Max Marchant

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Independent investigation into
the death of Mr Max Marchant,
a prisoner at HMP The Mount,
on 25 July 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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Marchant died from synthetic cannabinoid toxicity on 25 July 2022 at HMP The Mount.
(Synthetic cannabinoids are psychoactive substances – PS.) He was 26 years old. I offer
my condolences to Mr Marchant’s family and friends.
We did not find any evidence that Mr Marchant intended to take his life. Mr Marchant had a
history of using illicit substances in prison, and his death appears to have been an
accidental result of using drugs. The Forward Trust assessed him as at high risk of using
PS. Although I am satisfied that Mr Marchant knew the dangers of PS use and that he
received good support from his health and well-being worker, I am concerned that he was
moved to a wing known to be overrun with PS less than 36 hours before he died.
Tragically, the prevalence of PS on his new wing apparently weakened his resolve with
fatal consequences.
Mr Marchant was the second of two prisoners at The Mount to die from using PS in July.
Two more prisoners there have apparently died from PS in January 2023. In August 2022,
HMPPS Substance Misuse Group reviewed the prison’s drug strategy. Their report
evidenced significant amounts of PS in the prison and found that many improvements
were needed to reduce supply and demand. The prison has introduced new measures in
response and work is ongoing. I acknowledge that this is an area with constantly evolving
challenges and more can always be done. However, there are a number of factors that
mean that PS is likely to be especially prevalent at The Mount and I am extremely
concerned that unless more is urgently done to reduce drugs at the prison, more prisoners
will die there. Ongoing staff shortages perpetually undermine the prison’s efforts to reduce
supply and demand. This issue was highlighted both by HM Chief Inspector of Prisons and
HMPPS Substance Misuse Group. It is therefore imperative that the Director General for
Prisons considers how the prison can reasonably deliver an effective drug strategy in
these circumstances.
We found that Mr Marchant’s mental health care was inadequate, and that staff did not
take sufficient account of his neurodiversity.
Although it did not affect the outcome for Mr Marchant, the emergency response was poor.
The first member of staff on scene did not call an emergency code, there was a significant
delay before an ambulance was called and staff tried to resuscitate him despite the
presence of rigor mortis.
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 March 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 8
Findings ......................................................................................................................... 19
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Summary
Events
1. Mr Max Marchant had a childhood diagnosis of autistic spectrum disorder and
attention deficit hyperactivity disorder (ADHD). In 2018, he was sentenced to six
years for grievous bodily harm with intent.
2. Mr Marchant was released on licence from HMP Chelmsford on 1 October 2021.
On 15 November, he was recalled to Chelmsford for breaking the conditions of his
release by drinking alcohol. On 13 December, he transferred to HMP The Mount.
3. Mr Marchant had an extensive history of using PS, brewing fermented liquid (known
as hooch) for his own use and to sell to other prisoners, damaging prison property,
starting cell fires and self-harm by cutting and tying ligatures. He was assessed as
unsuitable to share a cell. Mr Marchant owed the prison a significant amount of
money for the damage he caused to cell fixtures and fittings.
4. Mr Marchant was found under the influence of PS on four occasions in January and
March 2022. From 9 February, he worked with a health and wellbeing practitioner
from the Forward Trust substance misuse team and received regular awareness
advice on PS and harm minimisation.
5. Mr Marchant was found to have brewed hooch on seven occasions. He spent two
periods in the prison’s care and separation unit (CSU) and was frequently moved
between wings in order disrupt his hooch brewing.
6. Mr Marchant said that his primary reason for brewing hooch was lack of money.
Monies he owed for damaging his cells were taken from his prison wages, and as
he often did not have employment, he had very little money to spend on items from
the prison shop.
7. In April 2022, the prison implemented a plan to give Mr Marchant a job and allow
him to keep more of his wages. Mr Marchant responded well to this for several
weeks before once again being found in possession of hooch.
8. Mr Marchant spent most of June in the CSU in an attempt to disrupt his hooch
brewing. The prison security department requested he be transferred to another
prison, and he was accepted at HMP Coldingley. Mr Marchant appeared to do well
in the CSU. On 4 July, he returned to a standard wing to await transfer.
