Malacai Samson

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Malacai Samson,
a prisoner at HMP Pentonville, on
23 August 2019
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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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.
On 22 July 2019, Mr Malacai Samson barricaded himself in his cell at HMP Pentonville
and began hanging himself as staff were trying to gain entry. He was resuscitated but died
in hospital on 28 August, having never regained consciousness. He was 32 years old. I
offer my condolences to Mr Samson’s family and friends.
Mr Samson moved from a mental health unit to Pentonville in November 2017, as a short-
term move ahead of an intended transfer to a suitable long-term prison. Despite the plan
to move him on, Mr Samson remained at Pentonville for the next 20 months, primarily
because he was resistant to moving to any prison where he would have to engage in the
group therapy work he needed to do for his sentence plan.
Mr Samson remained at Pentonville for far too long and I am concerned that no proper
consideration appears to have been given to transferring him to a new offender supervisor
when the relationship with his existing offender supervisor appeared to have broken down.
While I consider that Mr Samson was generally well supported through suicide and self-
harm prevention procedures, some aspects were not managed so well. I am concerned
that meaningful caremap actions were not set and that insufficient thought was given to Mr
Samson’s risk of suicide and self-harm at the final case review and in the hours before he
hanged himself.
Although staff believed that they needed to gain entry to Mr Samson’s cell on 22 July, given
his threat to take his life that evening, I consider that they should have considered other
options to keep Mr Samson safe and note that local procedures to inform the duty governor
were not followed.
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
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 20
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Summary
Events
1. In July 2007, Mr Malacai Samson was remanded in custody, charged with the
murder of his mother. In April 2008, he was convicted and sentenced to life
imprisonment for a minimum term of 14 years. Mr Samson had spent time at
several different prisons until November 2014, when he was admitted to the
Millfields Unit (a secure unit for prisoners diagnosed with personality disorders),
where he was diagnosed with antisocial and borderline personality disorders.
2. In November 2017, Mr Samson was discharged from the Millfields Unit and sent to
HMP Pentonville. The aim at Pentonville was first to allow Mr Samson a period of
time to become more stable, before his transfer to a prison that delivered the
programmes and pathways that met his sentence plan.
3. At his initial meeting with his offender manager, Mr Samson said that he wanted to
transfer from Pentonville as soon as possible. However, in subsequent meetings
with her, and other staff, Mr Samson maintained that he would not transfer to a
prison where he would have to engage in the group therapy work his sentence plan
required. In addition, Mr Samson made frequent threats of suicide or self-harm and
was monitored under suicide and self-harm prevention procedures, known as
ACCT. Mr Samson obtained razors with which he cut himself at times. He also
made threats towards his offender supervisor and appeared to believe that she was
responsible for his failure to progress through the system.
4. In April 2019, Mr Samson spoke to his offender supervisor about returning to the
Millfields Unit. She sent a referral, although this was not supported by Pentonville’s
healthcare team. In response, a clinician from the Millfields Unit came to
Pentonville to interview and assess Mr Samson.
5. On 19 July, Mr Samson’s offender supervisor told him that the Millfields Unit would
not readmit him but recommended that he should be transferred to a prison for
group therapy work. Mr Samson said that he had started food refusal and an officer
noted that day that he continued to make threats about taking his life, that he was
not eating and appeared frail.
6. During the afternoon of 22 July, Mr Samson barricaded his cell and told other
prisoners that he was going to kill himself. A custodial manager and a supervising
officer tried to persuade him to remove the barricade, which he refused to do. The
custodial manager then collected equipment to force entry into the cell. He found
that the bolt securing the third hinge was damaged and difficult to remove, which
caused a delay to opening the cell door. Mr Samson said that he would not allow
staff to come into the cell. While they were trying to open the door, Mr Samson sat
on the window ledge and tied a ligature around his neck and to the window bars
before letting himself slide off the ledge. The supervising officer radioed that Mr
Samson was hanging. Staff were able to enter the cell around eight minutes later
and nurses began cardiopulmonary resuscitation (CPR).
7. Paramedics arrived at 7.40pm and established a pulse. Mr Samson was taken to
hospital and placed in intensive care. He died in hospital on 23 August.
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Findings
8. Managing Mr Samson provided staff at Pentonville with considerable challenges.
While some positive actions were taken, and it is apparent that many staff knew and
understood the issues surrounding his care, there were some areas where this care
might have been improved.
9. Mr Samson was appropriately monitored under ACCT procedures in the time before
he hanged himself. However the ACCT caremap did not include a plan to address
some significant areas of risk, including the news that he could not return to the
Millfields Unit. We also found that staff underestimated Mr Samson’s risk of suicide
and self-harm at the final case review and in the hours before he hanged himself.
10. Mr Samson’s offender supervisor referred him to the Millfields Unit without the
support of Pentonville’s healthcare team. When she arranged to tell him that the
Millfields Unit would not take him back, there was no apparent thought given to his
immediate support needs on hearing the news.
11. Staff did not take any action when Mr Samson began refusing food. They did not
monitor and record his food intake and did not consider the impact on his risk of
suicide and self-harm.
12. On the day that Mr Samson hanged himself, the custodial manager did not inform
the duty governor that he had barricaded himself in his cell. The damage to the
door hinge securing bolt had not been identified by officers while making their daily
cell fabric checks.
Recommendations
• The Governor should ensure that staff manage prisoners at risk of suicide and self-
harm in line with national instructions, including that:
• support actions are set that are specific, meaningful and identify all of the
issues identified at assessment interviews and case reviews, including
ensuring that appropriate support is provided when difficult news is given to a
prisoner at risk of suicide and self-harm;
• prisoners’ access to razors is managed in line with national instructions; and
• case reviews consider all relevant information that affects risk, and staff
review the risk of suicide and self-harm whenever an event occurs which
indicates an increase in risk.
• The Governor should ensure that prison offender managers (previously known as
offender supervisors) are given appropriate support where needed, including that:
• prison offender managers are accompanied by a senior colleague, where
appropriate, in reiterating difficult messages to prisoners; and
• prisoners are reallocated to a new prison offender manager when the
relationship with the existing offender supervisor has broken down.
• The Governor and Head of Healthcare should ensure that all staff at Pentonville
understand that referrals to secure mental health units should only be made through
the prison’s mental health Inreach team.
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• The Governor and Head of Healthcare should ensure that staff manage a prisoner
who is refusing food in line with national guidelines.
• The Governor should ensure that staff inform the duty governor when a prisoner
has barricaded himself in his cell and that staff consider all options, including use of
trained negotiators, when dealing with prisoners who are threatening suicide or
significant self-harm.
• The Governor should share a copy of this report with CM A and arrange for a senior
manager to discuss the Ombudsman’s findings with him.
• The Governor should ensure that officers check the condition of door hinge securing
bolts when making their daily cell fabric checks.
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Pentonville informing
them of the investigation and asking anyone with relevant information to contact
him. Two prisoners responded, one anonymously.
14. The investigator obtained copies of relevant extracts from Mr Samson’s prison and
medical records. He interviewed 16 members of staff and three prisoners at
Pentonville between September 2019 and May 2020. Interviews carried out in April
and May 2020 were conducted by telephone due to revised working practices
during the COVID-19 pandemic. The investigation was subsequently transferred to
one of the investigator’s colleagues, who interviewed one further witness.
