Kevin McDonnel

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Kevin McDonnel,
a prisoner at HMP Nottingham,
on 29 September 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Kevin McDonnel was found hanging in his cell on 29 September 2022 at HMP
Nottingham. Staff tried to resuscitate him but were unsuccessful. He died on the
anniversary of his father’s death. Mr McDonnel was 47 years old. I offer my condolences
to his family and friends.
Mr McDonnel was the second person to take his life at Nottingham in three years.
Mr McDonnel was being monitored using suicide and self-harm prevention procedures
(known as ACCT) when he died. My investigation found that some aspects were managed
well but others less so, including lack of consistency in the staff attending case reviews
and failure to hold a case review ahead of the anniversary of Mr McDonnel’s father’s
death, which was a known trigger date.
In their last inspection of Nottingham in 2022, HM Inspectorate of Prisons identified that
quality of ACCT documents varied greatly and many prisoners at risk of self-harm felt
uncared for.
The clinical reviewer found that the mental health care Mr McDonnel received at
Nottingham was not equivalent to that which he could have expected to receive in the
community. She found that due to severe staff shortages in the mental health team, Mr
McDonnel did not get the expected level of care.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman December 2023
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
Summary
Events
1. On 7 July 2022, Mr Kevin McDonnel was remanded to HMP Nottingham charged
with assault.
2. On the morning of 30 July, an officer started suicide and self-harm monitoring
(known as ACCT) after Mr McDonnel cut his arm with a razorblade. Mr McDonnel
said he had self-harmed because he was being targeted by other prisoners who
were calling him a paedophile. He said he wanted to move to another wing.
3. Staff moved Mr McDonnel from E Wing to C Wing, and then to B Wing. However,
he said that he continued to feel under threat. He asked to move to F Wing, the
induction wing, but staff told him that this was not possible. He then said he would
hang himself, so staff placed him under constant supervision. He was under
constant supervision from 19 to 22 August and again from 26 August to 4
September.
4. Staff could find no evidence that Mr McDonnel was under threat, and there were
concerns that he was paranoid. A nurse noted that Mr McDonnel said he heard
prisoners shouting things about him which no one else heard.
5. On 5 September, Mr McDonnel told staff that the anniversary of his father’s death
was on 29 September. This was recorded in his ACCT document as a trigger date.
6. On 28 September, Mr McDonnel was scheduled to have an ACCT review.
However, due to a prison-wide training day, this review was moved to the next day.
7. At 11.22am on 29 September, while delivering Mr McDonnel’s lunch, an officer saw
Mr McDonnel on the floor of his cell with a ligature around his neck. The officer
shouted for staff assistance and entered the cell. When more staff arrived, they cut
the ligature and started cardiopulmonary resuscitation (CPR).
8. Staff and ambulance paramedics were unable to resuscitate Mr McDonnel and at
11.42am, a paramedic pronounced that Mr McDonnel had died.
Findings
9. Staff held frequent, multidisciplinary ACCT reviews and recorded a clear care plan.
However, the ACCT case coordinator changed far too frequently, as did the case
review attendees, which meant that there was not a consistent group of people
managing and inputting into Mr McDonnel’s ACCT. Also, more effort should have
been made to hold a case review before Mr McDonnel’s known trigger date to
reassess his risk.
10. The clinical reviewer found that the mental health care Mr McDonnel received at
Nottingham was not equivalent to that which he could have expected to receive in
the community. She found that, due to severe staff shortages within the mental
health team, Mr McDonnel did not get the level of care that would have been
expected given his risk level and needs.
Prisons and Probation Ombudsman 1
Recommendations
• The Governor should ensure that staff manage ACCT procedures in line with prison
policy including that:
• There is a consistent ACCT case coordinator and case review team
wherever possible.
• A case review is held shortly before an identified trigger date (such as the
anniversary of a death or anniversary of the offence).
• The Head of Healthcare should ensure there is adequate staffing within the mental
health team to allow the team to provide the service for which it is commissioned.
2 Prisons and Probation Ombudsman
The Investigation Process
11. HMPPS notified us of Mr McDonnel’s death on 29 September 2022.
12. The investigator issued notices to staff and prisoners at HMP Nottingham informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
13. The investigator visited Nottingham on 15 and 16 December. He obtained copies of
relevant extracts from Mr McDonnel’s prison and medical records.