9. On 14 July, another prisoner died from PS use. Mr Marchant appeared to have
been affected by the death and said it had made him think. On 20 July, he received
harm minimisation advice on the dangers of PS use.
10. The same day he was again found in possession of hooch. On 21 July, he
completed an in-cell pack on PS with his health and well-being worker. On 23 July,
Mr Marchant was moved to Nash A wing because under the prison’s health and
safety arson policy he needed to be in an anti-barricade cell. Evidence showed that
Nash A wing was known to be overrun with PS at the time.
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11. At 5.30am on 25 July, the night patrol officer found Mr Marchant unresponsive in his
cell. He did not radio an emergency code and there was a significant delay in
entering the cell and calling an ambulance. Staff gave Mr Marchant CPR despite
clear signs that he had died. Paramedics attended and pronounced Mr Marchant
had died at 6.13am.
Findings
12. There was a significant amount of PS in the prison at the time Mr Marchant died,
especially on Nash A wing (where he was moved two days before he died). Mr
Marchant was assessed as being at high risk of using PS, but no consideration
appears to have been given to this risk when moving him to a known PS hotspot.
13. The prison was not doing enough to reduce drug supply and demand. All forms of
drug testing were suspended until a few days before Mr Marchant died and only
50% of requested searches took place.
14. Since the death of Mr Marchant and another prisoner, the prison has put a number
of extra measures in place to reduce supply and demand, but prison management’s
efforts are undermined by an ongoing lack of operational staff. In particular, they are
still unable to run an effective drug testing programme and complete the number of
searches requested. Staff shortages have also resulted in a very limited regime,
and this has led to boredom and fuelled the demand for drugs.
15. Mr Marchant understood the dangers of PS use and received good support from his
health and well-being worker. We found no evidence that he intended to die on 25
July.
16. The plan to allow Mr Marchant to keep more of his wages and provide him with a
job in April was successful but the plan was not added to Mr Marchant’s prison
record and the prison’s approach to his debt was inconsistent.
17. The night patrol officer did not radio a code blue emergency when he found Mr
Marchant unresponsive. There was a significant delay before entering Mr
Marchant’s cell and an ambulance was called. Staff gave Mr Marchant CPR despite
clear signs he had died. Staff did not operate their body worn video cameras in line
with local and national guidance.
18. The prison did not have a process for tracking and storing closed ACCT documents.
19. The clinical reviewer found that Mr Marchant’s mental healthcare was not
equivalent to that he could have expected in the community.
Recommendations
• The Director General of Prisons should urgently consider what additional
support can be put in place to address staffing shortages at The Mount and how
the prison can reasonably be expected to deliver an effective drug strategy and
regime.
• The Governor should ensure that staff consider all of the prisoner’s specific
known risk factors before transferring them between wings.
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• The Governor should ensure that the review of the prison debt strategy
considers care planning for known debtors and ensures that all agreed care
plans are recorded on the prisoner’s record and therefore available for all staff to
see.
• The Governor should ensure that all staff are made aware of and understand
their role and responsibilities during medical emergencies, including that they
should radio a code blue emergency if they are concerned a prisoner is not
breathing and that they should enter cells as quickly as possible if there is
reason to consider that a prisoner may be at risk.
• The Head of Safety should ensure that OSG A understands his responsibilities if
he finds a prisoner unresponsive.
• The Governor should review the numbers of night orderly staff and consider
stationing one or more assist night orderlies at the further end of the prison to
minimise delays in entering cells at night.
• The Governor should ensure that all staff are given clear guidance about and
understand the circumstances in which resuscitation is inappropriate in line with
European Resuscitation Council guidelines.
• The Governor should ensure that staff operate their body-worn video cameras in
line with national guidance.
• The Head of Healthcare should ensure that:
• Staff use the alert function on SystmOne to include significant conditions
such as ADHD and autism on the patients record.
• All healthcare staff receive Oliver McGowan mandatory training on learning
disability and autism.
