Mark Mason

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Independent investigation into
the death of Mr Mark Mason,
a prisoner at HMP Durham,
on 8 December 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 Mark Mason died on 8 December 2022, after he was found hanging in his cell at HMP
Durham. This was the seventh self-inflicted death at Durham in three years. Mr Mason
was 45 years old. I offer my condolences to his family and friends.
Mr Mason said he had lived with thoughts of self-harm for years, but had resisted because
of his love for and from his family and partner. He was not subject to any additional
monitoring at the time of his death.
My investigation found that there were missed opportunities to provide support to Mr
Mason for his mental health and to manage the risk he posed to himself. The clinical
reviewer concluded that the mental health care Mr Mason received at Durham 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.
Adrian Usher
Prisons and Probation Ombudsman October 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 11
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Summary
Events
1. On 11 October 2022, Mr Mark Mason was remanded to prison, charged with
burglary and assault, and sent to HMP Durham.
2. Between 31 October and 27 November, Mr Mason’s partner contacted the prison
four times, raising concerns about Mr Mason’s safety. Mr Mason had told his
partner that he thought other prisoners were going to attack him. Mr Mason had no
known issues on the wing but would not come out of his cell because he said he
was scared. Mr Mason told staff he did not know why he was under threat or from
whom.
3. On 22 November, a supervising officer made a mental health referral for Mr Mason
as staff had reported that he was ‘hearing voices and was paranoid’.
4. On 29 November, Mr Mason’s partner contacted the prison again saying Mr Mason
needed to move wings as he was under threat. An officer conducted a welfare
check and noted that Mr Mason told him he was ok, and that his partner just worried
a lot. Mr Mason’s cellmate told the officer that Mr Mason was paranoid.
5. On 6 December, during a mental health assessment, Mr Mason became distressed
when he told the nurse that he was scared to leave his cell and wanted to be moved
somewhere safer. He said that he had had thoughts of self-harm for some years but
had managed not to act on them because of his family and partner. The nurse
assessed that Mr Mason was not psychotic but was anxious and low in mood. She
made a GP referral. She also offered to refer Mr Mason for anxiety management
but he declined. She discharged Mr Mason from the mental health team. She
discussed his safety fears with a wing officer who agreed to look into a wing move.
She did not mention Mr Mason’s thoughts of self-harm. The nurse did not think that
Mr Mason needed to be monitored under suicide and self-harm prevention
procedures.
6. On 7 December, Mr Mason’s cellmate was released from Durham. During
telephone calls to his partner, Mr Mason expressed anxiety about who his new
cellmate might be and whether they might be connected to the prisoners who
wanted to harm him.
7. On 8 December, at 9.30am, an officer arrived at Mr Mason’s cell with his new
cellmate. When he opened the cell door, they found Mr Mason had tied a ligature
around his neck and attached it to the bedframe. The officer called a medical
emergency code. He cut the ligature and started cardiopulmonary resuscitation
(CPR). A nurse then arrived and assisted with CPR. Control room staff called an
ambulance. Paramedics arrived at 9.49am and along with the nurse continued
CPR. At 10.07am, paramedics pronounced that Mr Mason had died.
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Findings
8. We found no evidence that supported Mr Mason’s concerns that he was under
threat from other prisoners. Staff did not therefore arrange a wing move, which
seems reasonable in the circumstances.
9. The clinical reviewer considered that given Mr Mason’s presentation during his
mental health assessment and his persistent thoughts of self-harm, the mental
health team should have offered further assessment and support.
10. The nurse who conducted the mental health assessment on 6 December, had not
properly reviewed Mr Mason’s medical records and had not identified that he had a
history of suicide attempts. This information would have added to the overall picture
of Mr Mason’s risk to himself and was again a missed opportunity, as was the
failure to pass on relevant information to wing staff. The clinical reviewer concluded
that the mental health care Mr Mason received was not equivalent to that which he
could have expected to receive in the community.
11. There was a delay in the emergency response, due in part to the delay in passing
information to the control room.
Recommendations
• The Head of Healthcare should ensure that all members of the Mental Health
Team:
• thoroughly check medical records prior to conducting assessments, so that
relevant historic information forms part of any consideration and
management of a prisoner’s risk of suicide and self-harm; and
• understand the importance of communicating risk information to relevant
members of prison staff.
• The Prison Group Director and Governor should examine in detail their processes
for acquiring an urgent ambulance, in conjunction with their partners in the local
ambulance service.