15. NHS England commissioned two clinical reviewers to review Mr Samson’s clinical
care at the prison. The investigator and one of the clinical reviewers jointly
interviewed clinical staff.
16. We informed HM Coroner for London Inner North of the investigation. The Coroner
gave 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 Samson’s brother to explain
the investigation and to ask if he had any matters he wanted us to consider. Mr
Samson’s brother did not respond.
18. We shared our initial report with HMPPS but were unable to contact Mr Samson’s
brother. HMPPS did not identify any factual inaccuracies in our report.
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Background Information
HMP Pentonville
19. HMP Pentonville is a local prison serving the courts of north and east London and
holds up to 1,310 men. Practice Plus Group, in partnership with Enfield and
Haringey Mental Health Trust, provides healthcare services at the prison.
HM Inspectorate of Prisons
20. The most recent full inspection of HMP Pentonville was in July 2022. Inspectors
found that there were serious deficiencies in the performance of the offender
management team which had suffered from poor leadership, oversight and a failure
to maintain basic processes. Fragile improvements had been made which were
threatened by staff shortages and poor morale. All sentenced prisoners now had a
prison offender manager (formerly known as offender supervisors). Inspectors
found the quality of case management was variable, and that until recently, prison
offender managers had been managing high risk cases without probation support or
supervision. They found that in most cases, there was little evidence of any
structured work with prisoners.
21. Inspectors found that the key worker scheme was not functioning and there was
little evidence that wing staff were actively assisting prisoners with sentence and
release planning.
22. Inspectors found that support for prisoners in crisis and those subject to ACCT
procedures was not good enough, and ACCT case management was weak. While
the ACCT case reviews were sufficiently detailed, associated care plans were often
incomplete or not used effectively to deliver tailored care and relevant support.
Inspectors found that senior leaders were aware of these concerns and had
advanced plans to improve case management, including ongoing training and the
use of named case managers. There was insufficient leadership and oversight of
suicide and self-harm prevention work.
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 annual report for the year to March 2020, the IMB recorded its view
that many of the prisoners at Pentonville had complex and multiple needs which a
local prison, serving the local courts, was ill equipped to address. The IMB also
reported problems in timeliness in responses for information from the offender
management unit (OMU), which the IMB acknowledged was often for reasons
outside the OMU’s control as they were often dependent on information from other
bodies, such as the probation service.
Previous deaths at HMP Pentonville
24. Mr Samson was the fourth prisoner to die at Pentonville since April 2017. Of the
previous deaths, two were self-inflicted and one was from natural causes. Our
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investigations into the two self-inflicted death found that staff underestimated the
prisoners’ potential risk of suicide or self-harm.
25. There was a further self-inflicted death in August 2019 when we again found that
staff underestimated the prisoner’s risk of suicide or self-harm.
Assessment, Care in Custody and Teamwork
26. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses for supporting and monitoring prisoners assessed as at risk
of suicide and self-harm. The purpose of the ACCT process is to try to determine
the level of risk posed, the steps that might be taken to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Levels of supervision and
interactions are set according to the perceived risk of harm. There should be
regular multidisciplinary case reviews involving the prisoner. Checks made on
prisoners should be at irregular intervals to prevent the prisoner anticipating when
they will occur. Part of the ACCT process involves assessing immediate needs and
drawing up a caremap to identify the prisoner’s most urgent issues and how they
will be met. Guidance on ACCT procedures is set out in Prison Service Instruction
(PSI) 64/2011.
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Key Events
27. On 30 July 2007, Mr Malacai Samson was remanded to HMP Feltham, charged
with the murder of his mother. He was convicted on 1 April 2008 and sentenced to
life imprisonment for a minimum term of 14 years. After spending time at HMP
Swaleside and HMP Elmley, Mr Samson moved to HMP Long Lartin in July 2009.
28. In November 2014, Mr Samson was admitted to the London Personality Disorder
Unit (the Millfields Unit), for assessment and treatment of his diagnosis of
schizophrenia and because of his history of self-harm. While at the Millfields Unit,
he was diagnosed with antisocial personality disorder and borderline personality
disorder.
29. On 28 November 2017, Mr Samson was transferred from the Millfields Unit to HMP
Pentonville, the prison local to the Unit. In a discharge summary the Millfields Unit’s
Lead Clinician and Head of Service wrote that, by the autumn of 2015, Mr Samson
had made no progress with his treatment targets. She wrote that staff at the
Millfields Unit had referred Mr Samson to HMP Gartree’s therapeutic unit, but
Gartree declined to accept him due to an historical sexual offence. She wrote that
the decision to transfer Mr Samson to Pentonville was in line with national policy
and the Unit would support his onward referral to a more suitable prison.
30. On arrival at Pentonville, Mr Samson said that he had consistent thoughts of suicide
and self-harm and staff started suicide and self-harm prevention procedures, known
as ACCT. Mr Samson had been supported through ACCT a number of times while
at previous prisons.
31. In December, Mr Samson was assessed by the prison’s Enhanced Support Service
(ESS) team. A psychiatric nurse told the investigator that the role of the ESS team
was to support prisoners with significant behavioural problems with the aim to
resolve the problem within three months. He said that Mr Samson did not have a
severe or enduring mental health illness, so he did not strictly meet the ESS team’s
criteria for support, but they took him onto their caseload following a request from
their commissioning body.
32. On 18 January 2018, Mr Samson was introduced to his offender supervisor. She
told him that she was going to arrange a meeting to include Mr Samson’s offender
manager to explore transfer options. Mr Samson said that he wanted to transfer as
soon as possible.
33. On 7 March, the offender supervisor and offender manager met Mr Samson to
discuss his transfer and other objectives. The offender supervisor told the
investigator that the plan was to move Mr Samson to a prison with an appropriate
pathway for his sentence plan, but he was not ready to transfer at that stage as he
needed to become more settled and stable and that the ESS team were helping him
with that.
34. At an ACCT case review on 8 March, Mr Samson said that he had mixed feelings
about his meeting of the previous day as he was unsure whether he would prefer to
transfer to another prison or remain at Pentonville until his re-categorisation review
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in November, when he hoped he would be re-categorised from category B to
category C.
35. On 26 March, prison staff closed the ACCT procedures, having noted that he had
made considerable progress in the past months, including building good
relationships with the ESS team. Mr Samson said that he had no present thoughts
of suicide or self-harm.
36. At the end of April, Mr Samson barricaded his cell with furniture and made some
superficial cuts to his arm and chest. He said that he did this as his Xbox had been
stolen and he had been given a psychoactive substance against his will. Staff
restarted the ACCT procedures and, at Mr Samson’s request, moved him to F wing,
the vulnerable prisoners’ (VP) wing. Mr Samson remained on F wing for the
remainder of his time at Pentonville.
37. On 11 May, the offender supervisor told Mr Samson that a pre-tariff sift was due
and that the dossier for this needed to be agreed by 1 August. She told the
investigator that the pre-tariff sift was to consider prisoners’ suitability to move to an
open prison. She said that Mr Samson was not suitable for an open prison, but the
pre-tariff sift was a process that needed to be completed. She said that she tried to
manage Mr Samson’s expectations about progress through the prison system and
this led to the difficulties that ultimately resulted in their relationship breaking down.
38. On 13 May, officers found Mr Samson hanging from a ligature in his cell. Entries in
Mr Samson’s records suggest he had grown increasingly paranoid in the previous
days and had told the psychiatric nurse that another prisoner had stolen his USB
stick on which he had stored music and photographs. Staff supported him through
the ACCT process until 1 June, when the ACCT procedures were closed.