14. The investigator interviewed seven members of staff from Nottingham. He
interviewed four in person while at Nottingham on 15 and 16 December.
15. NHS England commissioned an independent clinical reviewer to review Mr
McDonnel’s clinical care at the prison. The clinical reviewer conducted joint
interviews with the investigator, interviewing three members of healthcare staff via
video call on 14 December, 23 January and 9 February 2023.
16. We informed HM Coroner for Nottingham City and Nottinghamshire of the
investigation. He sent us the results of the post-mortem examination. We have sent
the Coroner a copy of this report.
17. The Ombudsman’s family liaison officer contacted Mr McDonnel’s daughter to
explain the investigation and to ask if she had any matters she wanted us to
consider. She asked why no prison staff attended her father’s funeral despite
promising to do so. We have addressed this in the report.
Prisons and Probation Ombudsman 3
Background Information
HMP Nottingham
18. HMP Nottingham is a resettlement and local prison serving the courts of
Nottinghamshire and Derbyshire. It has capacity for approximately 1,000 men.
Healthcare for the prison is provided by Nottinghamshire Healthcare NHS
Foundation Trust. Primary care provision, including substance misuse treatment is
provided 24 hours a day, seven days a week. Recovery services are provided from
7.00am to 9.00pm Monday to Friday, and 8.00am to 6.00pm on weekends. Mental
Health services are provided from 7.00am to 9.00pm seven days a week.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Nottingham was in May and June 2022.
Inspectors noted that the number of self-harm incidents had increased substantially,
and that Prisons and Probation Ombudsman (PPO) recommendations following
self-inflicted deaths were not always addressed.
20. Inspectors noted that many prisoners at risk of self-harm felt uncared for. The
quality of ACCT documents varied greatly. Most ACCT reviews were
multidisciplinary and well documented, but actions to address risks and triggers
were not always captured on care maps.
21. Inspectors found that only 55% of prisoners said they had a named officer or key
worker compared with 81% at the previous inspection. Although after the COVID-19
pandemic the frequency and quality of key work had started to improve, the key
work scheme at Nottingham was not effective enough.
22. Inspectors noted that over the previous 12 months, maintaining sufficient cover in
the mental health team had been difficult. The team was operating under significant
pressure which had been recognised as a service risk. They found that 73% of
prisoners said they had needed help with a mental health problem during their time
in prison. The team delivered a seven-day service and had developed
contingencies to ensure that prisoners with the most acute need or overt risk were
seen.
Independent Monitoring Board
23. 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 28 February 2022, the IMB
highlighted that there were fewer ACCTs opened during the reporting year. The
sixth version of ACCT had been introduced, and the prison undertook assurance
monitoring. The new process seemed to be taking some time to become
embedded, and the quality of ACCTs had been variable throughout the prison.
24. The report stated that the prison had increased its provision of key work, however
this remained an area for improvement, as prisoners’ access to a key worker was
limited and some prisoners said they had never received a key work session.
4 Prisons and Probation Ombudsman
Previous deaths at HMP Nottingham
25. Mr McDonnell was the tenth prisoner to die at Nottingham since September 2020.
Of the previous deaths, one was self-inflicted, one was drug-related and seven
were from natural causes.
Assessment, Care in Custody and Teamwork
26. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and self-harm. The purpose of ACCT is to try to determine the level of
risk, how to reduce the risk and how best to monitor and supervise the prisoner.
After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
Prisons and Probation Ombudsman 5
Key Events
27. On 7 July 2022, Mr Kevin McDonnel was remanded in prison, charged with assault,
and was sent to HMP Nottingham. It was not his first time in prison.
28. Mr McDonnel had a history of alcohol and substance misuse and was prescribed
methadone (an opioid drug used to treat heroin addiction). He also had a history of
depression, suicidal thoughts and self-harm, though he said he had no current
thoughts of suicide or self-harm when he arrived at Nottingham.