• Staff consider whether a prisoner’s neurodiversity presents a barrier to them
self-referring to services such as IAPT and psychosocial substance misuse
support.
• All referral forms include learning disability and autism in the list of
significant conditions.
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The Investigation Process
20. The investigator issued notices to staff and prisoners at HMP The Mount informing
them of the investigation and asking anyone with relevant information to contact
her. Two prisoners responded and were interviewed.
21. The investigator visited The Mount on 26 July. She obtained copies of relevant
extracts from Mr Marchant’s prison and medical records. She also obtained CCTV
and emergency radio traffic from 25 July. She requested recordings of calls made
by Mr Marchant on the prisoner telephone (PIN) system in the month prior to his
death. Although a disk was provided some weeks after he died, it was subsequently
found to contain only calls from early June. She obtained the Forward Trust’s root
cause analysis report into Mr Marchant’s death and HMPPS Substance Misuse
Group’s drug diagnostic report on The Mount, both produced in September 2022.
Further information was provided by the Deputy Governor, the Head of Safety, the
drug strategy manager, the Security Department and the Forward Trust.
22. NHS England and NHS Improvement (NHSE&I) commissioned a clinical reviewer to
review Mr Marchant’s clinical care at the prison. The investigator and clinical
reviewer interviewed seven members of staff jointly in August 2022. The
investigator interviewed two prisoners in September 2022 and two members of staff
in November and December 2022. The clinical reviewer spoke to one member of
staff in September 2022.
23. We informed HM Coroner for Hertfordshire of the investigation. The Coroner gave
us the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
24. The investigator contacted Mr Marchant’s next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Marchant’s next
of kin had a number of questions about his care which we have answered in this
report, in the clinical review and in separate correspondence. She provided regular
updates to Mr Marchant’s next of kin throughout the investigation.
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Background Information
HMP The Mount
25. HMP The Mount is a medium security prison holding about 1,000 men. Practice
Plus Group provide physical and mental healthcare. The Forward Trust is
contracted to provide psycho-social substance misuse services and, since February
2020, mental health support under the Adult Improving Access to Psychological
Therapies programme (IAPT). IAPT offers solution focussed cognitive behavioural
therapy (CBT) sessions. Counselling services are provided by the prison
Chaplaincy.
HM Inspectorate of Prisons
26. The most recent inspection of HMP The Mount was in March 2022. Inspectors were
concerned about the shortage of officers available to deliver a meaningful regime or
ensure prisoner access to activities or appointments. Many prisoners were locked in
their cells all day. Ofsted judged the provision of education, work and skills to be
inadequate.
27. Steps to disrupt the supply of drugs were having a positive impact and far fewer
men said they were easy to get hold of (29% compared to 50% at the previous
inspection), but intelligence-led drug testing was yet to restart and less than half the
requested cell searches were completed. Additional steps had been taken,
including improved information sharing with the local police and greater use of
CCTV around the perimeter wall. The prison photocopied all incoming mail and
drug detection dogs were at the prison every day. Management of intelligence
information was very good with prompt analysis.
Independent Monitoring Board
28. 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 February 2022, the IMB echoed
HMIP’s concerns that staffing levels had resulted in very limited time out of cell and
access to the gym, showers and social time. Considerable progress to prevent illicit
items from entering the prison was made under the restrictions imposed during the
COVID pandemic. The introduction of staff and visitor searching, screening of
incoming mail and greater vigilance of the perimeter had all contributed to this.
Previous deaths at HMP The Mount
29. Mr Marchant was the second prisoner to die from illicit drug use at The Mount in
July 2022. In our investigation into a death on 14 July, we found that there had been
a significant amount of PS in the prison at the time and measures brought in to
reduce supply and demand were undermined by chronic staff shortages. Two more
prisoners died in January 2023, although the cause of their deaths was not
established at the time of writing, they are suspected to be substance misuse
related. Our investigation into the other prisoner who died in July 2022 made near
identical findings in deficiencies in the emergency response and also found that
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their mental healthcare was not equivalent to that which they could have expected
to receive in the community. We also found weaknesses in mental healthcare in our
investigation into a self-inflicted death in March 2022.