39. On 4 July, the psychiatric nurse told Mr Samson that he had been discharged from
the ESS team. He said that Mr Samson should speak to his offender supervisor
about further options for engaging with offender behaviour programmes and other
treatments in support of his sentence planning. He told us that he continued to
support Mr Samson on an informal basis.
40. On 13 July, the offender supervisor completed a parole report. She noted that she
had had 14 formal meetings with Mr Samson. She wrote that she considered Mr
Samson suitable for HMP Grendon’s therapeutic community, who had agreed that
he was suitable for assessment given his current stability. She added, however,
that Mr Samson was resistant to the proposal as the length of the intervention at
Grendon would take him past his sentence tariff date. She wrote that Mr Samson
believed that he was ready to progress to a category C prison, and then to open
conditions, without the need for any psychological input. She wrote that such
thinking demonstrated Mr Samson’s lack of insight into his risk factors as well as his
unrealistic hope of progression at the time. She sent Mr Samson a copy of her
report for discussion.
41. On 3 August, the offender supervisor wrote an addendum to her parole report. She
wrote that Mr Samson wanted to highlight his difficulty in engaging in group work.
She added that she explained to him that that was why she believed a therapeutic
community would assist him.
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42. On 6 August, staff started ACCT procedures due to Mr Samson’s agitation over his
parole report. At the first ACCT case review on 8 August, Mr Samson complained
that his parole report would prevent his release at the next review. Staff closed the
ACCT procedures on 11 September.
43. In September, Mr Samson made a written complaint to say that there were
inaccuracies in the offender supervisor’s pre-tariff sift report. He asked for the
report to be amended and asked to be allocated a different offender supervisor.
Her manager responded that she did not have the resources to re-allocate Mr
Samson to a different offender supervisor at that time.
44. On 11 October, Mr Samson told a psychiatrist that he had a long list of people he
felt had played games with him or had lied to him. He said chief among these was
his offender supervisor. He said that he did not want to go to Grendon, but wanted
to go to HMP Warren Hill (a category C prison) where the therapeutic groups were
small.
45. On 23 October, the psychiatrist emailed the offender supervisor to say that Mr
Samson reported feeling full of rage and that he wanted to attack others. She
added that she was concerned about the potential risk to her.
46. On 25 October, a member of the ESS team met Mr Samson following a report of
him banging his head. Mr Samson said that he felt trapped and was angry that he
was not progressing through his sentence. Mr Samson said he might hang himself
if he did not receive an adequate response to a query about his last parole review.
She started ACCT procedures and arranged to meet Mr Samson for a number of
cognitive behavioural therapy sessions. She told the investigator that her
involvement was not to treat Mr Samson’s personality disorder, but to help him
manage his situation. (Mr Samson subsequently competed 18 therapy sessions
with her.)
47. Also on 25 October, the offender supervisor emailed Pentonville’s OMU, enclosing
the psychiatrist’s email to her. She said that in light of the deterioration in her
working relationship with Mr Samson, it would be helpful for him to have a swift
transfer from Pentonville so that he could settle in a more stable environment.
48. On 9 November, the offender supervisor met Mr Samson and noted that he was
dissatisfied with her pre-tariff sift report. She recorded that they spoke about prison
transfer and that it was time for that to happen given Mr Samson’s stability. She
said that Mr Samson expressed some anger and said that he did not care where he
was going.
49. On 24 November, Mr Samson handed a Will to a Supervising Officer (SO), in which
he said that he would kill himself. A Custodial Manager (CM) chaired an enhanced
ACCT case review later that day. He recorded that Mr Samson said that if his
concerns about his categorisation, sentence planning and transfer were not
addressed to his satisfaction by Christmas, he would take his life.
50. On 27 November, a prison manager chaired a complex case meeting with most of
the key staff involved in Mr Samson’s care. The meeting discussed options for
transfer to a number of different prisons, while also noting Mr Samson’s resistance
to group work. The meeting noted that Mr Samson was focussed on his tariff expiry
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of 2021, but also noted that he had not been able to progress since being in
Pentonville as the prison did not provide the sentence programmes he needed.
The offender supervisor and a SO from Pentonville’s offender management unit
were asked to take forward the work needed to arrange a transfer.
51. On 28 November, a CM chaired an ACCT case review. An SO recorded that she
told Mr Samson about the outcome of the complex case meeting and that they were
looking to transfer him to Grendon or Swaleside. Mr Samson said that he wanted to
go to a category C prison and wanted one-to-one sessions rather than group work.
It was agreed that a member of the ESS team, who attended the case review,
would identify prisons that provided clinical intense therapy.
52. On 20 December, at an ACCT case review, Mr Samson left the room when his
offender supervisor arrived and said that he would not remain in the same room as
her. Mr Samson was discussed in his absence, and she told the review that she
and an SO were having difficulty finding another prison to take him because of his
historic sexual offence. She told the investigator that she spoke with a prison
manager about re-allocating Mr Samson to a different offender supervisor, but it
was decided that she should continue in the role.
53. On 24 January 2019, at an enhanced ACCT case review, prison staff recorded that
Mr Samson had engaged positively. They closed the ACCT procedures. Mr
Samson was told that the strategic safety lead had agreed to review his case and
advise on the way forward with his sentence plan and future location. Mr Samson
said that he was pleased with the proposal.
54. The strategic safety lead told the investigator that he had been asked to review Mr
Samson’s file by several of the staff involved in his care, some of whom possibly
believed that he was overdue for re-categorisation to category C status. After
reviewing Mr Samson’s file, he emailed all those directly involved to say:
“I think it is probably sensible that we have a multi-disciplinary meeting … but I
confess that my initial take … is that there are significant risks attached to Mr
Samson and that they are some way away from being resolved. Areas of
concern include: significant violent index offence, untreated sexual offending,
regular and serious self-harm issues, recent … acts of serious violence to a
third party, unresolved personality disorder concerns … [I feel] that there is
already an emerging pathway towards addressing the concerns above … There
is a positive route open to Mr Samson, but it involves some hard decisions and
some difficult work ... I would be very reluctant to sign off on a re-categorisation
to category C and … I [don’t] think that should be put forward as a pathway at
this time. Having said that, it strikes me that there is option for him to address
some of the risk factors within the cat B estate and I would actively support and
encourage that.”
55. On 25 January, the Prison Service’s Public Protection Group wrote to Mr Samson
saying that his case would not be referred to the Parole Board before the expiry of
his tariff on 1 August 2021. They wrote that there was no realistic prospect that the
Parole Board would sanction his transfer to open conditions before then. Mr
Samson was advised to work in addressing his risks of reoffending and was
advised that Grendon had been identified as an appropriate placement for him. The
offender supervisor passed the letter to Mr Samson, with a cover letter to explain
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that staff were making efforts to arrange transfer to a prison where his needs could
be adequately met and where he could complete his psychologically informed work.
56. In early February, the offender supervisor emailed HMP Wakefield and HMP Garth
to ask if they would accept Mr Samson. On 7 February, she contacted the clinical
lead at Garth to ask if their Beacon Unit (part of the National Offender Personality
Disorder Pathway) was an option for Mr Samson, even if only in preparation for
further in-depth work. She explained that Mr Samson had been refused treatment
at Grendon and Gartree due to his historic sexual offence.