29. A GP at Nottingham prescribed methadone and chlordiazepoxide (also known as
Librium), thyamin and vitamin B compound to treat Mr McDonnel’s alcohol
withdrawal. The next day, following confirmation of Mr McDonnel’s community
prescriptions, a GP prescribed sertraline (an antidepressant).
30. Mr McDonnel was allocated a cell on F Wing, the induction wing, and remained
there for his first five days. He was moved to E Wing (primarily the young adults’
wing) on 12 July.
31. On 18 July, an officer noted that for the previous two days Mr McDonnel had
declined the regime (exercise, shower, association etc) and food. He said he was
under threat from other prisoners, as he had borrowed vape capsules and could not
return them. She offered to move Mr McDonnel to another wing and start a ‘self-
isolation plan’, but Mr McDonnel declined. (A self-isolation plan supports a prisoner
while they choose to stay confined in their cell and ensures they still receive a
regime.)
ACCT opened - 30 July
32. On 30 July, an officer noted that during a routine check, he found Mr McDonnel had
self-harmed by cutting his right forearm with a razor blade. Mr McDonnel said he
had done this because he felt under threat and wanted to move to another wing.
The officer started suicide and self-harm prevention procedures (known as ACCT)
and opened a challenge, support and intervention plan (CSIP). (CSIP is used to
manage those prisoners who are violent or who pose a raised risk of being violent.
Some prisons also use the CSIP framework to support victims of violence.) Staff
moved Mr McDonnel from E Wing to C Wing (a standard wing). They closed the
CSIP as Mr McDonnel said he felt better but he continued to be managed using
ACCT.
33. The next morning, a Supervising Officer (SO) held the first ACCT case review. Mr
McDonnel told him that prisoners had been kicking his door and calling him a
paedophile. He said he had self-harmed because he felt anxious and thought it
would speed up a wing move. When asked how he felt on C Wing, Mr McDonnel
said he thought his issues had followed him as he had heard prisoners on E Wing
talking to prisoners on C Wing about him and still felt anxious. The case review
team set observations at one an hour and two conversations a day.
34. On 31 July, a mental health nurse assessed Mr McDonnel. She noted that he was
acutely anxious and was visibly shaking and sweating a lot. He said that when he
was moved from E Wing to C Wing, he heard prisoners from E Wing shouting to
6 Prisons and Probation Ombudsman
other prisoners asking them to beat him up. She noted that she would ask a GP to
review his medication and would arrange low-level anxiety work.
35. On 4 August, a SO held Mr McDonnel’s second case review. Mr McDonnel said he
was doing a little better but was still having thoughts of suicide and self-harm as he
was still hearing threats coming from E Wing prisoners. The SO asked if Mr
McDonnel had considered a move to the other side of C Wing, away from E Wing,
and he said he would enquire about it. The case review team reduced observations
to one every two hours and two conversations a day.
36. On 6 August, staff moved Mr McDonnel to B Wing (a standard wing).
37. On 12 August, a SO held the third case review. Mr McDonnel said he wanted to
self-isolate as his issues had followed him to B Wing. The SO added a ‘self-
isolators’ regime to Mr McDonnel’s care plan. The case review team increased
observations to one an hour.
38. At his fourth case review on 19 August, Mr McDonnel said he was being targeted
and other prisoners were still calling him a sex offender. When the SO asked Mr
McDonnel how staff could help him, he said he wanted to move to F Wing. The SO
told him this was not possible because F Wing was the induction wing.
39. Mr McDonnel responded by saying that he would hang himself in his cell. The SO
noted that Mr McDonnel was not open to other options and was fixated on a move
to F Wing. Staff decided to place Mr McDonnel under constant supervision.
(Constant supervision involves being in a cell with a transparent Perspex door
through which staff, who monitor the prisoner at all times, can observe the
occupant.) He noted that Mr McDonnel was unhappy about this decision but walked
compliantly to the constant supervision cell on A Wing.
40. On 20 August, a prison manager held the fifth case review. Mr McDonnel said that
nothing had really changed for him, and that it would be considered a success if he
got out of prison next month without killing himself. The manager asked Mr
McDonnel how he felt about the possibility of moving to D Wing, a standard wing he
had not lived on before. Mr McDonnel said that he would “top himself” as it would
only take a couple of days for news to get round the wing. The case review team
kept Mr McDonnel under constant supervision.