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The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Durham informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
13. The investigator visited Durham on 2 and 3 April 2022. He obtained copies of
relevant extracts from Mr Mason’s prison and medical records.
14. The investigator interviewed three members of staff at Durham on 2 and 3 April
2022. The remaining five interviews took place over video call on 18 January, 9
March and 17 March 2023. The investigator tried to interview Mr Mason’s cellmate
but he had died shortly after his release.
15. NHS England commissioned an independent clinical reviewer to review Mr Mason’s
clinical care at the prison. The investigator and clinical reviewer conducted two joint
interviews with healthcare staff on 18 January.
16. We informed HM Senior Coroner for County Durham and Darlington 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 Mason’s partner to explain
the investigation and to ask if she had any matters she wanted us to consider. She
was concerned that Mr Mason was under threat from other prisoners, and asked
how the prison responded to this issue. She also said that Mr Mason had activated
his cell bell 15 minutes before he was found hanging. We have addressed these
issues in our report.
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Background Information
HMP Durham
18. HMP Durham is a local prison, serving the courts of Tyneside, Durham and
Cumbria. It has an operational capacity of 985 men. Spectrum Community Health
CIC provides primary healthcare services. Tees, Esk and Wear Valleys Foundation
NHS Trust provides mental health services.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Durham was in November 2021. Inspectors
reported that serious staff shortages had affected all aspects of healthcare provision
and caused delays for prisoners trying to access support. There was a high level of
demand for mental health care and referrals were received from a variety of
sources, including self-referral. These were triaged daily by the urgent care staff
and any patients deemed to have urgent needs were assessed within four hours.
Routine referrals were taking up to three weeks to assess in secondary care and up
to four weeks in primary care, which was too long.
Independent Monitoring Board
20. 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 31 October 2022, the IMB
reported that Durham was a safe prison, with safety a priority for staff at all levels.
However, prisoners were not satisfied with the expediency of healthcare available.
Previous deaths at HMP Durham
21. Mr Mason was the eighteenth prisoner at HMP Durham to die since December
2019. Of the previous deaths, six were self-inflicted, two were drug-related and nine
were from natural causes. Mr Mason’s death was the third self-inflicted death at
Durham in 2022 and there has been one self-inflicted death since.
22. Due to the number of recent self-inflicted deaths at Durham, the prison has been
receiving additional monitoring and support from HMPPS Headquarters. HMPPS
has delivered training on identifying risks, triggers and protective factors when
prisoners arrive at Durham and work is ongoing to improve first night procedures.
23. We have previously made a recommendation about ensuring healthcare staff
review the prisoner’s medical record before carrying out a mental health
assessment. We were told that the mental health triage and assessment processes
had been reviewed. All patients referred into the team are now offered a face to
face triage within 24 hours, which includes a discussion on current and previous
engagement with services. A formal process is also in place to allow both regional
community mental health trusts to review each system, with information being
reviewed and returned within 24 hours.
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24. We have also previously made recommendations about the importance of
communicating the details of a medical emergency as quickly as possible and
control room staff calling an ambulance as soon as they hear a medical emergency
code. In response, we were told that control room staff were aware of this
requirement and that instructions were displayed in the control room.
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Key Events
25. On 11 October 2022, Mr Mark Mason was remanded in prison, charged with
burglary and assault. He was sent to HMP Durham. It was not his first time in
custody.
26. When he arrived at Durham, Mr Mason tested positive for benzodiazepines, a type
of sedative medication that he was not prescribed. A nurse completed Mr Mason’s
reception health screen and noted that Mr Mason had a history of alcohol abuse
and benzodiazepine dependence. He prescribed medication to treat Mr Mason’s
drug and alcohol withdrawal and arranged for staff to monitor Mr Mason on his first
night. He noted that Mr Mason needed to be seen, monitored, and supported by
healthcare, and the Drug and Recovery Team (DART).
27. Another nurse completed the secondary health screen. Mr Mason told her he had
not self-harmed or attempted suicide in the last 12 months, and he had no current
thoughts of suicide or self-harm.
28. Prison staff completed a vulnerability assessment form for Mr Mason. They noted
he had no suicide and self-harm risks and that he told them that he had not self-
harmed or attempted suicide in the community or prison. (Mr Mason’s medical
records note that in 2018, while serving a previous sentence at Durham, Mr Mason
told a nurse that he had a history of attempted suicide by hanging, use of carbon
monoxide and overdose. Prison staff would not have had access to Mr Mason’s
medical records.)