57. On 18 February, an officer introduced himself to Mr Samson as his new key worker.
Mr Samson said that his only aim at that time was to get out of Pentonville and to
move to a category C prison. He talked about a meeting scheduled for 21
February, when he expected to be told that he would be asked to move either to a
category B prison or to Grendon, and that he did not agree with those options. The
officer’s records show that he continued to have regular and meaningful contact
with Mr Samson for the remainder of his time at Pentonville.
58. On 21 February, the member of the ESS team saw Mr Samson for a psychology
session. She noted that Mr Samson was mentally stable, but that he said he was
feeling scared and anxious following a meeting that morning when he was told that
he was to remain a category B prisoner. She also noted that Mr Samson’s transfer
had been placed on hold for the next three months to allow him to continue with
psychology sessions with her, through which he was making good progress.
59. On 22 February, Mr Samson told a substance misuse worker that he would no
longer engage with services as Pentonville and that he would rather die than remain
in the prison. She started ACCT procedures. She told the investigator that she first
became involved with Mr Samson for possible issues with misuse of cannabis and
psychoactive substances, but continued to see him more in the role of a crisis
worker.
60. At an ACCT case review on 24 February, Mr Samson said that he was upset when
told that he would have to wait a further three months for a categorisation review,
but he had no intention of harming himself and would discuss his thoughts with the
psychiatrist.
61. On 7 March, the referrals co-ordinator at Garth’s Beacon Unit emailed the offender
supervisor to say that Mr Samson appeared potentially suitable for their unit. The
co-ordinator attached referral forms and added that the admission process would
take around four to five months, even if Mr Samson’s case was prioritised.
62. On 22 March, prison staff closed the ACCT procedures. Two days later, Mr
Samson harmed himself by banging his head against a wall. Mr Samson said that
he had heard and seen demons. Prison staff restarted the ACCT procedures. The
next evening, Mr Samson was placed under constant supervision for several days.
63. On 26 March, the strategic safety lead chaired a meeting to discuss a team
approach in seeking Mr Samson’s agreement to move to the Beacon Unit. The
offender supervisor explained that Mr Samson’s agreement to participate in
treatment was an essential prerequisite. She also said that the Beacon Unit’s initial
response to her approach was the first positive response she had had from the
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various prisons she had contacted. The strategic safety lead noted that there were
potential hurdles, including Mr Samson’s possible refusal to agree to treatment at
the Beacon Unit. He said that alternative options needed to be put in place and the
meeting agreed that options included a general transfer to the long-term prison
estate, which would ideally be to Garth to leave the door open for a later move to
the Beacon Unit.
64. A CM chaired an ACCT case review that afternoon, which the strategic safety lead,
a psychiatrist and the key worker attended. Mr Samson was told about the possible
move to Garth and the strategic safety lead explained to him the re-categorisation
process and why he would remain a category B prisoner. Mr Samson agreed that
he might be able to re-establish a working relationship with his offender supervisor
and agreed that the best way forward might be to move to Garth on normal location
with a view to moving to the Beacon Unit in the future.
65. On 28 March, Mr Samson tested positive for a psychoactive substance.
66. On 10 April, at an ACCT case review, Mr Samson said that he trusted that the staff
were not lying to him and he was waiting for his transfer as promised. Mr Samson
denied any thoughts of self-harm and staff closed the ACCT procedures.
67. On 15 April, a CM told the offender supervisor that Mr Samson had returned the
Beacon Unit information pack back to him, saying it was not the place for him, but
that he wanted to meet her to discuss a way forward.
68. On 18 April, the offender supervisor told Mr Samson that she would schedule a
meeting for the following week to discuss a referral and transfer to a standard wing
at Garth. A psychiatrist also met Mr Samson that day and noted that he was
concerned about the prospect of mixing with non-vulnerable prisoners at Garth due
to the nature of his offence. He said that he had been attacked and threatened in
the past by other non-vulnerable prisoners.
69. On 26 April, the offender supervisor met Mr Samson and noted that while he
accepted that he needed treatment through the personality disorder pathway, he
was anxious about group work and felt that the groups at Garth’s Beacon Unit were
too large. Mr Samson asked to be considered for a return to the Millfields Unit and
the offender supervisor agreed to refer him for potential re-admission. In an email
to the Millfields Unit that day, she asked if a return was an option for Mr Samson
saying that he believed that he was now clearer on what would be expected of him
if he were to return.
70. On 3 May, Mr Samson contacted his offender manager to ask him to support his
return to the Millfields Unit. The offender manager replied to say that he had
already sent an email supporting the referral.
71. Also on 3 May, the offender supervisor submitted an intelligence report to say that
Mr Samson’s co-defendant had told her probation officer that Mr Samson had
telephoned her mother that day using a mobile telephone. Mr Samson’s co-
defendant said that Mr Samson had made similar attempts to re-establish contact
with her in the past, despite a restraining order prohibiting contact. The offender
supervisor noted that Mr Samson’s actions showed a clear escalation of risk and
coincided with him seeking a return to the Millfields Unit.
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72. Following the offender supervisor’s referral, a specialist registrar from the Millfields
Unit came to Pentonville on 29 May to interview Mr Samson. Mr Samson said that
he was working with a psychiatrist and that he hoped to return to the Millfields Unit
to engage in small groups. (The specialist registrar subsequently wrote a report
with recommendations for Mr Samson’s care, and which was disclosed to Mr
Samson on 19 July.)
73. On the morning of 31 May, a mobile phone was found in Mr Samson’s cell during a
security led search. Around an hour later, staff started ACCT procedures when Mr
Samson said that he would harm himself if his cell door was opened that day. Mr
Samson was placed on hourly observations. He was also suspended from his
prison job.
74. On 1 June, Mr Samson told an officer that the mobile phone did not belong to him
and he was worried that its discovery would jeopardise his return to the Millfields
Unit. He said that he would take his life if he did not return there and he showed the
officer a number of razor blades which he said he would swallow if anyone tried to
unlock his door.
75. An SO chaired an ACCT review that afternoon with a healthcare representative. Mr
Samson refused to come out of his cell but said that he would not kill himself until
he found out if he was to be re-admitted to the Millfields Unit. The SO noted that Mr
Samson’s level of risk was raised. He did not include any caremap actions.
76. Mr Samson refused to attend his next ACCT review, on 3 June, but the ACCT case
manager spoke to him at his cell door. Mr Samson said that he would take his life if
anyone tried to enter his cell but said he would come out of his cell if he was
allowed to go back to the Millfields Unit.
77. Also on 3 June, the offender supervisor emailed the strategic safety lead saying that
Mr Samson, by telephoning his co-defendant’s mother, had demonstrated his lack
of resolve to engage positively with the probation supervision process and asked if
it was now time for him to transfer to the long-term prison estate.
78. On 5 June, Mr Samson barricaded his cell door with a cupboard and tied a noose to
the cell window bars. He showed an SO a razor blade embedded in a piece of
wood which he placed in and out of his mouth. Mr Samson said that he wanted
staff to forcibly enter his cell so that he could kill himself in front of them. He
remained on hourly observations and no immediate relevant entry was made on his
caremap. Mr Samson remained barricaded in his cell for several days.
79. An SO chaired Mr Samson’s next ACCT case review on 6 June, which Mr Samson
refused to attend and repeated that he was waiting for staff to open his door so he
could take his life in front of them.