41. On 22 August, a prison manager held the sixth case review. He noted that Mr
McDonnel seemed less anxious, and more willing to consider other options. Mr
McDonnel said he was still dreaming about suicide and self-harm, but his thoughts
were not as strong. He noted that Mr McDonnel was still not happy with the idea of
moving to D Wing but understood that he could not remain under constant
supervision for the five weeks that remained of his sentence.
42. The case review team decided to stop constant supervision as they considered that
Mr McDonnel’s risk of suicide had reduced slightly. They set observations at three
an hour and two conversations a day.
43. On 24 August, a prison manager held the seventh case review. Mr McDonnel said
he still dreamt of self-harming and potentially taking his own life but that he felt fairly
settled on A Wing and had been thinking about other cells he could move to that
Prisons and Probation Ombudsman 7
might make him feel safer. The case review team assessed that Mr McDonnel was
showing positive progress and reduced observations to two an hour.
44. On 25 August, staff moved Mr McDonnel back to B Wing. He was offered cells on A
Wing, but they did not have a television or telephone, so he was moved to B Wing
where there were in-cell facilities. (It is not clear why Mr McDonnel was moved to B
Wing rather than D Wing as had been previously suggested.)
45. On 26 August, a Custodial Manager (CM) held the eighth case review. Mr
McDonnel said he had six razor blades in his cell, which staff removed with Mr
McDonnel’s assistance. (It is unclear how Mr McDonnel obtained the razor blades.)
The CM noted that IMHT had made a referral for Mr McDonnel to see a psychiatrist,
but due to a lengthy waiting list it would be a while before he was seen. Mr
McDonnel said that he had stopped taking his medication for anxiety and
depression as they were “messing with his head” and made him feel worse. Mr
McDonnel said that he had continuing thoughts of self-harm, including ones about
cutting his neck open. He said he did not understand why he was back on B Wing
as there were more prisoners out to get him on this wing. The CM noted that staff
were concerned that Mr McDonnel had been moved back to B Wing as he had
appeared to feel safer on A Wing. They decided to put Mr McDonnel back under
constant supervision. The CM noted that IMHT would visit Mr McDonnel over the
weekend.
46. Later that day, staff moved Mr McDonnel to a constant supervision cell on F Wing.
47. On 27 August, a prison manager held the ninth case review. Mr McDonnel said that
prisoners on A and B Wings had been coming to his door and threatening him, but
he could not give names. He asked if he could stay in a standard cell on F Wing,
but she said she would have to check.
48. On 28 August, a prison manager held the tenth case review. Mr McDonnel said he
still had suicidal thoughts and wanted to kill himself if he could get hold of a razor.
He said that prisoners believed he was a paedophile. When a nurse from the
mental health team asked Mr McDonnel who was saying this and why he was
concerned about it if he was not a paedophile, he could not answer. The manager
told Mr McDonnel that he would not be able to remain on F Wing and they were
looking to move him to A Wing. Mr McDonnel became argumentative, and she
explained that he could not stay in a constant supervision cell on F Wing and that
they wanted him to progress and find a place he would feel safe.
49. Later that day, staff moved Mr McDonnel to a constant supervision cell on A Wing.
50. On 29 August, a CM held the eleventh case review. She noted that Mr McDonnel
made good eye contact and she did not consider that he was currently in crisis, but
he said that he would kill himself if he had a razor. He said he had not been eating
for the past three days. She noted that he was clearly annoyed about being on A
Wing. The nurse who attended the review, noted that prison staff were going to
open a food refusal log.
51. On 3 September, an officer noted that during a welfare check Mr McDonnel said
that he had not eaten for three to four days but was drinking liquids. She noted that
Mr McDonnel began to say the food refusal was to do with his mental health, but
8 Prisons and Probation Ombudsman
then said it was in protest for being not allowed to stay on F Wing, as he had issues
on all other wings. She noted that she asked Mr McDonnel what the issues were,
but he would not say.
