Kevin Delahunty

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Independent investigation into
the death of Mr Kevin
Delahunty, a prisoner at HMP
Risley, on 29 March 2018
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to
any cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
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 Kevin Delahunty died in hospital on 29 March 2018 after he was found on fire in his cell
at HMP Risley on 25 March. He was 40 years old. I offer my condolences to his family
and friends.
Mr Delahunty had a history of substance misuse and there is evidence that he regularly
took drugs, including psychoactive substances (PS), at Risley. The evidence indicates
that before he died, Mr Delahunty tried to smoke PS, which he ignited from the electrical
socket in his cell, and that his clothes accidentally caught fire while he was under the
influence of the PS.
The details of this investigation are truly shocking. It is clear that Mr Delahunty was
determined to continue to use PS despite being fully sighted on the risks. It is extremely
troubling that, although his drug use was very clear to the prison, he was able to obtain PS
with ease.
Earlier this year, I raised my concerns about the availability of illicit drugs at Risley after a
prisoner died in March 2017. It is hard to conclude that the prison’s drug strategy is
working and, while that is the case, deaths such as that of Mr Delahunty are almost
inevitable.
This is a national problem and one which requires new and transformative action from the
centre to help prisons which are clearly struggling with the resources and tools available to
them to make the step change required. I understand that the Chief Executive of HM
Prisons and Probation Service intends to publish national guidance to all prisons on how to
tackle the availability and use of substances, including PS, this autumn. I welcome that.
I acknowledge the very significant steps which Risley has taken since Mr Delahunty’s
death to reduce drug supply and demand. In light of the factors identified above, I make
limited recommendations to them in relation to PS but fear I will be returning to this topic
before long if serious action is not taken by the Ministry of Justice. I hope that there will be
learning from the prison’s actions and that this tragic case will inform the promised strategy
and the 10 priority prisons project which the Prisons Minister launched recently.
This investigation has also highlighted some of the fire safety risks since prisons became
smoke-free environments, and from which other prisons might also learn.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Elizabeth Moody
Deputy Prisons and Probation Ombudsman December 2018
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Contents
Summary ...........................................................................................................................
The Investigation Process ..................................................................................................
Background Information .....................................................................................................
Key Events .........................................................................................................................
Findings .............................................................................................................................
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Summary
Events
1. On 24 March 2016, Mr Kevin Delahunty was remanded into custody, charged with
burglary. On 21 April, he was convicted and sentenced to five years in prison.
After spending time in a number of prisons, he was transferred to HMP Risley on 5
May 2017.
2. Mr Delahunty had a long history of drug misuse in the community and in prison.
Between May 2017 and March 2018, Mr Delahunty was found under the influence
of psychoactive substances (PS) more than 13 times. Staff offered support and
advised him of the dangers of his actions but he refused help.
3. At 5.01pm on 25 March, Mr Delahunty was locked in his cell. At 5.25pm, a support
worker, who worked on the wing landing, smelt burning and found Mr Delahunty on
fire in his cell. A general alarm was raised but no one called an emergency code.
Prison staff responded to the incident, extinguished the fire and removed Mr
Delahunty from his cell. They administered first aid treatment, assisted by
healthcare staff and the fire service when they arrived. An ambulance was called
but took over an hour to arrive. Paramedics then took over the emergency
treatment. They took Mr Delahunty to hospital, where he died of his injuries on 29
March.
4. The plug socket in Mr Delahunty’s cell had been used as an ignition source to light
a flame. A pipe was also found in his cell. The evidence indicates that Mr
Delahunty had been smoking an illicit substance and accidentally set fire to his
clothing while he was under the influence.
Findings
Assessment of risk
5. We found no evidence to suggest that Mr Delahunty’s death was deliberate or that
he wanted to take his life.
6. Although staff at Risley monitored Mr Delahunty four times under suicide and self-
harm prevention procedures, known as ACCT, there were some deficiencies in the
way they did so. There was no evidence that anyone from the healthcare or mental
health team attended the ACCT review on 14 July. Staff did not create an ACCT
caremap after they started ACCT monitoring on 7 September, and Mr Delahunty
was never referred for a mental health assessment, despite staff recognising that
he was at risk of suicide and self-harm.
Psychoactive substances
7. Mr Delahunty had a significant history of misusing drugs, particularly PS. He was
aware of the risks associated with PS but had access to and used illicit drugs at
Risley. Although Risley had a drugs strategy in place, more needed to be done to
eradicate the supply and demand of illicit drugs.
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Clinical care
8. The clinical reviewer concluded that the care that Mr Delahunty received at Risley
was not equivalent to that which he could have expected to receive in the
community. Healthcare staff were unaware that Mr Delahunty had been discharged
from hospital after serious self-harm and they did not therefore contribute to his
care. Healthcare staff did not use recognised tools to assess Mr Delahunty after he
had been identified as using illicit substances. There was a lack of integration and
information sharing between primary healthcare, substance misuse and mental
health services, particularly as Mr Delahunty had a long history of substance
misuse.
Emergency response
9. Staff did not use a medical emergency code after Mr Delahunty was found on fire.
There was also a three-minute delay in calling an ambulance. Although it is unlikely
that this affected the outcome for Mr Delahunty, it could make a crucial difference in
other cases.
Staff support
10. This was an extremely distressing incident for all staff involved and they continue to
require support.
Notifying families of serious illness
11. There was a delay in Risley notifying Mr Delahunty’s next of kin that he was
seriously ill and had been taken to hospital.
Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
risk of suicide or self-harm in line with national guidelines, including that:
• staff have a clear understanding of their responsibilities and the need to record
relevant information about risk;
• prison, healthcare and/or mental health staff work jointly to manage prisoners at
risk of suicide and self-harm; and
• case managers complete caremaps, setting specific and meaningful caremap
actions, identifying who is responsible for them and reviewing progress at each
review.
• The Governor should ensure that prisoners are unlocked during the core day and are
able to engage in full-time purposeful activity.
• The Governor should ensure that staff report and record all instances of illicit drug
misuse and refer prisoners promptly to appropriate prison support services.
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• The Governor and Head of Healthcare should formalise the way that PS incidents are
assessed and the handover of care from healthcare to prison staff including:
• The development and introduction of a PS assessment template for SystmOne,
to include routine recording of National Early Warning Scores (NEWS).
• The way that care and monitoring instructions are communicated to prison
colleagues.
• Notifying Change Grow Live (CGL) when primary healthcare staff are required to
attend a PS incident.
• The Governor and Head of Healthcare should implement a process to ensure that
healthcare staff are notified when prisoners return from hospital and that all discharge
information is shared promptly to inform care planning.
• The Governor and Head of Healthcare should ensure that prison, healthcare and
mental health teams share all relevant information to ensure that the prisoners
identified as being at risk of suicide and self-harm are referred urgently for a mental
health assessment.
• The Governor and Head of Healthcare should ensure that all staff are aware of PSI
03/2013 and radio a medical emergency code in an emergency situation, including in
the event of a fire.
• The Governor should ensure that when a prisoner is taken to hospital seriously ill, their
next of kin is informed without delay, are provided with comprehensive and accurate
information and are kept informed of progress.