Psychoactive substances (PS)
30. PS (formerly known as ‘legal highs’) continue to be a serious problem across the
prison estate. They can be difficult to detect and can affect people in a number of
ways, including increasing heart rate, raising blood pressure, reducing blood supply
to the heart and vomiting. Prisoners under the influence of PS can present with
marked levels of disinhibition, heightened energy levels, a high tolerance of pain
and a potential for violence. Besides emerging evidence of such dangers to
physical health, the use of PS is associated with the deterioration of mental health,
suicide and self-harm. Testing for PS is in place in prisons as part of existing
mandatory drug testing arrangements.
Measures to reduce supply and demand for drugs in place at The Mount
before Mr Marchant’s death
31. Enhanced gate procedures were introduced in May 2021. All staff and visitors are
searched, have their bags searched and walk through an airport style X-ray portal.
32. All prisoner mail is photocopied, checked by drug dogs and suspicious mail is put
through narcotics trace detection equipment (Rapiscan machine). The prison holds
a database of contaminated Rule 39 mail (confidential legal mail). All cards and
photographs sent to prisoners must be sent via online delivery and printing
services. Staff mail is logged and recorded.
33. Drug dogs, a regional resource, are based in the prison. Cell searches are
requested for prisoners with supporting intelligence of drug involvement. All
prisoners found under the influence are added to the daily briefing sheet, given
mandatory drug tests and receive a Code Blue Pack from the Forward Trust
substance misuse team. This contains information on the substance involved, harm
minimisation advice and a self-referral form.
34. A dedicated constable from the local police attends a quarterly police and prison
tasking meeting. All drug-related information reports are disseminated to the police.
Attention deficit hyperactivity disorder (ADHD)
35. Attention deficit hyperactivity disorder (ADHD) is a condition that affects people's
behaviour. People with ADHD can seem restless, may have trouble concentrating
and may act on impulse. Symptoms of ADHD tend to be noticed at an early age and
may become more noticeable when a child's circumstances change, such as when
they start school. The symptoms of ADHD usually improve with age, but many
adults who were diagnosed with the condition at a young age continue to
experience problems. People with ADHD may also have additional problems, such
as sleep and anxiety disorders.
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Autism Spectrum Disorder (ASD)
36. Autism is a neurodiverse condition. Autistic people may find it hard to communicate
and interact with other people, understand how others think and feel, take longer to
understand information and do or think the same things over and over. Some
autistic people need little or no support and some require daily care and support.
37. Asperger’s or Asperger Syndrome was a term used to describe autistic people with
above average intelligence.
LeDeR
38. LeDeR is a service improvement programme for people with a learning disability
and autistic people.
Inundation point
39. Cell doors have inundation points, a removable bung that allows a hose to be used
to spray water into a cell without opening the door.
Assessment, Care in Custody and Teamwork
40. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
41. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. 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 (PSI) 64/2011.
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Key Events
42. Mr Max Marchant had a childhood diagnosis of autistic spectrum disorder and
attention deficit hyperactivity disorder (ADHD). In 2018, he was sentenced to six
years for grievous bodily harm with intent.
43. From April 2019 to April 2020, Mr Marchant served his sentence at HMP The
Mount. He had an extensive history of using PS, brewing fermented liquid (known
as hooch), damaging prison property, starting cell fires and self-harm by cutting and
tying ligatures. He was assessed as unsuitable to share a cell. Mr Marchant owed
the prison a significant amount of money for the damage he caused to cell fixtures
and fittings. He was frequently managed under Prison Service suicide and self-
harm monitoring procedures (known as ACCT).
44. Throughout 2021, Mr Marchant was managed by the mental health team in
HMP&YOI Chelmsford and received regular therapeutic input. He was released on
licence from Chelmsford on 1 October 2021. On 15 November, he was recalled to
Chelmsford for breaking the conditions of his release by drinking alcohol. On 13
December, a nurse concluded that Mr Marchant was medically fit to transfer to The
Mount. He noted in Mr Marchant’s prison medical record that he would require
mental health input when he arrived there.