80. On 9 June, Mr Samson told the night officer that his offender supervisor had made
a mistake with his pre-tariff review, which meant that he would have to serve a
further eight years before being eligible for a move to an open prison. The night
officer submitted an intelligence report to say that Mr Samson said that he would
block the key holes and anti-barricade holes of his cell door and if staff entered his
cell he would take his life.
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81. On the morning of 10 June, an SO told Mr Samson that the situation could not
continue, and staff would enter the cell that day, using force if necessary. Mr
Samson responded by placing his head in the noose tied to the window bars. The
SO asked a psychiatrist to speak to Mr Samson. After speaking to them for some
time, Mr Samson agreed to remove the barricade, to surrender the noose and razor
blades, and to attend an ACCT case review.
82. An SO chaired an ACCT case review that afternoon. Mr Samson and a psychiatrist
attended, as did a Samaritans trained prison Listener, who attended at Mr
Samson’s request. Mr Samson said that he had a £150 debt to other prisoners,
whom he would not name, for losing the mobile phone, and he felt unsafe as a
result. He said that he wanted a job off the wing in the recycling or bin teams and
the SO agreed that that would be a good way to help him re-integrate onto the wing.
Mr Samson’s punishment for possession of the mobile phone included 42 days’ loss
of television. Mr Samson said that he would find that difficult and the SO agreed
that he could keep his television subject to good conduct. The SO wrote four
caremap actions: to remove the furniture from the cell, to remove the noose and
ligature, for Mr Samson to apply for a job and to allow Mr Samson a television. (It
is unclear what furniture was removed, but usual practice would be to return a
prisoner’s furniture within a brief time and this is what happened with Mr Samson.)
83. Over the following days, Mr Samson spent time out of his cell speaking to other
prisoners. An officer noted that he was in a much better mood.
84. On 13 June, the psychiatrist noted that Mr Samson was tired and low in mood but
was mentally stable. They spoke about the events of the past days and how he
might behave differently in the future.
85. At an ACCT case review on 17 June, chaired by an SO, Mr Samson said that he
feared that he would not be transferred to the Millfields Unit for the remainder of his
sentence. He said that he would then have to go through the process of re-
categorising to a category C, then to a category D, which he believed would take
him eight years over his tariff. Mr Samson said that he had made progress with the
psychiatrist, but he still had suicidal thoughts. The SO reduced Mr Samson’s
observations to one every two hours.
86. On 18 June, Mr Samson harmed himself by hitting his head against the wall. He
told staff that he was not having a good day. A Listener later spoke to Mr Samson.
87. At an ACCT case review on 24 June, Mr Samson said that he regretted harming
himself the week before as he was trying to move forward and to get a job and that
an SO had said he would help him with this. Mr Samson spoke about transfer to
another prison for a fresh start and where he could work with the mental health
team. An action point was added to Mr Samson’s caremap to contact OMU about
prison transfer.
88. On 25 June, the offender supervisor emailed the psychiatrist to say that Mr
Samson’s recent actions, including his attempted contact with his co-defendant and
discovery of a mobile phone, meant that he was unsuitable for the Millfields Unit at
that time. She added that she had informed the strategic safety lead in the hope Mr
Samson could be transferred to the long-term prison estate, which was part of the
original plan.
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89. On 28 June, an SO chaired an ACCT review where he noted that Mr Samson said
that he was feeling more optimistic about his future and did not want to die. The SO
reduced Mr Samson’s observations to once every three hours.
90. On 5 July, an SO chaired an ACCT case review. He noted that Mr Samson was
frustrated that he was still waiting for an answer about his possible transfer to the
Millfields Unit. The SO noted the prospect of closing the ACCT on 16 July, after
several key dates had passed: dates of birth of two of his siblings and the
anniversary of his offence.
91. On 10 July, Mr Samson told his key worker that everybody agreed Pentonville was
not the right place for him, but nothing was being done to move him out. The key
worker challenged Mr Samson on this and said that he had witnessed efforts to
move him which he had opposed. Mr Samson acknowledged that he had refused a
move to Garth, but explained that he would have to do group therapy at that prison
which would make him feel vulnerable to attack from other prisoners. Mr Samson
said that by November, he would have been at Pentonville for two years, when he
was initially told he would only be there for six months.
92. On 10 July, an officer noted a bruise on Mr Samson’s forehead. Mr Samson said
that he had hit his head on his cell wall after staff refused to let him make a
telephone call.
93. On 15 July, Mr Samson told his key worker that he was not in a good mood. He
said he was willing to move anywhere just to be out of Pentonville and would harm
himself if he had not moved by the end of the year.
94. At around 5.00pm, Mr Samson told an officer that he would refuse food until he was
moved from Pentonville. The officer noted that he contacted the prison’s offender
management unit, who told him that Mr Samson’s case was complex and he might
not move soon. He then noted that Mr Samson made threats to take another
prisoner hostage or assault a member of staff unless he was transferred. Mr
Samson also said that he would be “taken away in a body bag” on 27 November
(the second anniversary of his transfer to Pentonville). The officer noted that he
referred Mr Samson to healthcare for “his own wellbeing”. (There is no record in Mr
Samson’s healthcare record that they received or actioned any such referral.)
95. That day, several of the key staff exchanged emails about Mr Samson. The
strategic safety lead wrote that Mr Samson needed to address the areas in his
offending history to move successfully through his sentence. He wrote that his
understanding was that the work he had been doing with the psychiatrist had aimed
to get him into the best position to allow him to address his needs and that, while
that was happening, his time at Pentonville had seemed a reasonable compromise
for the potential future benefits. He went on to say that in the absence of any clear
progress, it was time for Mr Samson to be transferred to a longer term prison.
96. The offender supervisor responded to say that she had received the report from the
Millfields Unit, which recommended that Mr Samson’s pathway should be prison-
based, including treatment through a PIPE unit. She wrote that she agreed with
that plan and that she intended to share the report with Mr Samson on 16 July.
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97. On 16 July, an SO chaired an ACCT case review with the psychiatrist and Mr
Samson. Mr Samson said that he was frustrated that he had heard nothing about
his referral to the Millfields Unit. Mr Samson made threats to harm himself or take a
hostage if he was still at Pentonville in November. (The strategic safety lead had
earlier emailed the SO to say that he could not attend the review but would start the
process of looking for a suitable prison to transfer Mr Samson.)
98. On 19 July, an SO chaired an ACCT case review with Mr Samson, at which the
offender supervisor disclosed the report from the Millfields Unit recommending that
he should be transferred to a PIPE unit with treatment programmes involving group
work. The SO noted that Mr Samson said that he had predicted the
recommendation. He also said that when he had engaged in this type of work in
the past, he had been threatened by other participants and had responded though
self-harm. Mr Samson said that he would not engage in any more therapeutic work
and wanted to transfer to a prison or unit for vulnerable prisoners. The offender
supervisor said that she would give Mr Samson time to reflect on the report and
would speak to him again about it. Mr Samson said that he would begin an
escalating programme of self-harm, starting with food refusal, which he said he had
begun, and culminating in suicide by ligature in November. The SO noted that he
believed Mr Samson made the threats partly for affect and he therefore made no
change to Mr Samson’s level of conversations and observations, which remained at
three conversations a day and observations at three-hour intervals. He noted Mr
Samson’s level of risk as raised. He made no additions to Mr Samson’s caremap
and set the next ACCT review for 25 July, to allow time for the psychiatrist and
offender supervisor to speak to him further about the report. He subsequently
emailed a copy of the review to those involved in Mr Samson’s care.
99. A Listener told us that the news that he would not be returning to the Millfields Unit
affected Mr Samson, as he believed going to a prison such as Grendon would delay
his release from custody for several more years.
100. On the evening of 19 July, an officer noted in Mr Samson’s ACCT that he continued
to have thoughts of taking his life and that he said he was tired of management
lying to him. The officer also noted that Mr Samson was not eating, he was losing
weight and appeared frail.
101. On the afternoon of 20 July, an officer noted that Mr Samson had still not eaten.
102. On 21 July, Mr Samson told his key worker that Pentonville was meant to be a
stepping-stone to move to a category C prison, but he felt that he would never get
out of the prison and had started making plans to kill himself. The key worker
reminded Mr Samson that he had previously been told what he needed to do to
progress, but Mr Samson said it was impossible for him to achieve the goals he had
been set and he could not understand why he could not just be made category C to
allow him to move on. Mr Samson said that he had nothing to live for, that he was
going to stop working with the psychiatrist and indicated he might assault his
offender supervisor if she came to see him again. He said that his offender
supervisor had always wanted him to engage in group therapy, which he felt would
endanger his life. The key worker told the investigator that he told wing staff about
the conversation and then returned to his own wing.
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Events of 22 July 2019
103. A Listener told us that he spoke to Mr Samson from 11.00am until the early
afternoon. He said he had supported Mr Samson for the previous two years and
described Mr Samson as a troubled man who felt let down by the system. He said
that Mr Samson could be fine one minute, and completely different the next minute.
104. At around 3.00pm, an officer went to see Mr Samson after she was told that he
wanted to speak to her. Mr Samson asked her to arrange a meeting with 11 named
staff, including probation staff. He gave her a three-month time frame for the
meeting to ensure everyone would be present. He said that if nothing was done,
his plan was to hang himself in November on the second anniversary of arriving in
Pentonville. He also said that he had not eaten for 12 days and that he had razor
blades in his cell with which he planned to harm himself in two weeks’ time. Mr
Samson also asked her to help him write a Will. She said that she told an SO about
the conversation.
105. At around 3.30pm, Mr Samson argued with other prisoners at the pool table, after
which he returned to his cell. An officer asked Mr Samson if he was okay, and he
said the other prisoners were arguing and he did not want to get involved. The
officer then spoke to the other prisoners who said there had been a minor dispute
about whose turn it was to play.
106. At around 4.00pm, a Listener returned from work to the wing and noticed people
around Mr Samson's cell. He said Mr Samson was giving away his belongings and
said that he was going to barricade his cell and kill himself. He said that he told two
officers what Mr Samson had said. Another Listener gave similar evidence.
107. In an email at 4.02pm, the offender supervisor asked the key worker for further
information about Mr Samson’s threat to assault her. She then emailed others
involved with Mr Samson to say that given his threat, and the report from the
Millfields Unit, it was time to transfer him to a new prison. The strategic safety lead
emailed to say that he agreed that Mr Samson should be transferred, that he
believed Garth was an option, and he asked an SO to start the process. He added
a comment about the need to keep Mr Samson safe, given that he had mentioned a
fixed suicide plan.
108. At 5.00pm, Officer A noted in Mr Samson’s ACCT that his mood had deteriorated
quite quickly during the afternoon and that he had locked himself in his cell, saying
he was in a bad place. He wrote that he had given Mr Samson information about
Grendon and Warren Hill which he was reading. He wrote in a subsequent
statement that he felt uneasy about Mr Samson, so he spoke to an SO about
increasing the frequency of ACCT observations and decided to take his meal break
on the landing in case he was needed. (We were unable to interview Officer A
about the events of 22 July 2019 as he went on long term sick leave shortly after
our investigation began.)
109. Officer B told us that he spoke to Mr Samson from around 5.00pm to 5.30pm. He
said that Mr Samson was in a good mood and that he spoke about possibly going to
Warren Hill and about his interest in music and cooking. After leaving Mr Samson’s
cell, he told Officer A that Mr Samson had had a bad afternoon but was now feeling
better.
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110. An SO told us that he spoke to both officers’ concern about the frequency of ACCT
observations but, based on what Officer B said, he did not consider that an increase
of observations was needed.
111. At around 6.15pm, Officer C went to Mr Samson’s cell, and he asked to see the
wing SO. The officer told him that the prison was then in evening patrol state and
the SO had finished duty. Mr Samson then gave the officer a sealed envelope on
which he had written ‘Will’. The officer asked Mr Samson for an explanation, and
he said that he had had enough and asked to speak to a Listener.
112. Officer C unlocked a Listener so that he could speak to Mr Samson. She also
radioed CM A, one of the two senior officers on duty.
113. The Listener spoke to Mr Samson for several minutes until a CM and an SO arrived
and asked him to move away from the cell. He said that he could see that Mr
Samson had barricaded his cell.
114. The CM told us that he and the SO arrived on the wing at around 6.45pm. He
introduced himself to Mr Samson, spoke to him for a while and tried to persuade
him to remove the barricade so that he could go into the cell to speak to him. Mr
Samson refused to remove the barricade. The SO then took over talking to Mr
Samson as the CM went to collect equipment, including an Allen key to gain entry
to the cell.
115. The SO said that Mr Samson spoke about some of his personal history and was
very pessimistic. She said that she tried to make the conversation more positive by
talking about the future but Mr Samson said that he would be dead by the morning.
116. The Listener also spoke briefly to Mr Samson before Officer A began to speak to
him at around 7.05pm. The officer said that when he came to the door, Mr Samson
was pacing up and down in the cell but came to the cell door observation panel to
talk to him. At about the same time, the CM began to adjust the door hinges. He
adjusted the middle and bottom hinges with ease but found that the Allen key
recess of the bolt securing the top hinge had rounded off so the Allen key would not
engage. The CM said that Mr Samson realised what was happening and said that
they were “not coming into the cell”. He said that Mr Samson had already said that
he would kill himself that evening, so he considered that staff had to gain entry.
The officer told Mr Samson that it did not need to end that way and he tried to
distract him by talking about two of the prisons Mr Samson was interested in, but Mr
Samson said that he would never be allowed to transfer to those prisons or to
hospital and said that it was too late.
117. Mr Samson had a length of torn bed sheet in his hand and he then sat on the
window ledge and tied the ligature to the window bars and around his neck. Officer
A told his colleagues what Mr Samson was doing. Mr Samson then let himself slide
off the window ledge. The officer said that Mr Samson was hanging and the SO
radioed a code blue alarm, indicating a life-threatening medical emergency.
118. The CM had still not been able to adjust the top bolt, so he radioed for a door
enforcer ram and also radioed for the fire brigade to be called to assist in gaining
entry to the cell. The CM collected further tools and was able to adjust the top
hinge by hammering the Allen key into the bolt head recess.
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119. Staff went into the cell around eight minutes after Mr Samson began to hang
himself. One of the officers cut the ligature and Mr Samson was brought onto the
landing where nurses were waiting to treat him.
120. Nurses checked Mr Samson for signs of breathing and a pulse, but there was none.
They also found a second ligature around his neck which was hidden beneath his
T-shirt with razor blades attached and which the nurses cut away. Nurses also
found a foam ball, which was wet, and which Mr Samson had possibly held in his
mouth. The nurses started cardiopulmonary resuscitation (CPR). Initially, they
were unable to give a good supply of oxygen as the swelling to Mr Samson’s neck
made it difficult to insert an airway. However, they managed to insert an airway
after around 20 minutes and were then able to give a good oxygen supply.
Ambulance paramedics arrived at around 7.40pm and took charge of Mr Samson’s
care. The paramedics were able to establish a pulse and Mr Samson was taken to
University College Hospital at around 9.00pm. Mr Samson remained in intensive
care until he died on 23 August.
Contact with Mr Samson’s family
121. Pentonville made enquiries to locate Mr Samson’s family, but were told that all his
siblings had been subject to confidential adoptions. After Mr Samson’s death, a
clinician in contact with one of Mr Samson’s brothers made contact with Pentonville.
His brother attended Mr Samson’s funeral.
122. Pentonville contributed to the cost of Mr Samson’s funeral in line with national
instructions.
Support for prisoners and staff
123. The strategic safety lead debriefed the staff involved in the response when Mr
Samson was discovered. The staff care team also offered support.
124. The prison posted notices informing other prisoners of Mr Samson’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Samson’s death.
Post-mortem report
125. Mr Samson’s post-mortem report gave his cause of death as cerebral hypoxia-
ischaemia due to suspension, with a secondary cause of death as pneumonia.
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Findings
Management of risk of suicide and self-harm
126. Prison Service Instruction (PSI) 64/2011 contains guidance and mandatory
instructions on managing prisoners at risk of suicide and self-harm. Mr Samson
was supported under ACCT procedures throughout much of his time at Pentonville,
including when he harmed himself on 22 July. ACCT case reviews were generally
multidisciplinary and made up of staff who knew Mr Samson well. Generally, Mr
Samson received good support from staff, including from his key worker.
127. However, while there is much that was positive about Mr Samson’s general
management, we have concerns about aspects of his ACCT management.
Caremap
128. PSI 64/2011 instructed that, in the version of ACCT used in 2019, a caremap had to
be completed at the first case review for all prisoners subject to ACCT monitoring.
It said that the caremap should reflect the prisoner’s needs, the triggers of their
distress, and must aim to address the issues identified at the assessment interview
and at later case reviews. (In a revision to PSI 64/2011, issued in July 2021, the
caremap was replaced by a support plan.)
129. We consider that there were inadequacies in the use of the final caremap in
addressing Mr Samson’s risk. No caremap actions were made following his first
three ACCT case reviews. His sentence plan was clearly a considerable issue for
Mr Samson and caremap actions might have been used to ensure that this was
monitored and discussed at future case reviews. There was also no caremap
action made to address Mr Samson’s food refusal and apparent weight loss.
130. On several occasions, Mr Samson showed staff that he had accumulated razors
with which he threatened to harm himself, including the occasion when he
barricaded himself in his cell.
131. In April 2019, the Prison Service issued a safety briefing about the management of
razors in prisons. This requires that access to razors and other sharp items should
be discussed at ACCT case reviews and the outcome reflected in the caremap for
all prisoners subject to ACCT monitoring. While we recognise the difficulties in
managing access to razors for prisoners on normal location, there is no discussion
in Mr Samson’s case reviews about how he had managed to collect razors.
Level of risk
132. At his final ACCT case review, on 19 July, Mr Samson was told that the Millfields
Unit had not accepted his return. His next case review was set for 25 July, to allow
time for a psychiatrist and his offender supervisor to speak with him, which was not
included on the caremap. A substantial team of experienced staff were involved in
Mr Samson’s care and all would have realised his disappointment at hearing the
outcome of the referral. Mr Samson made frequent threats about taking his life,
which included very specific threats about taking his life if he did not return to the
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Millfields Unit. We consider that Mr Samson’s support team should have combined
to give greater thought to how and when to disclose the news to Mr Samson and to
the provision of additional support in the following days: this could have included
making prior arrangements for dates and times for key people to speak with him.
Given Mr Samson’s threats, more thought should also have been given to
increasing his level of risk and frequency of ACCT observations and conversations.
133. During the afternoon of on 22 July, there were clear signs of an escalation of risk:
Mr Samson asked an officer to help him write his Will, he spoke about using razors
to harm himself and he said he had not eaten for 12 days. He told another prisoner
that he was going to barricade himself in his cell. Officer A noted in Mr Samson’s
ACCT that his mood had deteriorated quite quickly during the afternoon. The SO
did not speak to Mr Samson himself but, after speaking to Officer B at about
5.30pm, he did not consider that he needed to adjust the level of observations.
134. Guidance in the ACCT document is that risk is high when a prisoner has frequent
suicidal ideas that are not easily dismissed, there is a specific plan with likely
access to lethal methods and the situation experienced causes unbearable pain.
135. While Mr Samson clearly received a great deal of support from staff through that
afternoon, we consider that the SO should have spoken directly to him and
considered increasing his level of risk and frequency of observations. We make the
following recommendations:
The Governor should ensure that staff manage prisoners at risk of suicide
and self-harm in line with national instructions, including that:
• support actions are set that are specific, meaningful and identify all of
the issues identified at assessment interviews and case reviews,
including ensuring that appropriate support is provided when difficult
news is given to a prisoner at risk of suicide and self-harm;
• prisoners’ access to razors is managed in line with national instructions;
and
• case reviews consider all relevant information that affects risk, and staff
review the risk of suicide and self-harm whenever an event occurs which
indicates an increase in risk.
Moving Mr Samson on from Pentonville
136. Mr Samson was transferred to Pentonville in November 2017, as it was the prison
local to the Millfields Unit. In their discharge summary, Millfields Unit staff explained
that Mr Samson had made no progress with his treatment targets, that he continued
to breach boundaries, and that the Unit would support Pentonville in Mr Samson’s
onward referral to a more suitable prison. Mr Samson was still at Pentonville 20
months later when he committed the act of significant self-harm that ultimately
resulted in his death.
137. No action was taken by Pentonville to transfer Mr Samson during the first several
months as the prison wanted him to stabilise and the ESS team were trying to
support him with this goal. Unfortunately, there appears to be no clear point when
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Mr Samson properly stabilised: he was clearly very frustrated with his situation and
often reacted by harming himself. In addition, he was found at times to have used
illicit substances and was also found in possession of a mobile phone with which he
attempted to contact his co-defendant.
138. When the offender supervisor began to speak with Mr Samson about a move to a
suitable prison for sentence progression, he resisted suggestions that involved
group work as he said that he feared for his safety when speaking about the
circumstances of his offence. Instead, Mr Samson believed he could go to a
category C prison and receive one-to-one support. There are also indications that
Mr Samson thought that he was progressing through his sentence solely on the
basis of time served, as he seemed to believe that he was potentially close to
becoming a category D prisoner and that there was a possibility that he might
achieve parole in the near future. In April 2019, there was a further pause in efforts
to transfer Mr Samson when he persuaded his offender supervisor to try to refer
him back to the Millfields Unit.