52. On 4 September, a prison manager held the twelfth case review. She noted that
when she asked Mr McDonnel how he had been over the past week, he said that
there had been no change When she challenged this by saying that he had had a
stable week with no incidents, he became agitated. She noted that Mr McDonnel
had settled on A Wing and there had been no issues. When she told him that he
would remain on A Wing, he said that other prisoners were out to get him. However,
he could not provide any names or give any witnesses. The case review team
agreed that Mr McDonnel should come off constant supervision. They set
observations at three an hour, with three conversations a day.
53. At his next case review on 5 September, Mr McDonnel said he felt ok, but nothing
had changed. A CM noted that staff on the wing had reported there was no
evidence that Mr McDonnel was under threat. The CM noted that Mr McDonnel had
supplied trigger dates (when his risk of suicide or self-harm might increase) for his
court appearance on 22 September, the anniversary of his father’s death on 29
September, and his sister’s death in mid-October, which were added to his care
plan. The case review team kept observations at three an hour, with three
conversations a day.
54. On 12 September, a CM held the fourteenth case review. Mr McDonnel said he was
not feeling good and continued to hear threats and accusations from other
prisoners. The CM noted that Mr McDonnel could not provide names.
55. The CM noted that Mr McDonnel wanted to continue self-isolation, as every time his
door opened, he was fearful that other prisoners would rush in. He noted that Mr
McDonnel wanted to be moved to the vulnerable prisoners (VP) Wing or D Wing.
The CM said that the VP Wing was unlikely to be an option as Mr McDonnel was
not a sex offender and D Wing would probably not be a good option as there were
limited single cells and he would not be located near a wing office. The case review
panel reduced observations to one an hour, with three conversations a day.
56. On 13 September, a CM noted that a decision was made to refuse Mr McDonnel’s
request to move to the VP Wing, as they wanted him to work with regular staff to
build stability.
57. On 16 September, an officer noted that Mr McDonnel self-harmed by making cuts to
his inner arm with a razor blade. Mr McDonnel said he had done this as he thought
prisoners were at his door threatening him. She noted that no prisoners had been
observed at Mr McDonnel’s door. (There is no evidence in the ACCT plan that staff
had considered whether Mr McDonnel should be allowed unsupervised access to
razor blades.)
58. A nurse attended to Mr McDonnel. He noted that Mr McDonnel had allegedly
swallowed a razor blade (but it is unclear if this was the case). Mr McDonnel
declined treatment from healthcare staff.
59. On 20 September, a CM held the fifteenth ACCT review. He noted that the review
was completed in preparation for Mr McDonnel’s court appearance on 22
Prisons and Probation Ombudsman 9
September, which had been identified as a trigger date. He noted that Mr McDonnel
refused to come out of his cell, due to feeling under threat. He noted that Mr
McDonnel showed some signs of paranoia.
60. A nurse from the mental health team, who was also in attendance, noted that it was
unclear if Mr McDonnel was unwell, as he heard prisoners shouting things about
him that no one else could hear. As Mr McDonnel was not a priority case for the
mental health team, and due to his own caseload pressures, he took no further
action.
61. On 23 September, a CM held the sixteenth case review. The CM noted that Mr
McDonnel had not self-harmed for several weeks (this was not the case as Mr
McDonnel had self-harmed on 16 September), but he still thought people were out
to get him, did not feel safe, and thought that he would harm himself. He noted that
Mr McDonnel’s cell was close to the wing office and the constant supervision cells,
where staff were stationed, but staff reported not hearing or seeing any threats
against Mr McDonnel from other prisoners.
62. The CM noted that Mr McDonnel said he had not felt safe to attend his video court
appearance the previous day, as he believed new prisoners from C and E Wings
were going to get him. He noted that Mr McDonnel said that he was eating only
sealed food, did not read or watch TV, and just sat in his cell with his earplugs in.
63. The CM noted the next video court appearance was on 6 October. He kept
observations at one an hour and three conversations a day.
64. On 27 September, a nurse saw Mr McDonnel to review his methadone dose. He
said he was not managing well on 30mg and needed an increase ‘because of
everything that was going on’. She noted that Mr McDonnel had previously been
prescribed 50ml, and to stabilise him in preparation for his potential release from
prison, she agreed to increase Mr McDonnel’s methadone to 40mg.