29. On 14 October, Mr Mason was moved to a shared cell on C Wing.
30. On 21 October, Mr Mason saw a substance misuse worker as part of the non-
clinical DART induction process. Mr Mason told her that he did not have issues with
drugs or alcohol and declined to engage. She advised Mr Mason of the self-referral
process if he changed his mind.
31. On 31 October, Mr Mason’s partner contacted the prison after Mr Mason told her he
was scared for his safety. An officer visited Mr Mason who said that he had
overheard other prisoners on the wing threatening to ‘set about’ someone in his cell.
The officer noted that Mr Mason had no known issues on the wing and that he told
her he did not know why he would be under threat. Mr Mason told her that he would
report anything further to staff and that he understood what support was available to
him.
32. On 7 November, the Safer Custody Department contacted a supervising officer
(SO) on Mr Mason’s wing, as his partner had again raised concerns about Mr
Mason’s welfare. The SO noted that Mr Mason told her that he heard other
prisoners saying his name and his cell number, and believed he was under threat,
but did not know why. The SO noted that Mr Mason would not come out of his cell,
but had been eating, as prison staff were taking food to his cell.
33. On 8 November, an officer noted that Mr Mason attended a video link for an
appearance at Nottingham Crown Court and was further remanded for three weeks.
The officer noted that there were no concerns raised.
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34. On 18 November, Mr Mason’s partner called the prison and told an officer that Mr
Mason had heard that boiling water mixed with sugar was going to be thrown in his
face. The officer rang prison staff on Mr Mason’s wing, who told him they would go
and check on Mr Mason. There is no evidence of a welfare check taking place.
35. A SO referred Mr Mason to the Mental Health Team. The referral form states that
‘staff on C-wing have reported that Mark [Mr Mason] may be hearing voices, he
appears to be paranoid that others on the wing are going to assault him however he
cannot confirm who or why.’
36. On 22 November, an officer noted that Mr Mason refused to attend a legal visit by
video link. The officer did not record the reason for Mr Mason’s refusal.
37. On 27 November, Mr Mason’s partner called the prison and told an officer that Mr
Mason would not come out of his cell, as prisoners were walking past his door
saying, 'get some sugar and a kettle, this is for Mason'. She asked for staff to carry
out a welfare check. There is no evidence of a welfare check taking place.
38. On 29 November, an officer noted that Mr Mason attended a video link meeting with
his legal team, in preparation for a court appearance at Newcastle Crown Court on
3 February 2023, where he was due to be sentenced. The officer noted that Mr
Mason raised no concerns or issues.
39. Later that day, Mr Mason’s partner rang the prison and spoke to Officer A and told
her that Mr Mason needed to move wings, as he was under threat. Officer A called
C Wing and spoke to Officer B, who told her that they were aware of Mr Mason's
requests and were dealing with them.
40. Officer B then conducted a welfare check on Mr Mason. He told Mr Mason that his
partner had called the prison and was concerned about him. Mr Mason replied that
he was ok and that his partner just worried a lot about him. Officer B noted that he
asked Mr Mason if he was under threat at all, and he said no, but he heard people
at his door asking him what he was in for.
41. Officer B noted that Mr Mason’s cellmate then said Mr Mason was just paranoid.
Officer B asked Mr Mason why he was worried about being on the wing, and Mr
Mason replied he was not. As there was no evidence that Mr Mason was under
threat and staff thought he was paranoid, a wing move was not facilitated.
42. Officer A noted that she called Mr Mason’s partner back, who was unhappy that Mr
Mason could not be moved right away. Officer A noted that Mr Mason’s partner told
her that Mr Mason’s legal team had written letters to Durham saying that Mr Mason
needed to move wings (Durham told us that they had not received any such letters).
43. On 30 November, Mr Mason made several telephone calls to his partner. The
investigator listened to the telephone calls between Mr Mason and his partner.
(While prisoners’ calls are recorded and a proportion listened to by staff to check for
illicit content, there is no evidence that staff had listened to any of Mr Mason’s calls
before his death.) Mr Mason told his partner that his cellmate had got something to
smoke from another prisoner, but he had not got any. She was annoyed by this and
said that Mr Mason would be left with nothing due to ‘double bubble’, Mr Mason
repeated that he did not get anything. (‘Double bubble’ is prison slang: when you
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borrow something from another prisoner you are expected to give at least double
back.)