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The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Risley informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded but one prisoner was interviewed at the investigator’s instigation.
13. The investigator visited Risley on 4 April. He obtained copies of relevant extracts
from Mr Delahunty’s prison and medical records.
14. NHS England commissioned a clinical reviewer to review Mr Delahunty’s clinical
care at the prison.
15. The investigator interviewed eleven members of staff and one prisoner at Risley in
May, jointly with the clinical reviewer. In addition, he interviewed a mental health
nurse by telephone and wrote to the nurse who attended to Mr Delahunty after the
cell fire to ask about her recollection of what happened. Neither were available to
be interviewed in person.
16. We informed HM Coroner for Greater Manchester West District of the investigation.
He gave us the results of the post-mortem examination and we have sent the
Coroner a copy of this report.
17. One of the Ombudsman’s family liaison officers contacted Mr Delahunty’s family to
explain the investigation and to ask whether the family had any questions or
concerns. They wanted to know whether Mr Delahunty had been prescribed
medication to help with his substance misuse at the time of his death and if he had
raised concerns about being bullied or in debt.
18. Mr Delahunty’s family received a copy of the initial report. The solicitor representing
the family wrote to us raising a number of questions that do not impact on the
factual accuracy of this report. We have provided clarification by way of separate
correspondence to the solicitor.
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Background Information
HMP Prison Risley
19. HMP Risley is a medium security training prison which holds over 1,000 convicted
men. Bridgewater Community Healthcare NHS Trust provides healthcare services
in the prison. There is 24-hour healthcare cover and substance misuse services.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Risley was conducted in June 2016. Inspectors
found that the daily regime was not being delivered. Inspectors were told that
difficulties in industrial relations had led to significant regime cuts in recent months.
Inspectors found that about a third of prisoners remained in their cells during the
working day. They noted that Risley did not provide enough full-time activity to
meet the needs of the population, and attendance and punctuality in learning and
skills activities were poor.
21. There was evidence to suggest that the availability and threat of PS at Risley was
undermining prisoner wellbeing and was a major challenge to the stability of the
prison. 60% of prisoners told inspectors that it was easy to obtain drugs, including
PS, at Risley. Inspectors found that health services were reasonable but the
requirement to respond to PS-related incidents placed significant additional
demands on the services. They noted that substance misuse services were good,
with a range of excellent recovery-focused interventions delivered by a well-
integrated and skilled drugs team. However, inspectors found that too many
prisoners had been maintained on opiate substitution rather than having their doses
reduced, as they should have done.
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 March 2017, the IMB was greatly
concerned with the use of illicit drugs in the prison and the additional problems
caused by PS. They noted that the high levels of substance misuse were a
challenge for staff and that there was a lack of drug dogs. The IMB noted that there
were problems running the prison due to the reduction in staffing levels. They said
that this had an adverse effect on the welfare of prisoners who were locked in their
cells for unacceptable periods.
Psychoactive substances (PS)
23. PS (formerly known as ‘new psychoactive substances’ or ‘legal highs’) are a serious
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
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dangers to physical health, there is potential for precipitating or exacerbating the
deterioration of mental health with links to suicide or self-harm.
24. In July 2015, we published a Learning Lessons Bulletin about the use of PS (still at
that time NPS) and its dangers, including its close association with debt, bullying
and violence. The bulletin identified the need for better awareness among staff and
prisoners of the dangers of PS, the need for more effective drug supply reduction
strategies, better monitoring by drug treatment services and effective violence
reduction strategies.
25. HMPPS now has in place provisions that enable prisoners to be tested for specified
non-controlled PS as part of established mandatory drugs testing arrangements.
Previous deaths at HMP Risley
26. Mr Delahunty was the eighth prisoner to die at Risley since January 2015. Of
these, Mr Delahunty was the third drug-related death.
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Key Events
27. On 24 March 2016, Mr Kevin Delahunty was charged with burglary and remanded
to HMP Leeds. It was not his first time in prison. He had a long history of drug and
alcohol misuse and was known to the community drug and alcohol services. He
had been diagnosed with depression and post-traumatic stress disorder (PTSD)
and was prescribed fluoxetine (for depression, anxiety and to manage his anger)
and inhalers (for asthma).
28. On 21 April 2016, Mr Delahunty was sentenced to five years in prison for burglary.
(His sentence was reduced to four years after he appealed.)
29. On 5 May, he was transferred to HMP Lindholme. During May and June, staff
found Mr Delahunty under the influence of spice, a PS. Staff referred him to the
substance misuse team. Intelligence reports noted his involvement in a number of
incidents, including trading PS on the wing. Mr Delahunty told staff that he had
accumulated debts and was being bullied but he did not name the perpetrators.
Staff instigated a violence reduction investigation and moved Mr Delahunty to a
different wing.
30. On 1 July 2016, Mr Delahunty was transferred to HMP Forest Bank after being
involved in an incident of indiscipline at Lindholme.
31. On 1 August, staff at Forest Bank started ACCT procedures after Mr Delahunty cut
his chest. He said that he had self-harmed to instigate a move to a different wing
because “trouble had followed him” in relation to previous drugs debt and he feared
for his safety. Staff submitted an intelligence report. The next day, after assessing
and reviewing Mr Delahunty’s risk, staff stopped ACCT procedures.
32. On 26 April 2017, staff found Mr Delahunty under the influence of PS. They
submitted an intelligence report and reduced his Incentives and Earned Privileges
(IEP) level to basic. (The IEP scheme is designed to encourage good behaviour
and challenge misbehaviour.) He was also sacked from his cleaning job. Staff
offered to refer him to the substance misuse team but he declined.
Mr Delahunty’s transfer to HMP Risley
33. On 5 May 2017, Mr Delahunty was transferred to HMP Risley.
34. A registered general nurse completed Mr Delahunty’s initial health screen. She
recorded that he was prescribed medication for depression, anxiety and asthma.
Mr Delahunty said that he had no thoughts of suicide or self-harm and had not
harmed himself in prison before (despite his previous self-harm at Forest Bank.)
She also recorded that Mr Delahunty had said that he did not misuse drugs (despite
his long history of substance misuse). She did not refer Mr Delahunty to the mental
health or substance misuse teams. The prison GP subsequently continued Mr
Delahunty’s medication prescriptions.
35. A substance misuse team leader for Change, Grow, Live (CGL), the substance
misuse service provider at Risley, said that CGL saw Mr Delahunty as part of his
reception screening. Mr Delahunty told him that he had completed an opiate
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detoxification programme in prison in 2016, had not used illicit drugs since then and
did not want any further interventions. Mr Delahunty said that he would attend
Narcotics Anonymous after he was released from prison. The substance misuse
team leader said that at the time, CGL used another database. They did not use
SystmOne, the electronic medical record, until October 2017.
36. After completing his reception screening, Mr Delahunty was located on A Wing. At
the time there was no specific induction wing. New receptions went on to any of the
main wings and attended an induction centrally.
37. On 26 May, Mr Delahunty was moved to E Wing after his induction. That day, staff
started ACCT procedures because Mr Delahunty made a ten-centimetre cut to his
forearm. He was transferred to hospital for treatment and returned later that day.
Healthcare staff recorded on SystmOne that they were informed by prison staff that
Mr Delahunty would be staying in hospital overnight. When they tried to find out
which ward he was on, the hospital told them that he had already returned to the
prison. No one from the healthcare team recorded whether Mr Delahunty had a
discharge letter from hospital.
38. The next day, a Custodial Manager (CM) chaired a multidisciplinary first ACCT
review. A mental health nurse, attended. Mr Delahunty said he had inherited a PS
debt from his cellmate. He said that he had self-harmed because other prisoners
were harassing him to clear the debt. He apologised for his actions, and denied
thoughts of suicide or self-harm. He admitted that he had used PS when he first
arrived at Risley. The review panel judged that Mr Delahunty’s risk of self-harm
was low and stopped ACCT procedures. The CM noted that Mr Delahunty was
willing to consider a move to C Wing, the drug recovery unit, but said that he was
settled on E Wing and had no intention of using PS again. The mental health nurse
recorded that Mr Delahunty did not need to be referred to the mental health team
but she would refer him to CGL.
39. After he self-harmed, Mr Delahunty failed to attend a number of healthcare
appointments in late May and early June 2017 to review his wound and remove his
stitches. The records do not explain the reasons for his non-attendance.
40. On 14 July, an Officer started ACCT procedures after Mr Delahunty made a large
cut to his head. A nurse treated Mr Delahunty’s cut after responding to a medical
emergency code red (which indicates blood loss). She recorded brief details on
SystmOne which included his clinical observations of blood pressure, pulse and
oxygen saturation levels (which were all in the normal range). Mr Delahunty said
that he had no suicidal thoughts. Staff completed an ACCT multidisciplinary review
which two members of the healthcare team attended. Mr Delahunty said that he
had self-harmed to instigate a move to a different wing because of drug (PS) debts
he had accumulated. He said that he feared for his and his family’s safety as his
personal address book had been taken from his cell and his family had been
contacted. Mr Delahunty did not name the prisoner to whom he was in debt.
41. The review panel scheduled hourly ACCT observations and staff were required to
have two conversations with him each day. They created a caremap in which they
noted that Mr Delahunty was under threat because of debts he had accumulated
and that a security relocation assessment (move to a different wing) should be
completed. Staff completed a relocation risk assessment and sent it to the security
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team. Mr Delahunty refused to be moved to another wing. Intelligence reports
noted that Mr Delahunty had a history of involvement in the trade and misuse of
drugs in the prison. There is no evidence that staff referred him to the mental
health team for an assessment.
42. The prison GP saw Mr Delahunty on 19 July and continued to prescribe him
fluoxetine. On 25 July, staff stopped ACCT procedures.
43. On 28 July, staff found Mr Delahunty under the influence of PS and radioed a code
blue (indicating that a prisoner is unconscious and/or has breathing problems). A
nurse examined Mr Delahunty and told staff to contact healthcare staff again if his
condition deteriorated. She noted that she would advise the prison GP that Mr
Delahunty’s fluoxetine should be withheld for 24 hours because of the risk of taking
it at the same time as PS. Staff placed Mr Delahunty on a disciplinary charge and
submitted an intelligence report. The prison GP wrote to Mr Delahunty and
reminded him of the dangers of using illicit drugs with prescribed medication, and
the support available to him.
44. On 31 July, while escorting Mr Delahunty to his Thinking Skills Programme (which
aimed to reduce his offending behaviour), staff realised that he was under the
influence of PS. They returned Mr Delahunty to his cell, gave him another
disciplinary charge and submitted an intelligence report. There is no evidence that
the healthcare team was told.
45. On 3 August, staff again found Mr Delahunty under the influence of PS and called a
code blue. When healthcare staff arrived, they found him on the floor, rigid and
they noted that he had vomited. First aid was administered and wing staff were told
to contact healthcare if Mr Delahunty’s condition deteriorated. There is no evidence
that staff referred Mr Delahunty to CGL.
46. Mr Delahunty was subsequently de-selected from the Thinking Skills Programme
because he had missed two consecutive sessions due to being under the influence
of PS. Intelligence noted that there was no evidence to indicate that Mr Delahunty
had been bullied or forced to take illicit substances.
47. On 4 August, a Supervising Officer (SO), Mr Delahunty’s offender supervisor,
chaired an IEP review after Mr Delahunty’s recent PS use. Mr Delahunty admitted
that he had smoked something, which he believed was PS-sprayed paper. The
review panel reduced Mr Delahunty’s IEP level to basic.
48. On the same day, a manager chaired a disciplinary hearing. The manager
recorded that although this was Mr Delahunty’s first disciplinary hearing, staff had
told him that Mr Delahunty had repeatedly been found under the influence of PS.
Staff present said that having to manage a number of PS incidents impacted on
resources, especially giving disciplinary charges. Staff said that when a prisoner
was found under the influence of PS, they would call for healthcare assistance if the
prisoner’s condition looked bad. If a prisoner’s condition appeared less serious,
staff would monitor the prisoner in their cell until their health improved. The officer
said that it usually took around 15 minutes for the effects of the drug to wane. The
manager told every prison officer present that prisoners should be given disciplinary
charges and every incident should be reported to the healthcare team. The
manager referred Mr Delahunty to CGL.
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49. On 11 August, staff reviewed Mr Delahunty’s IEP level again and recorded that he
would remain on basic. Mr Delahunty said that he was fully aware that his negative
behaviour was not acceptable.
50. On 29 August, staff radioed a code blue when they found Mr Delahunty lying on his
cell floor unresponsive. When Mr Delahunty eventually responded, his speech was
slurred and he was unsteady on his feet. Staff noted that it was evident that he was
under the influence of PS. Healthcare staff attended and deemed it unsafe to enter
the cell to examine Mr Delahunty due to the thick haze and smell of an illicit
substance. They instructed prison staff to contact healthcare staff again if his
condition deteriorated. Staff placed Mr Delahunty on a disciplinary charge.
51. On 31 August, before he attended the disciplinary hearing in the segregation unit,
Mr Delahunty complained that he had an open wound. He asked to see a nurse.
The nurse treated his wound. Mr Delahunty told her that he had fallen asleep with
something burning in his hand while he was under the influence of an illicit
substance.
52. At the disciplinary hearing, the manager referred Mr Delahunty to the independent
adjudicator because of his repeated use of PS.
53. Staff started ACCT procedures on 7 September because of Mr Delahunty’s low
mood. The Supervising Officer (SO) also Mr Delahunty’s offender supervisor spoke
to him about his PS use. Mr Delahunty said that his anti-depressant medication
had stopped working, and he asked to see the mental health team.
54. The next day, a CM completed the first ACCT review, assisted by a mental health
nurse. The CM described Mr Delahunty as “hyper” during the review. Mr
Delahunty was angry and frustrated and admitted to using PS. He said his anti-
depressant was not working and he wanted to be closer to his family in Yorkshire.
He said he had had mood swings for the past six years and had previously seen a
psychologist for PTSD. Mr Delahunty said that he was on basic IEP level. The
nurse reviewed instances of Mr Delahunty’s PS use and found that it coincided with
his assertions that his medication did not work.
55. Mr Delahunty said that he had no thoughts of suicide or self-harm but had refused
to eat or drink (since lunch time the previous day). The nurse noted that Mr
Delahunty would be referred to the mental health team and discussed at the next
weekly healthcare referral meeting. (There is no record of what was discussed at
this meeting.) The CM noted that she would contact the Offender Management Unit
(OMU) about the possibility of moving Mr Delahunty to a prison in Yorkshire. A SO
agreed to discuss Mr Delahunty’s sentence plan with him. Mr Delahunty promised
that he would eat and drink over the weekend. The review panel agreed that
scheduled ACCT observations would be set at three conversation each day and
night. However, they did not create an ACCT caremap to record how they would
address their concerns and reduce Mr Delahunty’s risk.
56. On 11 September, the SO completed an ACCT review. A nurse and a member of
the chaplaincy team attended. They noted that Mr Delahunty’s IEP level had been
restored to standard. Mr Delahunty said that the previous week had been “wobbly”
for him but he had no thoughts of suicide or self-harm, was happy to remain on E
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Wing and was aware of the available PS misuse support. ACCT monitoring was
stopped.
57. Prison records for 12 September indicate that the independent adjudicator added
14 days to Mr Delahunty’s sentence because of his continued use of PS.
58. On 29 September, staff offered Mr Delahunty a job for two weeks to keep him busy.
He accepted the job and told staff that he would not let them down.
59. On 17 October, staff found Mr Delahunty on his cell floor, incoherent and being sick.
Healthcare staff examined Mr Delahunty, confirmed he was under the influence of
an illicit substance and told wing staff to contact them again if his condition
deteriorated. (This incident was not recorded in Mr Delahunty’s medical record.)
Staff submitted an intelligence report which noted that there was no evidence to
suggest that Mr Delahunty had been bullied or forced to take illicit substances.
60. On 19 October, staff observed Mr Delahunty retrieving an unauthorised item from
his visitor in the visits hall. Staff searched Mr Delahunty, retrieved the item and the
police were notified. Staff submitted an intelligence report and Mr Delahunty’s IEP
level was reduced to basic for four weeks. He was also placed on closed visits for
three months.
61. Prison records on 25 October note that the independent adjudicator added a further
10 days to Mr Delahunty’s sentence because of his continued use of PS.
62. On 5 November, Mr Delahunty refused to allow staff in his cell. When a CM went to
see him, Mr Delahunty said that he had cut his forehead in protest that he was
facing a disciplinary charge (for threatening to go onto prison netting in an
unauthorised area) which he denied. He was also unhappy about the prison food.
A nurse was unable to go into his cell because his mood was volatile. Mr Delahunty
was conscious, orientated and there were no signs of blood on his head. He said
that he might self-harm to teach the prison a lesson as he was not getting the food
he ordered and felt that foreign national prisoners were treated better. The CM
started ACCT monitoring and placed Mr Delahunty on hourly observations until the
ACCT assessment and review were completed.
63. The next day the CM completed the ACCT assessment and another CM chaired the
first ACCT review. The CM, a member of the chaplaincy team and a nurse
attended. The other CM noted that Mr Delahunty’s mood was good. Mr Delahunty
apologised that he had overreacted the previous day. He said that he had no
thoughts of suicide or self-harm and had stopped his hunger strike. The review
panel noted that Mr Delahunty would remain on basic IEP level for his poor
behaviour but assessed that his risk of self-harm was low and stopped ACCT
procedures.
64. Staff reviewed Mr Delahunty’s IEP level on 15 November and decided that he
should remain on basic. His next IEP review was scheduled to take place in a
week’s time.
65. On 22 November, a SO reinstated Mr Delahunty’s IEP level to standard and
reminded him of the expected levels of behaviour required.
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66. On 23 December, staff found Mr Delahunty under the influence of an illicit
substance. A nurse attended E Wing and recorded that she examined Mr
Delahunty. He was swaying from side to side, his eyes were glazed and his speech
slurred. Mr Delahunty said that he had smoked a ‘spliff’ (which usually means a
rolled cigarette containing cannabis). She told wing staff to monitor Mr Delahunty
and to contact healthcare staff if his condition deteriorated. Although staff placed
Mr Delahunty on a disciplinary charge, the investigator found no record of this
incident on NOMIS or in intelligence reports.
67. At the subsequent disciplinary hearing on 27 December, the case was referred to
the independent adjudicator.
Events from 4 January 2018
68. On 4 January 2018, staff found Mr Delahunty rolling around on his bed,
unresponsive to verbal commands and foaming at the mouth. They radioed a
medical emergency code blue. An improvised smoking pipe and drugs kit were
found in his cell.
69. On 6 January, staff found Mr Delahunty and two other prisoners under the influence
of an illicit substance. After both incidents, a nurse confirmed that Mr Delahunty
had taken an illicit substance. Although no treatment was required, she told wing
staff to contact healthcare staff if his conditioned deteriorated. Staff gave Mr
Delahunty a disciplinary charge, submitted intelligence reports and reduced his IEP
level to basic. Intelligence reports noted that there was no evidence to suggest that
Mr Delahunty had been bullied or forced to take illicit substances. A prison GP
wrote to Mr Delahunty after these incidents to remind him of the risks of using illicit
drugs alongside prescribed medication.
70. On 9 January, Mr Delahunty attended a discipline hearing with an independent
adjudicator and was found guilty of using PS in December 2017. He had extra days
added to his prison sentence as a punishment. He also lost fourteen days of
association.
71. A SO spoke to and reviewed Mr Delahunty’s IEP level on 11 January. Mr
Delahunty said that he was fully aware of the impact and risks of PS. A week later,
Mr Delahunty asked to be referred to CGL for support. He told the SO that he
wanted to stop using PS.
72. On 15 January, staff noted that Mr Delahunty had recently had a mandatory drug
test and had tested positive for PS. On 18 January, the SO spoke to Mr Delahunty
who said that he wanted to stop using PS and had referred himself to CGL. He said
that he was looking forward to resuming open visits with his mother soon.
73. On 24 January, staff were told that a number of prisoners, including Mr Delahunty,
were planning a fight in the exercise yard. They searched his cell and found a
wooden table leg that he intended to use as weapon. Mr Delahunty told staff that
there had been ongoing issues between the prisoners on the north and south side
of E Wing. Staff gave him a disciplinary charge and submitted an intelligence
report. Intelligence reports noted that the majority of incidents in which Mr
Delahunty was involved related to the use of illicit substances. There was
intelligence that he was part of the drug use network on E Wing.
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74. On 27 January, staff recorded that Mr Delahunty had been involved in an altercation
with another prisoner. He refused to return to his cell. He attended an IEP review
where his IEP level was reduced to basic. Intelligence reports suggested that there
had been a significant deterioration in Mr Delahunty’s conduct.
75. On 31 January, prison records note that the independent adjudicator had added a
further 14 days to Mr Delahunty’s sentence because of his continued use of PS.
76. On 1 February, a SO had a long discussion with Mr Delahunty about his behaviour
and reviewed his IEP. Mr Delahunty had failed to attend his education classes from
29 January to 1 February. The SO decided to restore his IEP level to standard. He
explained to Mr Delahunty that he still had outstanding disciplinary charges which
might result in further punishments. Mr Delahunty said that he was aware that staff
were giving him another chance.
77. On 19 February, staff found Mr Delahunty under the influence of an illicit substance.
Healthcare attended his cell, staff submitted an intelligence report, gave Mr
Delahunty a disciplinary charge and reduced him to basic IEP.
78. On 27 February, 19 March and 20 March, staff again raised concerns about Mr
Delahunty’s poor behaviour after it was alleged that he had assaulted another
prisoner. Staff gave him a disciplinary charge placed him on report and submitted
intelligence reports.
79. On 23 March and 24 March, staff found Mr Delahunty under the influence of PS and
contacted healthcare staff who attended both incidents. They recorded that Mr
Delahunty was staggering around in his cell, which they were unable to enter
because of thick smoke fumes. Staff submitted intelligence reports and gave Mr
Delahunty a disciplinary charge.
Events on Sunday 25 March
80. At around 1.45pm, prisoners, including Mr Delahunty, were unlocked for the
afternoon association period (where prisoners mix with other prisoners and spend
time in the exercise yard).
81. CCTV shows Mr Delahunty leaving his cell at around 4.45pm and interacting with
other prisoners before returning, and then leaving his cell a number of times. His
demeanour appeared normal and there was no indication that he was under the
influence of an illicit substance. At 5.00pm, Mr Delahunty returned to his cell for a
final time.
82. CCTV shows that staff checked and locked all cell doors on Mr Delahunty’s landing
at 5.01pm. At 5.09pm, an Officer checked Mr Delahunty by looking through his
observation panel. The Officer raised no concerns.
83. A prisoner lived two cells away from Mr Delahunty’s cell. A care support worker
was conducting an ACCT constant observation watch on the prisoner and so was
outside his cell door. Both the care support worker and the prisoner told the
investigator that at around 5.20pm, they heard Mr Delahunty shouting. They were
not concerned as this was a frequent occurrence. The care support worker said
that the shouting stopped and started repeatedly for a few seconds. A few minutes
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later, the prisoner and the care support worker both realised that they could smell
something burning.
84. The prisoner believed that Mr Delahunty had used PS and asked the care support
worker to check on his wellbeing. He told the investigator that when you take PS,
you become unaware of your surroundings and become physically frozen, with
limited bodily movement. The prisoner said that he was therefore concerned for Mr
Delahunty.
85. The care support worker looked through Mr Delahunty’s cell door observation
panel. She said that he was standing up, with his back facing the door, and was on
fire with flames rising from the back of his t-shirt. He was not making any noise and
there was no smoke in the cell. To raise the alarm quickly, she immediately
pressed the emergency general alarm button outside Mr Delahunty’s cell (recorded
in the control room log at 5.25pm) and ran to the staff office at the end of the
landing to raise the alarm.
86. Officer A and Officer B ran to the office cupboard to obtain the fire kit which
included Respiratory Protection Equipment (RPE) - protective smoke hoods and the
cell inundation key (a special key that opens a small porthole in the cell door to
enable a fire hose to be put through to extinguish in-cell fires). Officer C and Officer
D ran to Mr Delahunty’s cell. They arrived within 21 seconds of the alarm being
raised.
87. Officer D looked through Mr Delahunty’s cell observation panel and saw Mr
Delahunty sitting on his bed, on fire. Neither the cell nor its contents were on fire
and there was minimal smoke. This meant that the domestic smoke detector, which
was positioned on the ceiling of the landing outside the entrance of the cell door,
was not automatically activated. Mr Delahunty was not making any noise, was
completely still and did not try to extinguish the fire. Officer D immediately retrieved
the water hose reel, which was at the end of landing almost opposite Mr
Delahunty’s cell door. While he did this, Officer C tried to break the observation
panel with his baton to access the cell quickly to use the firehose. However, Officer
A and Officer B arrived at 5.26pm in RPE and opened the fire access porthole with
the inundation key.
88. A CM who had arrived instructed the staff to enter the cell as soon as it was
deemed safe. At 5.27pm, Officer A and Officer B put smoke hoods on, placed the
firehose through the inundation porthole and pointed it into Mr Delahunty’s cell and
extinguished the fire. Officer Braddock said that he had initially shouted verbal
commands and instructions for Mr Delahunty to follow but he did not respond. He
noted that Mr Delahunty’s torso and trousers were on fire.
89. The CM radioed the control room and requested healthcare, an ambulance and the
fire brigade, recorded in the control room log at 5.28pm. At the same time, Officer
A and Officer B entered Mr Delahunty’s cell.
90. The officers noted that Mr Delahunty had significant burns to his body and that his
upper clothing was barely visible as a result of the fire. They noted that he was
conscious but unresponsive and appeared unable to comply when he was given
instructions and when the officers tried to move him. Officer A, Officer B and Officer
D lifted Mr Delahunty out of his cell and placed him on the wing landing. The
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officers continued to spray water into Mr Delahunty’s cell after which they closed the
cell door. Officer Mills placed wet blankets on Mr Delahunty and staff sprayed him
with water.
91. A nurse arrived on the wing landing at 5.30pm. She was the only nurse available
as there were two other ongoing emergencies at that time. She noted that Mr
Delahunty had third degree burns to the right side of his face, groin area, both arms
and the back and front of his upper torso. She gave him oxygen and monitored
him. She noted that Mr Delahunty’s temperature and heart rate were extremely
high. The CM noted that as Mr Delahunty became more aware of what had
happened he became distressed, started talking and pleading that he was in pain.
92. The fire brigade staff arrived at 5.46pm and took over care. Over a period of
around 35 minutes, Mr Delahunty’s temperature slowly reduced and staff stopped
dousing him with water. The fire brigade and prison staff applied cling film to Mr
Delahunty’s burns and wrapped blankets around him. CCTV shows that a fire
service officer opened Mr Delahunty’s cell door at 5.49pm and a small amount of
smoke came out of the cell, which activated the smoke detector.
93. Despite a number of calls to the emergency services for an ambulance, there was a
significant delay in an ambulance arriving because of other emergencies in the
community. Paramedics arrived at the prison at 6.26pm, and transferred Mr
Delahunty to hospital at 6.43pm.
94. Staff found an improvised pipe in Mr Delahunty’s cell and noted that he had used
the cell sockets to create a flame to light a PS pipe.
95. As a result of his extensive burns, Mr Delahunty developed multi-organ failure. He
failed to respond to intensive care treatment and his condition deteriorated. He died
on 29 March.
Contact with Mr Delahunty’s family.
96. On 25 March, prison records noted that between 6.30pm and 7.10pm, the prison
control room received a total of three telephone calls from Mr Delahunty’s sister and
mother. They said that they had been told through social media that Mr Delahunty
had been taken to hospital after an incident. The prison said that it was unable to
provide any information to the callers for security reasons.
97. A CM started her duty as the officer in charge of the prison at around 7.30pm and
received a handover from another CM. She was aware that it had been a busy
evening with two concurrent emergencies, including Mr Delahunty, that required
hospital admissions. She said that around 8.50pm she was contacted by the
bedwatch prison officers who had escorted Mr Delahunty to hospital. They told her
that Mr Delahunty’s mother had phoned the hospital and wanted to visit her son. At
this point, she said she did not know whether or not the prison had notified Mr
Delahunty’s family that he was hurt and in hospital. She told the bedwatch staff to
tell Mr Delahunty’s mother if she phoned again or tried to visit that she should
contact her at the prison. She contacted the duty governor who said that he would
speak to Mr Delahunty’s mother in the morning after the hospital had updated him.
She said that Mr Delahunty’s mother phoned the prison at around 8.50pm, and she
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told her that her son had been taken to hospital injured and that the duty governor
would speak to her in the morning.
98. At 9.30am on 26 March, the hospital doctor updated a nurse about Mr Delahunty’s
condition. Mr Delahunty had been placed in a chemically-induced coma because
he had 28% third degree burns. The doctor said that he was in a critical condition
but might survive. The duty governor phoned Mr Delahunty’s sister and updated
her.
99. Two prison managers in the safer custody team were appointed as prison family
liaison officers. At 10.30am, they called Mr Delahunty’s sister who agreed to meet
them at the hospital on 27 March. When they met, Mr Delahunty’s sister told them
that she had received phone calls and texts asking her to pay money into a bank
account, details of which she was given. The family liaison officers submitted an
intelligence report.
100. Risley maintained contact with Mr Delahunty’s family, and in line with national
instructions, they contributed to the costs of the funeral.
Support for prisoners and staff
101. A CM debriefed the staff who had been involved in the emergency response after
Mr Delahunty was transferred to hospital on 25 March. He spoke separately to the
care support worker and the prisoner. All staff and prisoners were offered the
support of the prison’s care team.
102. Risley posted notices informing other prisoners of Mr Delahunty’s death, and
offering support. Staff reviewed all prisoners subject to suicide and self-harm
prevention procedures in case they had been adversely affected by Mr Delahunty’s
death.
Post-mortem report
103. We are still awaiting the results of a post-mortem examination. The toxicology
report confirmed that PS was found in Mr Delahunty’s system. A makeshift pipe
found in Mr Delahunty’s cell at the time of his death was found to contain PS.
Inquest
104. An inquest was concluded in November 2024 which concluded that Mr Delahunty’s
death was due to misadventure. The coroner gave a verdict in which it was
recorded that Mr Delahunty was found in his cell with his upper body in flames. The
smoke alarm did not sound at this time. Prison officers extinguished the fire. Mr
Delahunty was transported by ambulance to hospital where he died from his
injuries. The use of spice was prevalent and unprecedented at the time of Mr
Delahunty’s death. There was inadequate communication about Mr Delahunty’s
drug misuse between healthcare, the prison and CGL which may have led to the
questionable management of Mr Delahunty’s substance abuse. Furthermore, the
prison had knowledge of the unsafe ignition method.
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Findings
Assessment of risk
105. Mr Delahunty had a number of risk factors, including a history of self-harm,
substance misuse, depression, anxiety and anger issues. He was prescribed
antidepressants. He was difficult to manage because his use of PS resulted in poor
behaviour.
106. Mr Delahunty was monitored under ACCT procedures for brief periods four times
between his arrival at Risley in May 2017 and his death.
107. PSI 64/2011 on safer custody requires all staff in contact with prisoners to be aware
of the risk factors and triggers that might increase prisoners’ risk of suicide and self-
harm, and to take appropriate action. The PSI states that staff should decide at the
first case review whether to refer someone for mental health or substance misuse
support services and ensure that the referral(s) are made.
108. In Mr Delahunty’s case, healthcare and mental healthcare team staff attended all
four first ACCT reviews held. Although they identified his risk factors, they failed to
refer him for a mental health assessment or to provide consistent information to
CGL about his substance misuse.
109. The PSI requires that caremaps reflect a prisoner’s needs, level of risk and the
triggers of their distress. They should aim to address issues identified in the ACCT
assessment interview. They must be tailored to meet prisoners’ individual needs
and reduce risk. They must be time-bound and say who is responsible for
completing the action.
110. At the ACCT review on 18 July, the panel noted that Mr Delahunty had been
referred to the mental health team. This was not recorded or updated on the
caremap nor recorded on SystmOne. There was no evidence that Mr Delahunty
saw a mental health nurse. Following Mr Delahunty’s self-harm on 7 September,
staff failed to update the caremap and to note a number of concerns discussed that
affected his risk of self-harm, including being far from his family, his PS use and his
sentence progression. The caremap also failed to note that they had referred Mr
Delahunty to the mental health team’s weekly referral meeting.
111. Although Mr Delahunty self-harmed at Risley, there is no evidence that he had
thoughts of suicide at Risley or that his self-harm was an attempt to take his life.
We found no evidence that Mr Delahunty intended to set fire to himself on 25
March. We make the following recommendation:
The Governor and Head of Healthcare should ensure that staff manage
prisoners at risk of suicide or self-harm in line with national guidelines,
including that:
• staff have a clear understanding of their responsibilities and the need to
record relevant information about risk;
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• prison, healthcare and/or mental health staff work jointly to manage
prisoners at risk of suicide and self-harm; and
• case managers complete caremaps, setting specific and meaningful
caremap actions, identifying who is responsible for them and reviewing
progress at each review.
Allegations of violence and intimidation
112. PSI 64/2011 sets out how violent prisoners should be managed. It says that all
verbal and physical acts of violence must be challenged, appropriate sanctions for
perpetrators applied robustly, fairly and consistently, and victims supported and
protected. Being a victim of intimidation or violence is a recognised risk factor for
suicide and self-harm.
113. Mr Delahunty twice reported that he had been bullied by other prisoners at Risley
due to debt that he had accumulated from his illicit drug use (27 May and 14 July
2017). However, there was no evidence before his death that he was being bullied,
although intelligence reports submitted after his death indicated that he might have
been in debt to other prisoners for drugs.
114. There is evidence that Mr Delahunty was heavily involved in the illicit drug trade in
prison and in acts of violence. While there was no evidence that Mr Delahunty had
been bullied into taking drugs, he was a victim of drug debt. However, this did not
stop him taking PS. Staff at Risley told the investigator that Mr Delahunty was a
likeable prisoner who was hooked on taking drugs, and this had an adverse effect
on his behaviour.
115. We are satisfied that there was no evidence available before Mr Delahunty’s death
that would have given staff reason to monitor him as a victim under anti-bullying
procedures. We make no recommendation.
Psychoactive substances at Risley
116. The investigator interviewed the Head of Healthcare, the Head of Security, the
Head of Violence and the Head of Safer Custody. All recognised the significant
challenge of PS use at Risley over the previous 12-18 months. They said that this
had had an impact on prison and healthcare staff’s morale, on resources and on the
delivery of the regime. They said that there had sometimes been daily PS
incidents, and on one occasion, there had been 18 recorded incidents in a day,
coupled with violence and safer custody concerns. It was identified in 2017 that
drones were one of the main ways that drugs were coming into Risley, which had
the fourth highest reported drone activity in prisons in England and Wales.
117. We examined Risley’s PS and substance misuse strategy, which was reviewed in
January 2018, and concluded that there were reasonable measures in place to
respond to the challenges of illicit substances, including PS. In the past twelve
months, the Governor has adopted various measures to combat the supply,
demand and management of prisoners suspected of taking illicit drugs, particularly
PS. While these measures have not eradicated the supply and demand, they have
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reduced the level of recorded PS incidents. Some of the measures implemented in
the last twelve months include:
• A weekly multidisciplinary Safety Intervention Meeting (SIM) to discuss prisoners
at risk, those who have any complex needs and the use of PS in the prison.
• Putting grills over all windows in D and E Wing, identified as the main areas of
drone activity, to prevent prisoners accessing packages dropped by drones.
• A multi-agency security project at regional level to review drone activity.
• Photocopying prisoners’ mail in response to an increase in PS sprayed on
letters. Staff also telephone solicitors to confirm that all Rule 39 (legally
privileged confidential mail) is legitimate.
• CGL-led initiatives, including a brief screening and awareness about the
dangers of PS in the Welcome and Reception centre, trained peer mentors to
work in the welcome centre, use of a weekly family group worker and
psychoactive substances specialist, pop-up PS awareness sessions delivered
on wings, wing observations, intelligence reports and PS information leaflets for
prisoners.
• A handover form for rapid communication to the CGL team from healthcare staff
if prisoners have been using PS.
• Introduction and use of a passive search dog which is based in the prison, works
alongside regional dog and search teams.
• Improved links with the police for intelligence-led searches.
• Regular regional meetings of the Heads of Security to discuss trends and issues
involving PS supply.
• A number of Safer Custody prisoner roadshows to deal with debt and reinforcing
their violence reduction policy.
118. Although we consider that Risley have responded proactively to the evolving
challenges of PS supply and demand, we recognise that this needs to continue. Mr
Delahunty was apparently able to obtain and use PS without difficulty at Risley and
continued to do so despite being made aware of the dangers, losing privileges and
having additional days added to his sentence.
119. It is clear, however, that more needs to be done to reduce both the supply and the
demand for PS at Risley. We note that there is evidence that prisoners are more
likely to use PS when they are subject to a reduced regime and spend long periods
in their cells. We therefore make the following recommendations:
The Governor should ensure that prisoners are unlocked during the core day
and are able to engage in full-time purposeful activity.
The Governor should ensure that staff report and record all instances of illicit
drug misuse and refer prisoners promptly to appropriate prison support
services. Psychoactive substances across the prison estate
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120. The PPO’s Learning Lessons Bulletin on PS, issued in July 2015, highlighted that
PS was then a source of increasing concern in prisons. Not only does PS use have
a profoundly negative impact on physical and mental health, but trading in these
substances can lead to debt, violence and intimidation. Mr Delahunty’s death is a
clear example of how dangerous PS is and illustrates why prisons must do all they
can to eradicate its use.
121. Both HM Inspectorate of Prisons and the Independent Monitoring Board have
expressed concern about the ready availability of drugs at Risley and it is obviously
a cause for concern that Mr Delahunty was apparently able to obtain and use illicit
drugs so readily at Risley.
122. Risley is not alone in facing this problem – it is a serious problem across much of
the prison estate. Individual prisons are for the most part doing their best to tackle
the problem by developing their own local drug strategies. However, in the PPO’s
view there is now an urgent need for national guidance to prisons from HMPPS
providing evidence-based advice on what works.
123. In a recent investigation, we recommended that the Chief Executive of HM Prison
and Probation Service (HMPPS) should issue detailed national guidance on
measures to reduce the supply and demand of drugs, including PS, in prisons. The
Acting Ombudsman also wrote to the Prisons Minister raising her concerns about
the high number of drug-related deaths she was investigating. The Chief Executive
has told us that HMPPS plans to issue a national drug strategy in the autumn of
2018. We therefore make no further recommendation.
124. Nevertheless, the scale of the challenge facing prisons in addressing the risks of PS
needs to be properly acknowledged. It is simply not acceptable that prisons are
expected, at worst, tacitly to accept the kinds of behaviours which led to Mr
Delahunty’s horrific death, and, at best, to deploy interventions which will only ever
achieve limited success. This is a national problem which needs national solutions
and an open acknowledgement of the resources required to address it effectively.
Clinical care
125. The clinical reviewer, considered that the standard of care Mr Delahunty received in
prison was not equivalent to that which he could have expected to receive in the
community. She noted that there was a lack of integration and information sharing
between primary healthcare, substance misuse and mental health services,
particularly as Mr Delahunty had a long history of substance misuse.
Responding to prisoners under the influence of illicit substances
126. There is significant evidence that Mr Delahunty’s illicit drug use on the day of his
death was not an isolated incident, and that he regularly misused drugs at Risley in
the period before his death. He made candid admissions to prison staff about his
history of drug use. On occasion, he told staff that he would engage with substance
misuse recovery groups at the prison but he did not do so and he continued using
drugs.
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127. Healthcare staff attended Mr Delahunty’s cell a number of times after he was found
under the influence of PS. Some of these were serious incidents and were
recorded as code blue emergencies. The clinical reviewer noted that on most
occasions, healthcare staff examined Mr Delahunty and recorded their clinical
observations. However, the National Early Warning Score (NEWS) system (a tool
to identify those whose health is deteriorating) was not used and the consistency
and detail of recording Mr Delahunty’s clinical observations was variable. When
healthcare staff assessed Mr Delahunty after such incidents, they handed his care
back to wing officers with instructions to monitor him, and to call healthcare again if
his condition deteriorated. We are concerned that this could mean that care was
handed back to non-clinical staff, with little specific direction about what signs of
deterioration they should look out for.
128. We are also concerned that when Mr Delahunty was seen after using PS, there is
no indication on SystmOne that healthcare staff had referred him to CGL, the
substance misuse service. The CGL team leader, said that the first record of CGL
being told of Mr Delahunty’s PS use was in January 2018. Until then, CGL had not
been aware of the nature and extent of Mr Delahunty’s illicit drug use or how often
the healthcare team had been called to see him. When CGL received a referral in
January 2018, he said that Mr Delahunty declined support.
129. CGL’s lack of involvement in Mr Delahunty’s care is extremely disappointing,
especially as wing and healthcare staff were fully aware of the extent of his illicit
substance misuse (PS) at Risley. It is shocking that over an eight-month period
(May – December 2017), Mr Delahunty’s many instances of PS use failed to trigger
CGL’s support, and that existing systems for multi-disciplinary information sharing
did not work. Given the safety risks associated with PS use, this is unacceptable
and a robust information sharing system and process for joint risk assessment is
urgently needed.
130. The CGL team leader told us that at the time of Mr Delahunty’s death, CGL had
only used SystmOne for a few months, and that this was beginning to improve
information sharing and referrals to CGL. Nonetheless, it is clear that a formalised
process for recording and sharing information about the care of prisoners found
under the influence of illicit substances is required. We make the following
recommendation:
The Governor and Head of Healthcare should formalise the way that PS
incidents are assessed and the handover of care from healthcare to prison
staff including:
• The development and introduction of a PS assessment template for
SystmOne, to include routine recording of National Early Warning Scores
(NEWS).
• The way that care and monitoring instructions are communicated to prison
colleagues.
• Notifying Change Grow Live (CGL) when primary healthcare staff are
required to attend a PS incident.
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Mental health support
131. Mr Delahunty had a history of depression and anxiety, for which he took anti-
depressants. He self-harmed seriously enough to require hospital admission in
May 2017 but the healthcare team was unaware of his discharge from hospital and
unable to follow up on any immediate care. It is essential that healthcare staff are
aware of a prisoner’s discharge from hospital, especially after serious self-harm so
that hospital discharge advice or appropriate care plans can be implemented. The
clinical reviewer noted that this was a missed opportunity for staff to have
completed a mental health assessment after a period of crisis. Mr Delahunty then
failed to attend several healthcare appointments to dress his wound and remove his
stitches, and the healthcare and mental healthcare teams missed a further
opportunity to contribute to his wellbeing.
132. While Mr Delahunty did not consistently show signs of mental ill health at Risley, he
self-harmed, was monitored under ACCT procedures a number of times and
showed signs of frustration, anxiety and anger, all of which should have prompted
staff to refer him for a mental health assessment. While we acknowledge that a
member of the mental and healthcare team saw Mr Delahunty at the first ACCT
reviews, none completed a mental health assessment despite his clear risks. Early
mental health intervention might have supported Mr Delahunty through periods of
crisis. We make the following recommendations:
The Governor and Head of Healthcare should implement a process to ensure
that healthcare staff are notified when prisoners return from hospital and that
all discharge information is shared promptly to inform care planning.
The Governor and Head of Healthcare should ensure that prison, healthcare
and mental health teams share all relevant information to ensure that the
prisoners identified as being at risk of suicide and self-harm are referred
urgently for a mental health assessment.
Detection and extinguishing of cell fires
133. The Crown Premises’ Fire Inspector, HMPPS (Health, Safety, Fire & Litigation
Cluster for the North-West Region) and the fire service also investigated the
circumstances of Mr Delahunty’s death. The fire service report noted the ignition
source of the fire in Mr Delahunty’s cell as “smoking materials” and the main cause
of fire as “Careless handling - due to sleep or unconsciousness”.
134. The HMPPS Health, Safety and Fire report noted that the staff acted swiftly and in
the best interest of Mr Delahunty’s safety to remove him from his cell. It described
the fire as unusual as no items other than the Mr Delahunty’s clothing was alight. It
noted that the domestic smoke detectors did not activate at the time of the fire.
However, when they were tested immediately after the incident, they operated
effectively and were noted to have been installed in the correct position in line with
fire safety instructions.
135. There was evidence of the use of illicit smoking paraphernalia in the cell, including
two metal foil strips in the electrical socket, a plastic spoon with a gel-type
substance and an improvised pipe. The report noted the use of metal foil strips in
electrical sockets, placed in a gel to heat up to a temperature sufficient to cause a
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synthesis in the gel to provide an ignition source. It noted that this technique had
been seen in a number of cell fire incidents across the prison estate and this was
the most likely ignition source in this incident.
136. The report recommended that the Governor should investigate the use of PS in the
prison. It also recommended that prison bedding should be urgently reviewed as, if
Mr Delahunty’s bedding had not been issued by the prison in line with fire safety
standards, the fire might have “been more significant”.
137. E Wing has not yet been upgraded with in-cell Automatic Fire Detection. The report
noted that smoke detectors were outside cells and were domestic smoke alarms
approved by the National Fire Safety Team. They are visually checked daily and a
functional check is carried out on a monthly basis.
138. Before Mr Delahunty’s door was opened, no smoke had escaped onto the landing
area which explained why the smoke detector was not activated during the incident.
The fire report noted that Risley might want to seek guidance from the National Fire
Safety Section about the siting of smoke detectors.
139. We make no recommendations on fire safety as we are aware that the Governor
will need to address the recommendations in all the fire investigation reports.
Emergency response
140. Staff attended Mr Delahunty’s cell promptly and assessed the situation
appropriately and in line with their safety policy and training. They ensured that the
fire was extinguished before opening the cell door. They removed Mr Delahunty to
a place of safety in less than four minutes of the alarm being sounded and
administered first aid immediately.
141. In line with Prison Service Instruction 03/2013, staff should have used a medical
emergency code when they found Mr Delahunty. This would have triggered the
control room to call an ambulance immediately. Instead, a support worker pressed
the general alarm button after she discovered Mr Delahunty on fire, which meant
that an ambulance and the fire service were only called after a CM radioed the
control room.
142. We are concerned that the support worker and the first responding officers did not
radio an emergency code, even though staff had seen Mr Delahunty on fire and
knew that this was not a false alarm. Mr Delahunty received prompt emergency first
aid and it is unlikely that the three-minute delay in calling an ambulance would have
changed the outcome for him. However, such a delay could be critical in other life-
threatening situations. We make the following recommendation:
The Governor and Head of Healthcare should ensure that all staff are aware of
PSI 03/2013 and radio a medical emergency code in an emergency situation,
including in the event of a fire.
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Staff support
143. This was an extremely distressing incident for all staff involved and the competent
handling of it is testament to their training and skills. Without exception, all of the
staff interviewed agreed that they had been very well supported by colleagues and
managers after the incident. It was clear that some of the interviewees were still
coming to terms with the events of 25 March and had been significantly affected by
them. A post-incident group support session was also arranged.
144. However, a number of staff said that they found it uncomfortable to speak in a
group situation. Individual support and counselling had also been offered to staff.
Staff involved have undoubtedly found peer support very useful, but it was apparent
from the investigation interviews that some staff are still very traumatised by the
incident. While Risley has acted in line national instructions to support staff and we
do not make a recommendation, we draw this issue to the Governor’s attention as
he might exceptionally wish to make further support available to staff.
Notifying families of serious illness
145. Prison Rule 22(1) requires the Governor to tell a prisoner’s next of kin or spouse if
the prisoner dies, becomes seriously ill or sustains any severe injury. In this case,
Mr Delahunty’s family should have been told when he was taken to hospital
seriously injured. This did not happen.
146. Instead his family learnt from other sources – presumably via a prisoner or
prisoners using illicit mobile phones - that he had been involved in a serious
incident and subsequently that he had been transferred to hospital. They tried a
number of times to find out what happened by contacting the prison and hospital.
Yet, Risley did not speak to his family until 8.50pm, over three and a half hours after
the incident.
147. While it is important that the prison maintain strict security procedures in such
circumstances, it is equally important that they contact a prisoner’s next of kin
promptly to avoid them hearing distressing news from another source. We make
the following recommendation:
The Governor should ensure that when a prisoner is taken to hospital
seriously ill, their next of kin is informed without delay, are provided with
comprehensive and accurate information and are kept informed of progress.
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