65. The next ACCT review was originally set for 28 September, however, due to a
prison-wide training day the review was changed to 29 September. A CM told the
investigator he was not aware of the training day when he originally booked the
ACCT review.
66. At around 8.45am on 28 September, a CM went to Mr McDonnel’s cell to inform him
that his ACCT review would not take place as planned, and that it was rescheduled
for the following day.
67. At 9.00am, an officer conducted a welfare check on Mr McDonnel, as Mr McDonnel
was on the Safeguarding and Self-Isolators lists, and because the following day
was the anniversary of the death of Mr McDonnel’s father (a trigger date). He spoke
to Mr McDonnel for about two minutes. He told the investigator that Mr McDonnel
said he was fine but wanted a transfer.
Events of 29 September
68. On 29 September, at around 4.00am, an officer noted that Mr McDonnel had been
awake all night. He noted that Mr McDonnel was under the illusion that someone
was after him, and that staff were in on it. He noted that Mr McDonnel had been
10 Prisons and Probation Ombudsman
seeing and hearing things all night that related to him being imminently attacked. He
noted that Mr McDonnel claimed to have heard on the radio that people were being
unlocked and he had seen people on the stairs trying to sneak to his cell past the
wing office. He noted that he reassured Mr McDonnel the best he could, by doing
extra patrols and trying to convince him no one was around, but this had not been
enough to alleviate Mr McDonnel’s fears.
69. At 8.00am an officer took Mr McDonnel to collect his medication. He noted that Mr
McDonnel was not typically talkative in the mornings, he did not really engage with
him, but this was not unusual.
70. At 9.15am, an officer responded to Mr McDonnel’s cell bell. He noted that he had a
lengthy chat with Mr McDonnel who was excited about being released and asked
about collecting property that he had left in the prison’s reception. He noted that he
told Mr McDonnel that he would investigate the matter, and that Mr McDonnel was
thankful. He noted that with Mr McDonell mentioning release and that he appeared
in a positive mood, he had no concerns.
71. At 10.01am, Mr McDonnel rang his cell bell. An officer attended the cell and spoke
to Mr McDonnel for around 90 seconds.
72. At 11.22am, an officer unlocked Mr McDonnel’s cell door to provide him with lunch.
She told the investigator that when she opened the door, she saw Mr McDonnel on
the floor with a ligature tied around his neck and attached to the bed frame. She
said Mr McDonnel was a strange purple colour. She shouted for staff support three
times. An officer who was walking by responded. The officer entered the cell,
quickly followed by her colleague.
73. One officer told the investigator she had difficulty removing the ligature from around
Mr McDonnel’s neck as it was very tight. She said she radioed for staff assistance
and gave the cell number but was not able to get her words out due to panic and
shock. She told the investigator that after removing the ligature, more prison staff
attended, and they began cardiopulmonary resuscitation (CPR).
74. At 11.23am, a CM called a ‘code blue’ medical emergency.
75. At 11.24am, healthcare staff arrived at Mr McDonnel’s cell. A nurse told the
investigator that healthcare staff took over CPR, and that Mr McDonnel had no
pulse, and the defibrillator registered as having no shockable rhythm. They tried to
administer oxygen, but this was difficult due to the secretions in Mr McDonnel’s
mouth.
76. Control room staff called the ambulance service at 11.25am. At 11.32am,
paramedics arrived, followed by a further ambulance crew.
77. At 11.42am, paramedics stopped CPR and pronounced that Mr McDonnel had died.
Contact with Mr McDonnel’s family
78. On 29 September, the prison appointed a family liaison officer (FLO). Mr McDonnel
did not have a next of kin recorded in his prison record, but the police managed to
trace Mr McDonnel’s sister, who then contacted his daughter.
Prisons and Probation Ombudsman 11
79. The FLO and a prison manager visited Mr McDonnel’s daughter on 4 October.
80. The prison chaplain conducted Mr McDonnel’s funeral. The prison contributed to
the costs of Mr McDonnel’s funeral in line with national policy.
Support for prisoners and staff
81. After Mr McDonnel’s death, prison and healthcare staff involved in the emergency
response attended a debrief to ensure they had the opportunity to discuss any
issues arising, and so they could be offered support. The staff care team also
offered support.