139. For Mr Samson to make true progress through his sentence, it was essential for him
to engage and deal with the significant issues surrounding his offence. However,
he either failed, or refused, to understand this and when he was told that he would
not be returning to the Millfields Unit, this was a pivotal moment for him. It is
unclear how or why his offender supervisor was unable to impress upon Mr Samson
what he needed to do to progress, but this was clearly the key issue. We note that
their relationship became very strained, and Mr Samson also made some veiled
threats towards her: possibly because he did not want to hear what she was telling
him or perhaps due to clash of personality. We cannot say what alternative steps
might have made a difference, but we do not consider that sufficient thought was
given in considering how to resolve the impasse, such as transferring Mr Samson to
a different offender supervisor. She said that she and her manager did discuss this
option, but we are unclear why Mr Samson was not transferred given the clear
breakdown in the relationship. We make the following recommendation:
The Governor should ensure that prison offender managers (previously
known as offender supervisors) are given appropriate support where needed,
including that:
• prison offender managers are accompanied by a senior colleague, where
appropriate, in reiterating difficult messages to prisoners; and
• prisoners are re-allocated to a new prison offender manager when the
relationship with the existing offender supervisor has broken down.
Attempted return to the Millfields Unit
140. On 26 April 2019, Mr Samson asked his offender supervisor about returning to the
Millfields Unit and she agreed to send a referral. Following his assessment, a
member of the Unit advised Pentonville that referral to a prison PIPE unit seemed
the appropriate pathway. Mr Samson was told of this outcome on 19 July, just days
before his significant act of self-harm. We understand that prison referrals to the
Millfields Unit would ordinarily come from the prison healthcare team following an
assessment by the prison psychiatrist. In Mr Samson’s case, the referral came
direct from the offender supervisor without apparent consultation with the mental
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health inreach team (although she did inform a psychologist involved in Mr Samson
support).
141. We cannot say what might have happened had the offender supervisor asked
Pentonville’s mental health inreach team to consider Mr Samson’s suitability for
referral to the Millfields Unit, although there is no indication of any significant
change in his behaviour or mental health state since his discharge from the
Millfields Unit in November 2017. We cannot say how Mr Samson might have
responded had he been told in April that there was no basis for a further referral to
the Millfields Unit. However, we do not consider that it was helpful for him to spend
the following three months waiting and hoping for an outcome that always seemed
destined to be a refusal to re-admit him. We make the following recommendation:
The Governor and Head of Healthcare should ensure that all staff at
Pentonville understand that referrals to secure mental health units should
only be made through the prison’s mental health Inreach team.
Management of Mr Samson’s food refusal
142. Chapter 10 of PSI 64/2011, Management of prisoners who refuse food and/or fluids
and medical treatment, says that food and fluid refusal is not considered in law to
be a form of self-harm, but that the ACCT process may provide a useful way of
recording the care offered and facilitate information sharing and that many prisons
put in place a food refusal log. It instructs that every effort must be made to try to
find out why the prisoner is refusing food and/or fluids and address the reasons for
their refusal. PSI 64/2011 also refers to Department of Health guidance on practical
and clinical management of individuals during and following refusal to eat. This
guidance states that it is critical that a thorough assessment of a person’s mental
capacity and nutritional status is undertaken immediately and there should be
regular reassessments of the person’s physical and mental state.
143. The psychologist noted on 13 June that Mr Samson appeared to have lost a lot of
weight and she referred him to the primary care team. On 15 July, Mr Samson
refused his evening meal, and he told an officer that he would no longer take food
until he was transferred. On 19 July, Mr Samson said at an ACCT case review that
he had started food refusal as a course of self-harm. On 22 July, he said that he
had not eaten for 12 days.
144. Despite all of these references, prison and healthcare staff did not take any specific
action. They did not start a food refusal log or create a food and fluid care plan to
monitor Mr Samson’s nutritional needs. His food refusal was not included as an
issue on his caremap. We note that Mr Samson’s weight at post-mortem was 42kg,
which is 14.6kg less than when he was last weighed in April 2018. Although we
cannot speculate what his weight had been on the day that he harmed himself and
was sent to hospital, there is considerable evidence that he had stopped eating
properly and had lost weight.
145. The clinical reviewers noted that Mr Samson’s records contain reference to periods
of time when he was not eating, but they note the absence of records of his weight
on an ongoing basis and that there are no reassessments of his nutritional needs
following the initial assessments after Mr Samson’s arrival in Pentonville. We
recommend that:
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The Governor and Head of Healthcare should ensure that staff manage a
prisoner who is refusing food in line with national guidelines.
Events of 22 July 2019
The decision to enter Mr Samson’s cell
146. Mr Samson had barricaded himself in his cell for ten days in the beginning of June,
until staff eventually persuaded him to remove the barricade and to come out of his
cell for an ACCT case review.
147. However, in the late afternoon of 22 July, CM A decided to gain entry into Mr
Samson’s cell without delay. Mr Samson said that he would kill himself if staff came
into the cell, but the CM’s assessment was that staff needed to enter the cell as Mr
Samson had also said that he intended to take his life that evening.
148. We appreciate that CM A found himself in a very difficult position that afternoon. He
did not know Mr Samson, and most of the staff, including those who best knew Mr
Samson, would have left the prison by that time. However, Mr Samson had not
started to harm himself at the point that CM A arrived on the wing and Officer A,
whom Mr Samson appeared to like and trust, was on duty. In addition, we note that
Pentonville’s Contingency Plan on dealing with barricades instructs that the orderly
officer should take instruction from the duty governor. We believe that CM A should
have spent more time in evaluating the situation and in considering alternative
options. For instance, he could have asked the officer and prisoner Listeners to
speak with Mr Samson while he took advice from the duty Governor, and he might
have considered the use of trained negotiators. He might also have considered
placing Mr Samson under constant supervision through the night.
Difficulty in entering the cell
149. When CM A decided to enter the cell, the barricade meant that he had to use the
anti-barricade Allen key to remove the cell door. When attempting to remove the
top bolt, he found that the Allen key recess had rounded off, which took an
additional eight minutes to remove. An officer told the investigator that he was in
charge of maintenance and facilities at Pentonville and explained that full checks on
the door hinge bolts were made every six months, which included unscrewing and
re-screwing each bolt. He also understood that a visual check of the bolts formed
part of the standard daily cell fabric checks made by officers, which CM A confirmed
to be the case. We do not know how visible the existing damage was to the final
bolt, which would of course have been further damaged when it was removed that
day. We make the following recommendations:
The Governor should ensure that staff inform the duty governor when a
prisoner has barricaded himself in his cell and that staff consider all options,
including use of trained negotiators, when dealing with prisoners who are
threatening suicide or significant self-harm.
The Governor should share a copy of this report with CM A and arrange for a
senior manager to discuss the Ombudsman’s findings with him.
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The Governor should ensure that officers check the condition of door hinge
securing bolts when making their daily cell fabric checks.
Clinical care
150. The clinical reviewers noted that Mr Samson did not have a severe or enduring
mental illness but had antisocial and borderline personality disorders and a complex
post-traumatic stress disorder. The reviewers noted that the healthcare provisions
at Pentonville were not commissioned to provide the sustained therapeutic
intervention required for people diagnosed with such personality disorders.
However, the reviewers noted that the ESS team kept Mr Samson on their caseload
for a considerable time and continued to support him informally, even after he had
been discharged from their caseload. They found that this was an example of good
practice and above the standard expectation of the service. The clinical reviewers
also noted the considerable support Mr Samson received from a worker from the
Building Futures team and individual psychology support from the psychologist.
Inquest
151. An inquest into Mr Samson’s death that concluded on 11 December 2023 found
that his medical cause of death was cerebral hypoxia ischaemia following
suspension and pneumonia. The inquest jury concluded that his death was from
misadventure exacerbated by the mechanical failure of the cell door hinge bolt.
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