44. Mr Mason’s partner told Mr Mason she would ring the prison the following day and
ask for him to be moved to another wing. Mr Mason told her that he did not collect
his lunch or go to prison visits as ‘they’ were on the landing. (‘They’ appears to be a
reference to the prisoners who Mr Mason believed were threatening him.) Mr
Mason told his partner that prison staff had not heard anything about him being
under threat and thought it was all in Mr Mason’s head.
45. On 1 December, Mr Mason telephoned his partner on many occasions. During
these calls his partner said she was frustrated because she was having to call the
prison every day about Mr Mason being under threat. Mr Mason told her that he
heard prisoners asking if ‘Mason is still on the wing’.
46. Mr Mason said to his partner, ‘I don’t want to do something stupid’. She responded
saying ‘you best not kill yourself or nowt’. Mr Mason said that he would not.
47. Mr Mason’s partner tried to encourage Mr Mason to make a mental health/GP
referral. Mr Mason said he could not leave his cell. His partner said that he left his
cell on a Friday to order his canteen (items from the prison shop), and therefore
could make the referral then. Mr Mason was resistant to this suggestion.
Events of 6 and 7 December 2022
48. On 6 December, a nurse saw Mr Mason for a mental health assessment following
wing staff’s referral. Mr Mason initially refused to leave his cell because he was
scared of being attacked but then agreed to go to an interview room when an officer
accompanied him.
49. The nurse noted that Mr Mason was low in mood and very fearful that someone
would attack him. He said that due to threats he had received when he arrived on C
Wing, he was paranoid that something was going to happen to him and wanted to
be moved somewhere safer. He said that he always had thoughts of self-harming
but that he had had these thoughts for some years and had always managed not to
act on them because of the love of his family and partner.
50. The nurse noted that there was no evidence of hallucinations, that Mr Mason was
clean and tidy, and that he engaged well with good eye contact. She assessed that
Mr Mason was not psychotic but was fearful and anxious. She said that she would
refer him to a GP to discuss his low mood and anxiety, which he was happy with.
She also offered him a referral to Rethink for anxiety management, but he declined.
She noted that after the assessment, she spoke to an officer who said that he would
discuss whether Mr Mason could be moved. She discharged him from the mental
health team. The nurse made comprehensive notes in Mr Mason’s medical record
following the assessment.
51. On 7 December, Mr Mason telephoned his partner many times. During these
conversations Mr Mason told his partner that his cellmate had not heard other
prisoners calling Mr Mason’s name.
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52. At around 5.20pm, Mr Mason telephoned his partner again and told her that his
cellmate had been released and he was worried about who his new cellmate would
be. Mr Mason said that his new cellmate might be ‘their’ friend (‘their’ appears to be
a reference to the prisoners who Mr Mason believed were threatening him).
53. Mr Mason told his partner that his cellmate was content to have their cell locked all
day, and he was worried that a new cellmate might not want to do the same. Mr
Mason told his partner that he had asked staff for a wing move and she asked him
to wait a couple of days for prison staff to arrange the wing move. (An intelligence
report confirms that Mr Mason told staff he was frightened and had requested to
move off C Wing.)
54. Mr Mason called his partner again at 6.51pm. He sounded a bit agitated and was
still concerned about who his new cellmate would be. Mr Mason told his partner that
‘they [other prisoners] will start shouting soon’.
Events of 8 December 2022
55. On 8 December, an operational support grade (OSG) noted that he started his
morning checks at 5.00am, and when he came to Mr Mason’s cell and looked
through the observation panel, he saw movement on the bed so assumed Mr
Mason was fit and well. The OSG noted that over the previous week, Mr Mason had
not activated his cell bell during the night and had raised no concerns.
56. CCTV footage shows that at 5.50am, Mr Mason turned on the light in his cell. From
a review of the CCTV, there is no indication that he used his cell bell that morning
(when a cell bell is pressed, a light is activated outside the cell but no cell bell light
could be seen on the CCTV).
57. At 7.14am, Mr Mason telephoned his partner, who was surprised that he called her
so early. The call lasted for three minutes and 40 seconds. Mr Mason sounded
subdued but did not say anything that would have caused his partner concern. Mr
Mason ended the call saying he would phone his partner back once she had woken
up properly.
