on him. She also said
that they thought they could see Mr Williams breathing.
20 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
131. At the time, PCO C made a comment about not wanting to enter the cell and get
blood on her shoes for the second time in a week. She told the investigator that it
was “stupid comment”, that she “said it without thinking” and that she “did not know
where it came from”.
132. Although we consider that the comment was inappropriate, we are satisfied that it
was not the reason for staff deciding not to enter the cell. Mr Williams had clearly
cut himself and may have been in an agitated state. We accept that it was not
unreasonable in the circumstances for PCO C and the NSO to be concerned that
he might have a blade. We do not, therefore, criticise them for not entering the cell
immediately, although we think that other staff might have made a different decision
in the same circumstances. Nor do we criticise the COM for advising them to wait,
given they had told her that Mr Williams was breathing.
133. We cannot say whether the two minute delay entering the cell and starting CPR
may have affected the outcome for Mr Williams.
Contact with Mr Williams’ family
134. Prison Rule 22 requires that the Governor should inform families at once when a
prisoner dies. PSI 64/2011 requires that wherever possible, the family liaison
officer and another member of staff visit the next of kin or nominated person to
break the news of the death. It notes that time will be of the essence in order to try
to ensure that the family do not find out about the death from another source. If the
next of kin lives a long distance away, consideration must be given to requesting
the assistance of a family liaison officer from the nearest prison.
135. We are concerned that prison staff did not contact Mr Williams’ father until seven
hours after he had died. The FLO told the investigator that she did not phone Mr
Williams straight away as he was in his late 70s and she did not know if he lived
with anyone. She said that she considered asking a family liaison officer to break
the news in person and that she tried to contact a family liaison officer several times
overnight but was unsuccessful. She added that while staff were waiting for a
family liaison officer to arrive at the prison, it reached a stage where she was
concerned that his father would find out of his death by other means. It was at that
point that the Deputy Director advised her to phone Mr Williams’ father.
136. While we appreciate that Mr Williams’ father was elderly and that staff phoned him
before he found out by other means, we consider that they should have notified him
sooner. Mr Williams’ father lived approximately 44 miles from the prison, which we
do not consider was far enough away to warrant them contacting another prison.
We therefore consider that Dovegate should have sent an officer and/or prisoner
manager as soon as possible that morning, rather than waiting for a family liaison
officer. We make the following recommendation:
The Director should ensure that a member of Prison Service staff informs a
prisoner’s next of kin of their death promptly, in line with national guidance.
Psychoactive substances
137. Post-mortem toxicology results found evidence of PS in Mr Williams’ system, but
the pathologist did not consider it caused Mr Williams’ death. We are satisfied that
Prisons and Probation Ombudsman 21
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
the substance misuse team at Dovegate reviewed Mr Williams frequently, created a
care plan, provided appropriate harm minimisation advice about PS and attended
ACCT reviews. We are also satisfied that Dovegate has a comprehensive local
drug strategy.
Learning Lessons
138. We have identified a number of concerns in this report. We consider it is important
that staff learn from our findings. We recommend the following:
The Director and Head of Healthcare should ensure that a copy of this report
is shared with the staff named in this report and that a senior manager
discusses the Ombudsman’s findings with them.
Inquest
139. At the inquest, which took place on 15 April 2024, the Coroner concluded that Mr
Williams died of misadventure.
22 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE