Marc Skelly

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Independent investigation into
the death of Mr Marc Skelly,
a prisoner at HMP Lindholme,
on 22 June 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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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is 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 Marc Skelly was found hanging in his cell at HMP Lindholme on 16 June. He died in
hospital on 22 June. He was 33 years old. I offer my condolences to his family and
friends.
Mr Skelly had a number of risk factors which indicated that he was at risk of suicide and
self-harm. He often told staff that he felt unsafe in prison. Mr Skelly was monitored under
suicide and self-harm prevention measures (known as ACCT) for the majority of his time at
Lindholme. We found some deficiencies in the way ACCT procedures were managed.
The clinical reviewer concluded that the care Mr Skelly received for his substance misuse
and mental health was not equivalent to that which he could have expected to receive in
the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Prisons and Probation Ombudsman October 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 12
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Summary
Events
1. In August 2021, Mr Marc Skelly was remanded into custody, charged with robbery.
He was sentenced to eight years in prison in November and was sent to HMP
Lindholme in February 2022.
2. Mr Skelly had a history of self-harm, mental illness and substance misuse. He was
managed under a care, support and intervention plan (CSIP) after he told prison
staff that he was under threat from other prisoners and had drug-related debts.
3. On 6 February, prison staff started suicide and self-harm prevention procedures,
known as ACCT, after Mr Skelly’s mother telephoned the prison and expressed
concern that he was suicidal. Mr Skelly was monitored under ACCT procedures for
the majority of his time at Lindholme.
4. On 3 June, Mr Skelly’s custodial behaviour deteriorated, and he was moved to the
care and separation unit. A mental health nurse advised against Mr Skelly’s
segregation, and he was returned to the wing.
5. On 10 June, Mr Skelly started isolating in his cell because he believed he was
under threat from other prisoners. Staff monitored Mr Skelly under the prison’s self-
isolation strategy.
6. At 10.59am on 16 June, an officer carrying out an ACCT check found Mr Skelly
sitting on the floor, with a ligature around his neck which was attached to the toilet.
Staff and paramedics resuscitated him, and he was taken to hospital. Mr Skelly did
not regain consciousness and, at 5.25am on 22 June, it was confirmed that he had
died.
Findings
1. The investigation found that Mr Skelly received appropriate support through a
challenge, support and intervention plan (CSIP). There were a number of failings in
the management of ACCT procedures. Case reviews were not always
multidisciplinary and Mr Skelly’s most recent caremap did not include a specific
action to address his substance misuse. Prison staff did not carry out a post-
closure review.
2. Mr Skelly was not seen by the substance misuse service in the weeks before his
death despite his history of substance use and drug-related debt.
3. Mr Skelly had been diagnosed with personality disorders and was prescribed
antidepressants and antipsychotic medication. His mental healthcare was provided
primarily through the ACCT process and healthcare staff did not assess if his
mental health should be addressed on an individual therapeutic basis. The clinical
reviewer concluded that Mr Skelly’s substance misuse and mental healthcare was
not equivalent to that which he could have expected to receive in the community.
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Recommendations
• The Governor should ensure that staff manage prisoners at risk of suicide and self-
harm in line with national instructions. In particular, staff should:
• hold multidisciplinary ACCT reviews; and
• set effective caremap objectives which are specific, time-bound, meaningful,
aimed at reducing risk and updated at each case review.
• The Governor should ensure that ACCT post-closure reviews are conducted in
line with Prison Service instructions and should be held to check the prisoner’s
progress and to decide whether further monitoring is needed.
• The Head of Healthcare should ensure that prisoners who need mental health
support receive a full mental health assessment to determine if they need individual
therapeutic intervention.
• The Head of Healthcare should ensure that the substance misuse team considers a
prisoner’s substance misuse history and custodial behaviour when assessing the
required level of substance misuse support.
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The Investigation Process
4. The investigator issued notices to staff and prisoners at HMP Lindholme informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
5. The investigator obtained copies of relevant extracts from Mr Skelly’s prison and
medical records.
6. NHS England commissioned a clinical reviewer to review Mr Skelly’s clinical care at
the prison. The investigator and clinical reviewer jointly interviewed healthcare staff.
7. We informed HM Coroner for South Yorkshire East District of the investigation. We
had not received a copy of the post-mortem examination at the time of writing this
report. We have sent the Coroner a copy of this report.
8. We wrote to Mr Skelly’s next of kin, his mother, to explain the investigation and to
ask if she had any matters she wanted us to consider. Mr Skelly’s mother asked:
• Why was Mr Skelly not moved to another prison after he jumped on the netting?
• What action did staff take when Mr Skelly was in debt to other prisoners?
• Was Mr Skelly being monitored under suicide and self-harm prevention
measures?
We have answered Mr Skelly’s mother’s questions in this report. Mr Skelly’s mother
also raised other matters that we have addressed separately.
9. Mr Skelly’s mother received a copy of the initial report. She did not raise any further
issues, or comment on the factual accuracy of the report.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP LIndholme
11. HMP Lindholme is a medium security prison near Doncaster, which holds
approximately 1,000 men. Care UK provides healthcare services, with healthcare
staff on duty between 7.30am and 7.30pm every day.
HM Inspectorate of Prisons
12. The most recent inspection of HMP Lindholme took place in October 2017.
Inspectors reported that levels of self-harm were higher than at similar prisons.
Drug use, debt and violence were often linked to the causes of self-harm and two
self-inflicted deaths had been linked to drug use.
13. Inspectors found some improvements in the care of prisoners at risk of self-harm
and subject to ACCT processes. Case management was more consistent, ACCTs
were quality assured and findings were discussed at the monthly safer custody
meeting. Inspectors came across examples of good care for prisoners, with the
most complex cases considered at weekly multidisciplinary safety meeting.
However, for other prisoners, the quality of ACCT care provision was mixed,
caremaps were not robust enough to address all identified issues and some reviews
were not sufficiently multidisciplinary.
Independent Monitoring Board
14. 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 January 2022, the IMB reported
that the number of self-harm incidents had decreased slightly in comparison to the
previous year. The number of ACCT documents opened in the reporting period had
also decreased. The IMB reported that 80.6% of prisoners said they felt safe, in
comparison to 81.8% in October 2019.
15. The IMB was pleased to report that there were no deaths in custody during the
reporting year.
Previous deaths at HMP Lindholme
16. Mr Skelly was the second prisoner to die at Lindholme since June 2020. The
previous death was drug-related. There are no similarities between our findings in
the investigation into Mr Skelly’s death and our investigation findings for the
previous death.
Assessment, Care in Custody and Teamwork
17. Assessment, Care in Custody and Teamwork (ACCT) is the Prison Service care-
planning system used to support prisoners at risk of suicide or self-harm. The
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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.
18. After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
ACCT plan should not be closed until all the actions of the caremap have been
completed.
19. All decisions made as part of the ACCT process and any relevant observations
about the prisoner should be written in the ACCT booklet, which accompanies the
prisoner as they move around the prison. Guidance on ACCT procedures is set out
in Prison Service Instruction 64/2011 on safer custody.
Challenge, Support and Intervention Plan
20. A challenge, support and intervention plan (CSIP) is the national case management
model for managing those who are violent or pose raised risk of harming others
through violent behaviour. It can also be used to support victims or potential victims
of violence.
21. It aims to challenge violent behaviours and set clear expectations on what
behaviours are not acceptable, making sure that punitive measures are not applied
in isolation. It places equal focus on ensuring that individuals with challenging
behaviours can progress towards a more positive outlook, where they choose not to
reoffend.
22. CSIP should be targeted at those individuals who display more challenging violent
behaviours or those who show signs they are highly likely to display this behaviour.
These challenging behaviours could be identified by the nature or frequency of their
violence or the extent to which their behaviour strongly indicates that they are likely
to display more challenging violent behaviours. It is important that CSIP is never
used in place of an ACCT plan.
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Key Events
23. On 21 August 2021, Mr Marc Skelly was remanded to HMP Leeds, charged with
robbery. Mr Skelly had been in prison before. On 31 November, he was found
guilty and sentenced to eight years in prison. Mr Skelly had a history of attempted
suicide, substance misuse, anxiety and depression and personality disorders. He
was managed under Prison Service suicide and self-harm monitoring procedures
(known as ACCT) for the majority of his time at Leeds after cutting himself. Mr
Skelly told staff that he knew other prisoners from his time in the community. He
believed he was under threat from other prisoners due to his offence and was
moved to a different wing on two occasions.
24. On 21 December, Mr Skelly was transferred to HMP Humber. He was managed
under ACCT procedures on one occasion after he harmed himself by cutting
himself.
25. On 21 January 2022, prison staff told Mr Skelly that he had been accepted at HMP
Lindholme. Mr Skelly was very happy with this news and said it would make it
easier for his parents to visit.
HMP Lindholme
26. On 2 February 2022, Mr Skelly was transferred to HMP Lindholme. A nurse
completed his initial health screen and noted his history of depression and anxiety.
Mr Skelly said that he did not have any thoughts of suicide and self-harm. The
nurse prescribed him antidepressants and antipsychotic medication which he was
not allowed to keep and administer himself. The nurse referred him to the prison’s
mental health team.
27. Prison staff completed a cell-sharing risk assessment (CRSA), which recorded that
Mr Skelly posed a standard risk for sharing a cell. In line with COVID-19
restrictions, Mr Skelly was placed in isolation for ten days. A prison officer
completed his first night induction interview. She noted that he had a positive
attitude and had recently been monitored under ACCT procedures. Mr Skelly said
that he did not have any thoughts of suicide or self-harm. He was allocated a
keyworker who completed regular welfare checks. Mr Skelly told his keyworker that
he was happy to be at Lindholme and he did not share any issues or concerns.
28. On 5 February, Mr Skelly threatened his cellmate because he was unhappy about
having to isolate. Prison staff increased Mr Skelly’s cell-sharing risk to high and
moved him to a single cell.
ACCT monitoring: 6 February to 18 March
29. On 6 February, Mr Skelly’s mother telephoned the prison and said that Mr Skelly
had told her that he was feeling suicidal. Prison staff started ACCT monitoring and
added two actions to Mr Skelly’s caremap which were to continue to engage with
the mental health team and substance misuse service.
30. On 9 February, Mr Skelly moved to K wing and prison staff noted that he had settled
well. That day, a mental health nurse assessed Mr Skelly and diagnosed him with
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anxiety, depression, borderline personality disorder, emotionally unstable
personality disorder and possible dissocial personality disorder.
31. On 13 February, Mr Skelly told a prison officer during an ACCT check that he
wanted to move to another wing and asked to speak to the supervising officer on
the wing. The prison officer submitted a challenge, support and intervention plan
(CSIP) referral to the safer custody team which stated that Mr Skelly did not appear
to have many friends on the wing and may have debt-related problems. The safer
custody team allocated a senior officer as Mr Skelly’s CSIP case manager and an
officer as his CSIP liaison officer.
32. That day, the CSIP liaison officer spoke to Mr Skelly in his cell. Mr Skelly said he
felt unsafe on the wing because other prisoners were using PS and he had argued
with another prisoner. Mr Skelly did not disclose any further details about the
argument. Mr Skelly said he was not in debt, and she noted that Mr Skelly had
plenty of property and canteen items in his cell to support this.
33. The CSIP liaison officer reviewed Mr Skelly’s ACCT plan and noted that Mr Skelly
had told his ACCT case manager that he was settled on K wing and had not raised
any issues. Mr Skelly declined a referral to the substance misuse service. She
advised Mr Skelly that he could access the prison’s violence reduction regime and
isolate in his cell. Mr Skelly said he did not want to isolate. She submitted a
security information report.
34. Prison staff carried out regular ACCT case reviews with limited healthcare input. Mr
Skelly initially denied being in debt to other prisoners. On 19 February, he harmed
himself by cutting his arm and barricaded himself in his cell. After prison staff had
removed the barricade, Mr Skelly said he was in debt to other prisoners and was
unable to settle on the wing. Mr Skelly said other prisoners whom he knew before
he came to prison had threatened him in his cell. During an interview with the safer
custody team, Mr Skelly refused to name the prisoners involved. Prison staff
submitted a security information report and increased Mr Skelly’s observations to
one every hour. Mr Skelly moved to G wing on 25 February.
35. Prison staff also submitted a CSIP investigation and referral form about Mr Skelly’s
debt. The safer custody team spoke to Mr Skelly about his debt issues and created
a debt management plan and a CSIP intervention care plan the CSIP case manager
noted on Mr Skelly’s care plan that he would continue to receive support through
ACCT monitoring, wing staff and the safer custody team.
36. On 2 March, Mr Skelly agreed to speak to a substance misuse support worker. Mr
Skelly said he had used PS, pregabalin and tramadol on the wing. A nurse from the
substance misuse service created a substance misuse care plan. Mr Skelly
continued to use illicit substances.
37. On 12 March, prison staff agreed to stop ACCT monitoring. Mr Skelly’s risk of
suicide and self-harm was assessed as low, and staff noted he was receiving
support from the safer custody team to ensure he did not incur further debt.
38. On 17 March, prison staff started ACCT monitoring again after Mr Skelly climbed on
the railings. He told staff that he was being bullied on the wing but denied any
thoughts of suicide and self-harm. Prison staff submitted an intelligence report and
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submitted a CSIP referral form. Mr Skelly’s ACCT case manager noted that he was
being transferred to Doncaster and ACCT monitoring would continue until he had
settled.
39. Mr Skelly was transferred to HMP Doncaster on 18 March and on 21 March, he
attended a family court hearing. During his time at Doncaster, staff continued with
ACCT procedures. Over the following weeks, staff noted that Mr Skelly’s mood was
low, but he said that he had no thoughts of suicide and self-harm.
HMP Lindholme: 6 April to 16 June
40. On 6 April, Mr Skelly returned to Lindholme and was allocated a cell on the reverse
cohort unit on G wing. During his first night induction interview, Mr Skelly said that
he had issues with other prisoners on K and G wing but refused to discuss this
further. He was allocated a keyworker who completed regular welfare checks. Mr
Skelly told his keyworker that he was receiving support from the mental health
team.
41. A nurse completed Mr Skelly’s initial health assessment and noted his history of
depression and anxiety. Mr Skelly said that he did not have any thoughts of suicide
and self-harm and his antidepressant prescription was continued. The nurse
referred him to the mental health team.
42. On 12 April, a substance misuse service worker completed a telephone assessment
with Mr Skelly. He said that he had not smoked PS or taken illicit pregabalin for
eight weeks. The substance misuse service worker noted that Mr Skelly did not
have any immediate substance misuse support needs. On 15 April, Mr Skelly
moved to L wing, where he attended recovery support programmes to help him
remain drug-free.
43. On 28 April, prison staff held a CSIP review. Mr Skelly said that he was under
threat from other prisoners. That day, a substance misuse service worker noted
that Mr Skelly struggled with anxiety and feeling low. Mr Skelly said that he did not
have any debt issues. The substance misuse service worker noted that Mr Skelly
was struggling to leave the wing to collect his medication, that he should continue to
attend recovery programme groups and would be assessed again on 28 July.
ACCT monitoring: 4 May to 2 June
44. On 4 May, prison staff started ACCT monitoring after Mr Skelly cut himself. Mr
Skelly told an ACCT case review that he was being bullied on L wing. Prison staff
added three actions to Mr Skelly’s caremap which said that he should engage with
the mental health team, continue to take his medication and consider a transfer to
another prison. There was no caremap action to address Mr Skelly’s substance
misuse, even though this was recorded as a trigger for his self-harm.
45. On 12 May, Mr Skelly moved to G wing. Prison staff noted that he had settled well,
had a new job and denied using illicit substances. A substance misuse service
worker noted on 19 May that Mr Skelly had not used illicit substances for six weeks
and knew how to seek substance misuse support. There is no evidence that the
substance misuse team saw Mr Skelly again before he died.
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46. On 19 May, prison staff agreed to stop ACCT monitoring. There was no healthcare
input. Staff assessed Mr Skelly’s risk level as low and the actions on his caremap
were complete. The post-closure phase would end on 27 May. An alert to this
effect was added to Mr Skelly’s electronic prison record, known as NOMIS. There
is no evidence that the post-closure review took place. Mr Skelly moved to J wing
on 23 May.
47. On 26 and 30 May and 1 June, prison officers gave Mr Skelly an incentives and
earned privileges (IEP) warning for refusing to attend work. Mr Skelly did not attend
an appointment with a psychiatrist on 30 May.
48. On 2 June, Mr Skelly told a mental health nurse that he did not always collect his
prescribed medication because he felt anxious waiting in the queue. The mental
health nurse arranged for him to collect his medication first or last to reduce his
waiting time. This significantly improved Mr Skelly’s compliance with collecting his
medication.
3 to 15 June
49. At around 1.52pm on 3 June, Mr Skelly accessed the safety netting for
approximately twenty minutes. (Mr Skelly was subsequently found guilty at a
disciplinary hearing and received a loss of privileges for 21 days.) Prison staff
moved him to the Care and Separation Unit (CASU). A mental health nurse
assessed Mr Skelly’s health and advised against his segregation. The nurse noted
that his mood was low, he felt anxious and had thoughts of suicide and self-harm.
Prison staff submitted a security intelligence report and moved him back to K wing
that day.
50. At 3.30pm, a Supervising Officer (SO) started ACCT monitoring. He completed the
immediate action plan and assessed Mr Skelly as at medium risk of suicide and
self-harm. Mr Skelly told the SO that his head ‘wasn’t in the right place’ and that he
did not want to talk. He decided Mr Skelly should be monitored four times an hour.
51. At 11.30am on 4 June, a SO completed an ACCT assessment with a nurse. Mr
Skelly said that he was in debt to other prisoners and wanted a move to another
prison. The SO added three actions to Mr Skelly’s careplan which said that Mr
Skelly should engage with the substance misuse and mental health teams and
consider a transfer to another prison. Mr Skelly denied any thoughts of suicide and
self-harm and said that he intended to isolate in his cell for his own safety. The
reduced Mr Skelly’s observations to two every hour.
52. On 6 June, the CSIP case manager carried out an ACCT case review. A SO
attended and there was no healthcare input. Mr Skelly said he had decided not to
isolate in his cell and did not have any feelings of suicide or self-harm. The case
manager reduced Mr Skelly’s observations to one every hour.
53. Mr Skelly had a meeting with his prison offender manager (POM) to discuss his
sentence plan objectives. She told the investigator that Mr Skelly said he wanted to
move prisons because he had issues on whichever wing he was located. He did
not want to discuss the issues further and said he hoped ACCT monitoring would
stop soon. She said Mr Skelly engaged well during the meeting and appeared
positive and upbeat. He did not express any feelings of suicide and self-harm. She
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told Mr Skelly that he could not apply for a transfer until he had been free of
disciplinary action for three months.
54. On 10 June, Mr Skelly told an officer he was under threat on the wing, and he
intended to isolate himself in his cell. The officer completed a CSIP investigation
and referral form and community concern form to inform the safer custody team that
Mr Skelly was isolating himself. The safety custody team recorded this information
and allocated an officer as his liaison officer.
55. A SO carried out an ACCT case review on 14 June with a Custodial Manager (CM).
There was no healthcare input. The SO noted that Mr Skelly was isolating in his
cell because he felt under threat. The SO spoke to Mr Skelly about moving to
another wing. Mr Skelly said he would consider moving to G wing and he had
submitted a request to transfer to another prison. The SO noted Mr Skelly’s
requests on his ACCT document and agreed that these would be discussed at his
next ACCT case review with the CSIP case manager on 21 June. Mr Skelly asked
the SO to remove two belts from his cell because he wanted to harm himself to
relieve stress. The SO removed the belts and increased Mr Skelly’s observations to
two an hour.
Events of 16 June
56. At 8.30am on 16 June, an officer noted in Mr Skelly’s prison records that he had
intended to stop isolating in his cell. Mr Skelly said that he wanted to mix with other
prisoners. CCTV footage showed that Mr Skelly left his cell at around 9.00am and
was talking to other prisoners. At around 10.03am, two prisoners went into Mr
Skelly’s cell and left shortly afterwards. CCTV footage shows that Mr Skelly left his
cell at 10.08am and walked around the wing. Mr Skelly did not appear upset or
distressed. Shortly afterwards, Mr Skelly told the prison chaplain that he felt
vulnerable and wanted to go back in his cell. The prison chaplain noted in Mr
Skelly’s prison records that he had passed this information to an officer.
57. At around 10.20am, an officer spoke to Mr Skelly at his cell door. He said that he
felt unsafe on the wing and wanted to isolate in his cell. He refused to discuss this
further and said he wanted to speak to the safer custody team. She told a SO that
Mr Skelly was isolating in his cell and made an entry in his ACCT plan. She also
asked the liaison officer to see Mr Skelly in his cell. She locked Mr Skelly in his cell
at around 10.21am.
58. Mr Skelly telephoned his sister at 10.26am. The investigator listened to the
telephone call. Mr Skelly sounded upset and told his sister that he had no money.
He said he had not received the £20 she had sent him. Mr Skelly’s sister agreed to
send another £20. Mr Skelly’s account shows he received £20 on 8 June, and he
bought telephone credit that day. Mr Skelly’s sister told him that someone was
claiming his son was not his. Mr Skelly said he was ‘losing his head’, felt paranoid
and needed to talk to someone. He told his sister that he wanted a transfer to
another prison and would call her again at 3.00pm.
59. At 10.59am, the officer went to Mr Skelly’s cell to carry out an ACCT check. On her
way to Mr Skelly’s cell, she passed the liaison officer, who told her she would see
him shortly. When the officer arrived at Mr Skelly’s cell, she looked through the cell
door observation panel and saw him slouched in a sitting position on the floor, with
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a ligature attached to the toilet. She radioed a medical emergency code blue
(indicating a prisoner is unconscious or has breathing difficulties). The control room
called an ambulance immediately. She entered Mr Skelly’s cell and used her fish
knife to remove the ligature from his neck. A SO arrived very shortly afterwards and
started cardiopulmonary resuscitation (CPR). A defibrillator was attached to Mr
Skelly and did not initially detect a shockable rhythm.
60. A nurse and a healthcare assistant arrived at Mr Skelly’s cell at around 11.05am
and took over CPR, assisted by another nurse. The defibrillator detected a
shockable rhythm. Paramedics arrived at 11.17am and took over Mr Skelly’s care.
They connected Mr Skelly to a portable ventilator and took him to hospital. Two
prison officers escorted Mr Skelly and did not use restraints.
61. Mr Skelly remained sedated and ventilated in hospital until his family agreed to
withdraw active treatment. At 5.25am on 22 June, it was confirmed that Mr Skelly
had died.
Contact with Mr Skelly’s family
62. The prison appointed a CM as the family liaison officer. At around 12.00pm on 16
June, she contacted Mr Skelly’s mother and told her that Mr Skelly had been taken
to hospital. Mr Skelly’s mother visited him in hospital before he died on 22 June.
The prison contributed to the cost of Mr Skelly’s funeral in line with Prison Service
instructions.
Support for prisoners and staff
63. After Mr Skelly’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
64. The prison posted notices informing other prisoners of Mr Skelly’s death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Skelly’s death.
Post-mortem report
65. The post-mortem report gave Mr Skelly’s cause of death as hanging. The post-
mortem toxicology results did not detect any illicit substances in Mr Skelly’s blood.
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Findings
Management of Mr Skelly’s risk of assessment of risk and self-harm
66. Prison Service Instruction (PSI) 64/2011 on safer custody, requires all staff who
have contact with prisoners to be aware of the triggers and risk factors that might
increase the risk of suicide and self-harm, and take appropriate action. Mr Skelly
had a number of these risks, including previous self-harm, poor mental health,
substance misuse, personality disorders, debt and being a potential victim of
bullying and violence. He was appropriately monitored under ACCT procedures for
the majority of his time at Lindholme.
67. However, the overall management of ACCT procedures was not consistently in line
with PSI 64/2011. Mr Skelly’s ACCT case reviews were not always multidisciplinary
which meant that prison and healthcare staff did not fully consider his risk factors
and triggers for his self-harm.
68. Caremaps should reflect the prisoner’s needs, level of risk and the triggers of their
distress. Instructions say they should aim to address issues identified in the ACCT
assessment interview and later reviews, and consider a range of factors including
health interventions, peer support, family contact and access to diversionary
activities. Each action on the caremap should be tailored to the individual needs of
the prisoner, be aimed at reducing risk and be time bound. When staff started
ACCT monitoring on 4 May, Mr Skelly’s caremap did not refer to his substance
misuse, even though it was one of the triggers for starting ACCT monitoring. Mr
Skelly had incurred drug-related debt despite denying that he was using illicit
substances. We recommend:
The Governor should ensure that staff manage prisoners at risk of suicide
and self-harm in line with national instructions. In particular, staff should:
• hold multidisciplinary ACCT reviews; and
• set effective caremap objectives which are specific, time-bound, meaningful,
aimed at reducing risk and updated at each case review.
Post-closure review
69. We consider that the decision to stop ACCT monitoring on 19 May was appropriate.
All support actions on Mr Skelly’s caremap were complete, his risk of suicide and
self-harm was low, and Mr Skelly did not express any thoughts of suicide and self-
harm.
70. PSI 64/11 states that after ACCT monitoring ends, a post-closure monitoring form
must be completed for at least seven days to inform the post-closure review. The
post-closure interview must review the caremap and the prisoner’s progress since
the ACCT was closed. Although prison staff continued to monitor Mr Skelly after
ACCT monitoring was stopped, they did not carry out a post-closure review as they
should have done. The failure to do so meant that they did not assess how Mr
Skelly was coping. For example, Mr Skelly received an IEP warning on 26 May
which indicated his behaviour was deteriorating and he might have been struggling
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on the wing. However, prison staff missed the opportunity to consider the impact on
him at a post-closure review. We recommend:
The Governor should ensure that ACCT post-closure reviews are conducted
in line with Prison Service instructions and should be held to check the
prisoner’s progress and to decide whether further monitoring is needed.
Substance misuse and mental healthcare
71. The clinical reviewer noted that there was no documented communication between
the substance misuse team and mental health team about Mr Skelly’s mental state,
self-harm and substance misuse. She concluded that Mr Skelly’s substance misuse
and mental healthcare was not equivalent to that which he could have expected to
receive in the community.
72. Mr Skelly had a long history of substance misuse and was supported by the
substance misuse team when he arrived at Lindholme in February. When Mr Skelly
returned to Lindholme from Doncaster in April, he told a substance misuse support
worker that he had not used illicit substances and it was decided that he did not
need support. During a substance misuse assessment on 28 April, a substance
misuse support worker noted that Mr Skelly was located on the drug recovery wing
and would be reviewed again in July. Mr Skelly told a substance misuse support
worker on 19 May that he had not used illicit drugs for over a month, and he did not
need any support. However, this was not supported by prison intelligence which
indicated that Mr Skelly was using illicit substances and was in debt to other
prisoners as a result.
73. The clinical reviewer noted that while Mr Skelly was referred to the substance
misuse team promptly when he returned to Lindholme, he denied recent drug use
and the substance misuse team decided he did not have any immediate needs
despite his recent history of substance misuse and drug-related debt.
74. Mr Skelly was diagnosed with anxiety and personality disorders. However, his
mental healthcare was provided primarily through the ACCT management process.
The clinical reviewer considered that in view of his history of self-harm, anxiety and
fluctuating mood, healthcare should have considered addressing his mental health
needs on an individual therapeutic basis, which might have provided a better sense
of his mental state. We recommend:
The Head of Healthcare should ensure that prisoners who need mental health
support receive a full mental health assessment to determine if they need
individual therapeutic intervention.
The Head of Healthcare should ensure that the substance misuse team
considers a prisoner’s substance misuse history and custodial behaviour
when assessing the required level of substance misuse support.
Self-seclusion strategy
75. Lindholme’s Isolating Individuals Strategy (published in 2019) says that prisoners
identified as self-isolating for longer than 24 hours should be referred to safer
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custody and entered on the CSIP database. Prisoners who are confirmed as self-
isolating should be allocated a liaison from safer custody to understand why they
are isolating themselves, to seek a solution and signpost to other support.
76. Mr Skelly was first identified as self-isolating on 10 June when he told prison staff
during an ACCT case review that he wanted to remain locked in his cell because he
was under threat from other prisoners. A prison officer completed a community
concern form and a CSIP investigation and referral form. Safety custody allocated
a prison officer as Mr Skelly’s safer custody liaison officer to ensure that Mr Skelly
was being appropriately monitored while he was self-isolating.
77. A Senior Officer spoke to Mr Skelly to determine why he did not want to participate
in the normal wing regime and to ensure Mr Skelly understood the self-isolator
regime. Mr Skelly was reminded of the support available from Listeners and the
Samaritans. Mr Skelly continued to receive support through ACCT monitoring and
staff explored a wing move and transfer to another prison during Mr Skelly’s next
case review. We are satisfied that prison staff took appropriate action when Mr
Skelly was identified as self-isolating. In July 2022, after Mr Skelly’s death,
Lindholme also introduced an isolation management record to monitor and support
self-isolating prisoners.
Management of Mr Skelly’s debt
78. Lindholme’s safety toolkit provides instructions to staff to help improve prison safety
and to reduce the level of violence and suicide and self-harm. The toolkit brings
together material about safety, including strategy, learning, examples of effective
practice tools and guidance. The toolkit provides specific guidance to enable staff
to identify and manage prisoners who are in debt.
79. The purpose of the safety kit is to enable prison staff to understand why prisoners
get into debt and what can be done to assist prisoners who have debt-related
problems. It goes on to say that prisoners identified as being in debt should be
offered support through a debt management plan to explore strategies to reduce
debt and to prevent them from incurring further debt. Mr Skelly often denied to
other prisoners that he was in debt. He told staff that he was being threatened and
prison staff established that this was related to debt. When Mr Skelly told prison
staff he was in debt, they arranged for him to move wings and provided appropriate
support through a debt management plan. Prison staff also submitted a CSIP
investigation and referral form to inform the safer custody team. Mr Skelly’s debt
management plan identified that the possible triggers for his debt were substance
misuse and his relationship with other prisoners whom he knew from the
community.
80. After an initial period of settled behaviour, prison staff received security intelligence
that indicated that Mr Skelly was in debt again. Despite their best efforts, Mr Skelly
remained in debt to other prisoners for the majority of his time at Lindholme. We
are satisfied that Lindholme has an appropriate strategy to manage and support
prisoners who are in debt and that prison staff supported Mr Skelly to prevent him
incurring further debt.
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Inquest
81. At the inquest held on 6 December 2023, the Coroner concluded that Mr Skelly died
by misadventure.
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