HMP The Mount
45. A nurse completed an initial health assessment. Mr Marchant said he had problems
with alcohol and drug misuse and had self-harmed within the previous year. She
referred him to the mental health and substance misuse teams for assessment. A
prison GP continued Mr Marchant’s prescriptions for Concerta XL (for ADHD) and
quetiapine (an anti-psychotic originally prescribed at HMP Chelmsford for
insomnia).
46. On 15 and 17 December, a nurse was unable to review Mr Marchant’s mental
health because the wing was locked down due to staff shortages. The nurse
eventually completed the assessment by telephone on 19 December. Mr Marchant
asked for counselling for his anxiety and depression and the nurse sent him a self-
referral form for the IAPT service. (Mr Marchant does not appear to have completed
this form.) Mr Marchant said he was otherwise well. The nurse added him to the
psychiatrist’s list for a medication review and discharged him from the mental health
service.
47. On 30 December, a Forward Trust worker completed a triage assessment in
response to the nurse’s referral of 13 December. Mr Marchant denied having any
lack of control over alcohol and drug consumption and was deemed unsuitable for
structured treatment or further assessment for substance misuse support or the
IAPT service.
48. On 1 January 2022, Mr Marchant rang his emergency cell bell. Officers responded
and found him unresponsive on his bed. They were worried he was having a stroke
and called a code blue emergency. Nurses attended and Mr Marchant came round
and admitted he had been smoking PS. The nurses examined him and found no
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signs of neurological damage. Mr Marchant was observed every 30 minutes for two
hours and then hourly overnight.
49. In response to this, on 4 January, the Forward Trust sent Mr Marchant a service
pack containing harm minimisation advice, leaflets on the dangers of PS and hooch
and a self-referral form.
50. On 6 January, a consultant forensic psychiatrist reviewed Mr Marchant. He said Mr
Marchant was pleasant and calm. Mr Marchant said he felt well on his medication
but experienced agitation in the early evening. He noted the rationale for prescribing
Mr Marchant quetiapine at Chelmsford was unclear and decided to reduce Mr
Marchant’s dose gradually and review him in six weeks.
51. On 13 January, an officer suspected Mr Marchant was under the influence of PS.
He was put on 30 minute wellbeing checks and after about half an hour he said he
was OK. Neither the Forward Trust nor the prison’s security department were
informed about this as they should have been.
52. Staff found 20 litres of hooch in Mr Marchant’s cell on 20 January. Mr Marchant said
he had nothing to do and needed money to pay for vape capsules.
53. On 31 January, staff found ten litres of hooch in Mr Marchant’s cell in two five litre
containers. Mr Marchant broke the glass observation panel in his cell door, made a
barricade, threatened to take an overdose and set fire to tissue paper. Staff used
the inundation point to try to extinguish the fire, but Mr Marchant obstructed the
hose with a bucket. Staff entered the cell and removed Mr Marchant to the care and
separation unit (CSU – segregation unit). As they entered the cell, Mr Marchant
took an unknown quantity of tablets.
54. A nurse attended Mr Marchant’s removal to the CSU and examined him there. He
told her he had taken an overdose of quetiapine, naproxen (a painkiller) and
omeprazole (for acid reflux, which was not prescribed to him) and complained of a
tight chest. She requested an emergency ambulance, and Mr Marchant was taken
to hospital. Staff began ACCT monitoring. Mr Marchant returned to prison next day
and was placed in the CSU after a nurse judged he was medically fit for
segregation.
55. The prison was unable to locate or provide the ACCT document to the investigator.
The information relating to ACCT reviews below is taken from Mr Marchant’s prison
record and clinical record.
56. On 1 February, Mr Marchant was found guilty of breaking prison rules at a
disciplinary hearing and punished with seven days cellular confinement and forfeit
of privileges. The prison also decided to reclaim money in compensation for the
damage to his cell from Mr Marchant’s prison earnings.