82. The prison posted notices informing other prisoners of Mr McDonnel’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide
and, or self-harm in case they had been adversely affected by Mr McDonnel’s
death.
Post-mortem report
83. The post-mortem report concluded that Mr McDonnel died from asphyxiation by
hanging. Methadone and flecainide toxicity was listed as a contributory factor. Both
drugs were prescribed to Mr McDonnel.
12 Prisons and Probation Ombudsman
Findings
Management of Mr McDonnel’s risk of suicide and self-harm
84. Prison Service Instruction (PSI) 64/2011, Managing prisoners at risk of harm from
self, from others and to others (Safer Custody), sets out the procedures (known as
ACCT) that staff should follow when they identify that a prisoner is at risk of suicide
and self-harm.
85. Staff monitored Mr McDonnel using ACCT from 30 July up to his death on 29
September. This included two periods under constant supervision.
86. We found that some aspects of the ACCT procedures were managed well. There
were frequent case reviews, which were all multidisciplinary, and records were
detailed, with clear explanations for the decisions taken. There was an appropriate
care plan and staff tried to address Mr McDonnel’s concerns about his safety by
arranging wing moves.
87. However, we found that there was a lack of continuity with regard to attendees at
the ACCT case reviews and there were six ACCT case coordinators. Also, while
there was always a representative from the mental health team present, the
attendee changed frequently with eight different representatives in all.
88. Wherever possible, there should be a consistent case review team for prisoners
being supported using ACCT. This not only means that staff build up a good
knowledge of the prisoner and their risks and needs but can also make it easier for
the prisoner to engage if the case review team is familiar to them. While we
appreciate that there can be difficulties getting the same people to attend case
reviews, and that Mr McDonnel’s frequent wing moves and periods under constant
supervision did not help with this, we consider that the ACCT coordinator role
should have been carried out by fewer people and there should have been more
consistent attendance from members of the mental health team.
89. Staff did not hold a case review with Mr McDonnel before his trigger date of 29
September (the anniversary of his father’s death). A CM told the investigator that at
the time of setting the review date, he did not know that there was a prison-wide
training day on 28 September, resulting in a lack of staff. He said that despite the
training day, he tried to arrange for Mr McDonnel’s ACCT review to go ahead, but
due to his other responsibilities that day he was unable to conduct the review. Mr
McDonnel’s ACCT review was rearranged for the next day.
90. A nurse told the investigator that on the morning of 29 September, he tried to find
the CM to conduct Mr McDonnel’s ACCT review but could not. He told the
investigator that he tried to find someone else to conduct Mr McDonnel’s ACCT
review with him. He said he spoke to a prison manager and with staff from the
Safety Team, but he was unsuccessful. He told the investigator that he documented
what he had done and then went to conduct another prisoner’s ACCT review.
91. The CM told the investigator that on the morning of 29 September, he had a
doctor’s appointment and so arrived late to the prison. He said he intended to
Prisons and Probation Ombudsman 13
conduct Mr McDonnel’s ACCT review after he arrived, but shortly after his arrival he
was told that Mr McDonnel had died.
92. We accept that the circumstances on 28 September made it more challenging for
the CM to arrange a case review. However, having identified Mr McDonnel’s trigger
dates, staff needed an opportunity to assess whether his level of risk had increased
and whether additional measures, such as more frequent observations or more
support, were required. We consider that arranging a case review should have been
prioritised.
93. We recommend:
The Governor should ensure that staff manage ACCT procedures in line with
prison policy including that:
• There is a consistent ACCT case coordinator and case review team
wherever possible.
• A case review is held shortly before an identified trigger date (such as
the anniversary of a death or anniversary of the offence).
Clinical care
94. The clinical reviewer concluded that the mental health care Mr McDonnel received
at Nottingham was not equivalent to that which he could have expected to receive
in the community.
95. Mr McDonnel was referred for a mental health assessment on 7 July, following his
reception health screen. However, he was not seen for a face to face assessment
until 31 July, which was outside the expected five-day timescale. Mr McDonnel
should have had an urgent mental health assessment when he was placed under
constant supervision, but this did not happen.