58. CCTV footage shows that at 9.30am, an officer arrived at Mr Mason’s cell, along
with Mr Mason’s new cellmate. The officer opened the cell door, and the prisoner
moved to go into the cell, but then turned to the officer and said something. The
officer noted that on looking into the cell, he could see Mr Mason with a ligature
around his neck, which had been secured to the bed frame. He radioed a code blue
medical emergency, shouted to alert prison staff and then entered the cell. Two
other members of prison staff responded and entered the cell.
59. The officer cut Mr Mason’s ligature, put Mr Mason on the floor and began CPR. He
said that Mr Mason had a cold hand, grey complexion, and blood stains around his
mouth. Staff fetched a defibrillator and attached it to Mr Mason. It advised and
delivered one shock but after that advised no shock and to continue with CPR.
60. At 9.34am, a nurse attended the cell and assisted with CPR. She told the
investigator that Mr Mason had no pulse.
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61. At 9.49am, paramedics arrived at Mr Mason’s cell. At 9.51am, prison staff carried
Mr Mason out onto the landing where paramedics took over chest compressions,
and the nurse continued maintaining Mr Mason’s airway, providing ventilations and
suction.
62. After discussions between healthcare and paramedics CPR was stopped. Mr
Mason was pronounced dead at 10.07am.
63. The police investigated Mr Mason’s death. They said that two other ligatures were
found in Mr Mason’s cell which appeared to be created from the same bed sheet.
These ligatures had small amounts of blood on them. The police said this could
indicate that Mr Mason made several unsuccessful attempts to hang himself.
Contact with Mr Mason’s family
64. On 8 December, the prison appointed two family liaison officers. That afternoon,
they visited the home of Mr Mason’s partner. She was not at home, so they
contacted her by telephone, and told her that Mr Mason had died.
65. The family liaison officers kept in contact with Mr Mason’s partner over the following
days, offering support and advice.
66. The prison contributed to the costs of Mr Mason’s funeral in line with national policy.
Support for prisoners and staff
67. After Mr Mason’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.
68. The prison posted notices informing other prisoners of Mr Mason’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 Mason’s death.
Post-mortem report
69. The post-mortem report concluded that the cause of Mr Mason’s death was
pressure to the neck caused by hanging.
70. Toxicology results found no drugs or alcohol in Mr Mason’s system.
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Findings
Assessment of Mr Mason’s risk of suicide and self-harm
71. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), provides guidance to staff on
identifying prisoners who might be at risk of suicide and self-harm. It lists the risk
factors and triggers that might increase a prisoner’s risk and sets out the
procedures (known as ACCT) that staff should follow when they identify a prisoner
at risk of suicide and self-harm.
72. Mr Mason was not assessed as being at risk of suicide or self-harm while he was at
Durham so was never monitored using ACCT. He possessed some of the risks and
triggers for suicide and self-harm listed in PSI 64/2011, including being charged
with a violent offence and being fearful of violence or intimidation and he had a
history of suicide attempts. Whether or not his fears about his safety on C Wing
were justified, they meant that he barely left his cell and had no support network in
prison beyond his cellmate and, perhaps, staff. If his fears for his safety were
unfounded, the policy notes that irrationality or being out of touch with reality also
raises the risk of self-harm.
73. On 6 December, during a mental health assessment, Mr Mason told the nurse that
he had had thoughts of self-harm for some years but had not acted on them
because of his family and partner. The nurse told the investigator and clinical
reviewer that she had checked Mr Mason’s medical records before carrying out the
assessment and had not seen anything of concern, including no references to
previous suicide attempts. However, Mr Mason’s medical records state he had a
history of attempted suicide by hanging, use of carbon monoxide and overdose.
This information, had it been accessed, would have added to the overall picture of
the risk Mr Mason may have posed to himself.
74. After the assessment, the nurse did discuss Mr Mason’s concerns about his safety
with a wing officer. However, she did not tell the officer that Mr Mason had ongoing
thoughts of self-harm.
75. The clinical reviewer considered that given Mr Mason’s presentation at the mental
health assessment and his persistent thoughts of self-harm, this was a missed
opportunity for the mental health team to offer him further support and assessment.
She also found that the failure to identify that Mr Mason had a history of suicide
attempts and to pass on information to wing staff about his thoughts of self-harm
were also missed opportunities to manage Mr Mason’s risk to himself.
76. We recommend:
The Head of Healthcare should ensure that all members of the Mental Health
Team:
• thoroughly check medical records prior to conducting assessments, so
that relevant historic information forms part of any consideration and
management of a prisoner’s risk of suicide and self-harm; and
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• understand the importance of communicating risk information to
relevant members of prison staff.
Mr Mason’s location
77. Population management in prisons is complex, with many factors needing to be
considered. The safety of prisoners is one of these factors. However, moving a
prisoner takes up time and resources, and so the reason for moving a prisoner must
be legitimate.
78. It is evident from Mr Mason’s telephone conversations with his partner, his
reluctance to come out of his cell, and from conversations he had with prison and
healthcare staff, that Mr Mason sincerely believed that he was under threat from
other prisoners. He, and his partner, asked for a move from C Wing.
79. However, other than Mr Mason’s account, there was no evidence available to staff
that he was under threat. Additionally, Mr Mason did not name the prisoners who he
believed were threatening him, and so prison staff could not investigate the matter
further. Therefore, prison staff were not required to move Mr Mason.
80. Prison staff referred Mr Mason for a mental health assessment after staff and Mr
Mason’s cellmate raised concerns that Mr Mason was paranoid. We consider that
staff responded appropriately in the circumstances.
Clinical care
81. The clinical reviewer concluded that the mental health care Mr Mason received at
Durham was not equivalent to that which he could have expected to receive in the
community. She found that there were a number of missed opportunities to assess
and manage the risk Mr Mason posed to himself, and also to communicate
important information about Mr Mason to other staff within the prison.
82. The clinical reviewer made a number of other findings and recommendations on
issues unconnected to Mr Mason’s death, which the Head of Healthcare will want to
address.
Emergency response
Delay in calling an ambulance
83. PSI 03/2013, Medical Emergency Response Codes, requires all prisons to have a
medical emergency response code protocol in place, the purpose of which is to
ensure a timely, appropriate, and effective response to medical emergencies. When
a medical emergency is discovered, staff should call the appropriate medical
emergency code straightaway so that relevant staff, including healthcare staff, are
alerted, the correct equipment is brought, and an ambulance is called immediately.
The PSI says that the person using the medical emergency code must also provide
relevant information about the condition of the prisoner to the control room staff, so
that they can pass it on to the ambulance service for use in the triage process.
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84. On 8 December, at 9.30am, when the medical emergency code blue was called, an
officer was in the control room handling the radio traffic. She was accompanied by
an OSG, who was handling the telephone.
85. The OSG told us the procedure for calling an ambulance at Durham requires control
room staff to have specific information about the prisoner and their condition before
they can call the ambulance service. He said that sometimes the ambulance service
will insist they are provided with this information before they send an immediate
response ambulance, which will usually arrive within 15 minutes.
86. The OSG told us that when they received the code blue over the radio, limited
information about Mr Mason or his condition was provided, so the officer radioed
staff who were with Mr Mason for further information but received no response. The
OSG told us that there was a lot of radio traffic at the time and staff were
telephoning the control room on unrelated matters, which caused communication
problems. The OSG told us that eventually a staff member radioed the control room
providing the relevant information and he then called the ambulance service.
87. This resulted in a five minute delay after the code blue was called. An ambulance
was then dispatched to the prison. We are unable to say whether this delay affected
the outcome for Mr Mason but we know that in a medical emergency, a delay of a
few minutes could be critical.
88. We recommend:
The Prison Group Director and Governor should examine in detail their
processes for acquiring an urgent ambulance, in conjunction with their
partners in the local ambulance service.
Governor to note
Welfare checks and Prison-NOMIS case notes
89. PSI 23/2014 Prison-NOMIS (Prison National Offender Management Information
System), states all staff who have contact with a prisoner and who have access to
Prison-NOMIS must update case notes on a regular basis.
90. Prison-NOMIS shows that Mr Mason’s partner contacted the prison on five
occasions raising concerns about Mr Mason’s safety. However, on three of these
occasions: 17, 27 and 29 November, staff did not make a note on Prison-NOMIS
confirming that a welfare check had taken place, and so on these occasions staff
did not report on Mr Mason’s welfare. (In his statement, Officer B said he did
conduct a welfare check on 29 November.)
91. As stated in PSI 23/2014 prison staff should update Prison-NOMIS case notes after
every welfare check. This would have ensured that information about Mr Mason
was effectively shared with other staff to inform assessment and management of
risk. The Governor will wish to consider this learning.
Prisons and Probation Ombudsman 13
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Inquest
92. At the inquest, heard from 15 to 26 September 2025, the jury concluded that Mr
Mason, “died of a ligature which was self-inflicted but his probable intent cannot be
determined”.
14 Prisons and Probation Ombudsman
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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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