57. A nurse attended an ACCT review the same day. Mr Marchant was unable to say
why he started the fire and took an overdose. He said he had problems with alcohol
and drinking was his way of coping with prison life. He denied feeling suicidal and
said he was angry and disappointed the hooch had been confiscated. Mr Marchant
agreed to work with the Forward Trust on his substance misuse issues.
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58. On 2 February, Mr Marchant initially refused to take his Concerta XL, but changed
his mind after the mental health team manager spoke to him. Mr Marchant told a
senior prison manager that he sometimes ‘went blank’ and felt unable to control his
behaviour. He thought this was due to ADHD. They spoke about Mr Marchant’s
Buddhism, and she arranged for the Buddhist chaplain to visit him the next day.
She said she would contact the Forward Trust to see if they would work with Mr
Marchant on his alcohol misuse. ACCT monitoring was stopped on 7 February.
59. On 9 February, a Forward Trust health and well-being worker completed a triage
assessment with Mr Marchant. She said Mr Marchant was very frustrated and
vented a lot of feelings. He admitted to using PS throughout his current sentence
and to using hooch more regularly since his recall. He said he drank alcohol and
used cannabis in the community as a form of escape. Mr Marchant completed a
questionnaire on his PS use and scored 14/15 indicating he was at high risk from
PS. She gave Mr Marchant harm minimisation advice and put him on the list for a
full assessment.
60. Later the same day, Mr Marchant broke one of the taps in his cell, causing a flood,
and used the tap to break his glass observation panel. He was found guilty of
damaging prison property and the cost of replacing the panel was added to the
money he already owed to the prison.
61. A prison GP and a nurse reviewed Mr Marchant in the CSU on 17 February. Mr
Marchant seemed calm and said he was reading and listening to the radio. The GP
said he would further reduce Mr Marchant’s quetiapine and that Mr Marchant
agreed with this plan. The GP told him that he was changing his prescription from
Concerta XL to Delmosart. He explained they were the same drug but a different
brand name.
62. On 21 February, Mr Marchant told a nurse during the daily CSU nurse visit that he
was frustrated about being in so much debt in prison and that his weekly money
was not enough to pay the debt to the prison and buy everything he needed.
63. On 1 March, Mr Marchant moved from the CSU to the Wellbeing Unit – a unit for
prisoners who wanted to remain drug free.
64. On 3 March, a well-being worker completed a full assessment of Mr Marchant’s
substance misuse. Mr Marchant spoke about his use of PS, alcohol and cannabis.
He said he struggled to control his impulses around illicit substances even though
he knew they were bad for him. He said he had really good support in the
community but had given in to temptation to drink alcohol and that had led to his
recall to prison. She reiterated harm minimisation and safe use techniques. She
completed a recovery plan and arranged to see Mr Marchant again.
65. On 6 March, an officer suspected that Mr Marchant was under the influence of PS
in his cell. There was a significant amount of vomit in his cell. He was observed
every 30 minutes and the Forward Trust was informed. Despite this, no one from
the Forward Trust went to see Mr Marchant.
66. On 16 March, staff found 19 litres of hooch in Mr Marchant’s cell in two litre bottles
and a bucket after a drug dog indicated his cell during a wing search. Mr Marchant
threatened to burn his cell down and later made a barricade. A Supervising Officer
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(SO) talked him into removing it and she, a Custodial Manager (CM) and another
SO spoke to Mr Marchant in the SO’s office. Mr Marchant said he sold hooch for
money because any money he might earn from a prison job would be taken in
payment for damage he had caused.
67. The CM persuaded Mr Marchant he would be better off working and spending some
time out of his cell. She said she would speak to the activities department about
finding a job for him.
68. Mr Marchant’s ACCT document was re-opened (again we have not seen this
document). A nurse attended a review and reported that Mr Marchant said he could
not cope in the prison environment sitting in his cell all day doing nothing. The next
day, Mr Marchant said he was interested in attending education to take his mind off
making hooch.