96. The clinical reviewer found no evidence that a mental health care plan was created
for Mr McDonnel at any time during his stay at Nottingham. When Mr McDonnel told
staff on 5 September that the anniversary of his father’s death was on 29
September, a nurse recorded this in his medical record but took no further action to
escalate his care in the lead up to this date. There was also no escalation of his
care when he told a nurse on 12 September that he was struggling, or when he self-
harmed on 16 and 20 September.
97. At interview, the Acting Clinical Matron for Mental Health told the investigator and
clinical reviewer that the mental health team was very short staffed at the time of Mr
McDonnel’s death, with only 3.5 mental health nurses in post when there should
have been 12. As a result, they prioritised attending ACCT reviews, medical
emergencies and seeing the patients most at risk. Mental health assessments and
interventions were not routinely offered.
98. She said that Mr McDonnel had been assessed as an ‘amber’ patient (out of green,
amber and red, with red being the highest risk). She said that on reflection, if the
team had been fully staffed, Mr McDonnel would have been escalated to a complex
case and managed as a ‘red’ patient. The Head of Healthcare has since told us that
14 Prisons and Probation Ombudsman
the mental health team is now seeing ‘amber’ patients but that there are still two
vacant posts within the team. We recommend:
The Head of Healthcare should ensure there is adequate staffing within the
mental health team to allow the team to provide the service for which it is
commissioned.
Governor to Note
Key worker support
99. The Prison Service’s Manage the Custodial Sentence Policy Framework 2018,
states that all prisoners within the male closed estate must be allocated to a prison
officer who will have a key worker role. It also says that Governors must ensure that
time is made available for an average of 45 minutes per prisoner per week for the
delivery of key work, which should include time with each prisoner.
100. During his 12 weeks at Nottingham, Mr McDonnel received only one key worker
session, on 21 July 2022 from an officer. On 4 August, at an ACCT review, a SO
recorded that he had allocated another officer as Mr McDonnel’s key worker.
However, no further key worker sessions are recorded, either by this officer or
anyone else.
101. The prison was unable to explain why Mr McDonnel received only one key work
session during his time at Nottingham. However, they said that the process for
allocating key workers had changed and while it used to be done centrally on a
random basis, officers were now allocated six prisoners on their wing to enable
more consistent support. They said that every prisoner (apart from recent arrivals
on the induction wing) was allocated a key worker and that officers were detailed to
carry out key worker sessions (although sometimes redeployment meant they did
not always happen). The prison also told us that for prisoners under constant
supervision, consideration was given to whether they should be allocated a key
worker from the Safety Team. If they remained with their wing key worker, then they
would still be seen daily by an officer from the Safety Team.
102. We note that, according to the prison, a greater proportion of prisoners are
allocated a key worker now (over 90%) than when HM Inspectorate of Prisons
carried out its inspection in May and June 2022 (55%). We do not make a
recommendation, but the Governor should monitor whether the key work system is
delivering meaningful key work sessions to prisoners at Nottingham.
Prison-NOMIS case notes
103. PSI 23/2014 Prison-NOMIS (Prison National Offender Management Information
System), states all staff who have contact with a prisoner and who have access to
Prison-NOMIS must update case notes on a regular basis.
104. On 28 September, an officer conducted a welfare check on Mr McDonnel. He told
the investigator he conducted this check as Mr McDonnel was on the Safeguarding
and Self-Isolators lists, and because the following day was the anniversary of his
father’s death (a trigger date).
Prisons and Probation Ombudsman 15
105. CCTV footage shows that the officer had a two-minute-long conversation with Mr
McDonnel; but he did not record this conversation on Prison-NOMIS as a case
note.
106. The officer visiting Mr McDonnel is evidence of good practice, however as stated in
PSI 23/2014 he should have updated Mr McDonnel’s Prison-NOMIS case notes.
This would have ensured that information about Mr McDonnel was effectively
shared with other staff to inform assessment and management of risk.
Inquest
107. The inquest, held from 9 to 19 July 2024, concluded that Mr McDonnel died by
suicide. The jury found that failings by prison staff and healthcare staff in the
management of Mr McDonnel’s ACCT and in his mental health care, probably more
than minimally contributed to Mr McDonnel’s death by suicide.
16 Prisons and Probation Ombudsman
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