69. On 22 March, a well-being worker attended an ACCT review. Mr Marchant said he
was frustrated that he had no money and owed about £1,000 to the prison. He
made hooch to pay for living costs as the money he earned went to pay off his
debts.
70. On 23 March, Mr Marchant told a SO that he was in debt to other prisoners for the
confiscated hooch and needed to move to a different wing. The next day, four litres
of hooch were found in Mr Marchant’s cell. Mr Marchant barricaded his cell, tied a
ligature to the cell light and threatened to hang himself. Staff persuaded him to
remove the barricade and he agreed to move to Dixon wing at the other end of the
prison.
71. The next day, a senior prison manager spoke to Mr Marchant about his continued
brewing of hooch, barricading and damaging cells. Mr Marchant repeated that his
biggest issue was paying off his debts to the prison. She subsequently spoke to a
CM and agreed to come up with a support plan for Mr Marchant. (Again, as the
prison was unable to provide us with Mr Marchant’s ACCT document, we have not
seen this.). Mr Marchant was referred to the mental health team for review.
72. At an ACCT review on 25 March, Mr Marchant said he had threatened to hang
himself to force move to another wing. A nurse attended the ACCT review. After the
review the nurse recorded on SystmOne that he had assessed Mr Marchant and
discharged him from the mental health team.
73. A well-being worker also saw Mr Marchant on 25 March. He said he was happy on
Dixon wing and had more support there. She reassured him that they could
continue to work together even though he had moved. Mr Marchant said making
hooch made him anxious and he did not want to make it. His debts were building up
and he had threatened self-harmed to force a move to a different wing. He asked to
go through the PS in-cell pack with her the following week and she agreed. She
said she thought Mr Marchant would always seek illicit substances because of his
autistic traits and ADHD.
74. At about 6.00pm the same day, Mr Marchant pressed his cell bell. An officer said Mr
Marchant had vomited and was swaying in his cell. He asked her to open the door
for some air. She suspected he was under the influence of PS and put him on 15
minute wellbeing observations. She also submitted an information report to the
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security department. The Forward Trust records indicated they were not informed.
This was the last time Mr Marchant was found under the influence of PS before he
died.
75. On 26 March, a senior prison manager told Mr Marchant that she had agreed he
could keep £10 a week in his account and, if he worked, he could buy items from
the prison shop and use some of his earnings rather than constantly paying off his
debts for damage. Mr Marchant subsequently started work as a wing cleaner and
painter.
76. The senior prison manager saw Mr Marchant on 1 April. He said he was doing well
on Dixon wing and his mental health had improved since he had started work as a
wing painter. Mr Marchant talked in detail about his family and his drug use in the
community. Mr Marchant said he used PS in prison because it helped him to ‘block
things out’.
77. On 24 April, an officer said Mr Marchant had worked well for several weeks and had
been very helpful and polite.
78. The next day, staff found 51 litres of hooch found in Mr Marchant’s cell in two litre
and five litre containers and bin bags. The Forward Trust was informed. Mr
Marchant was removed from his job the next day.
79. The well-being worker visited Mr Marchant on 27 April in response to the hooch
find. He told her he had wanted to make some hooch for his birthday (on 2 May).
He was annoyed to lose his job and said he was back to ‘square one’ with having to
make hooch to make money.
80. On 1 May, Mr Marchant broke his observation panel. He told an officer that he was
frustrated to be in his cell when others were out. On 5 May, the prison security
department received intelligence that Mr Marchant was involved in the production of
hooch found in the wing kitchen.
81. The well-being worker saw Mr Marchant on 20 May. He said he was doing well and
had last used PS before he moved to Dixon wing. (Although he had been found
under the influence on 25 March while on Dixon wing, it seems that it was a
relatively settled period for Mr Marchant.). They completed the PS in-cell pack
together. Mr Marchant said he was selfish when he used PS and became greedy.
He said he felt panicked if he did not have access to PS because he thought it
helped him to sleep. He told her about witnessing a PS overdose and finding it
traumatic.
82. On 27 May, the security department decided to move Mr Marchant to the CSU for
seven days after receiving multiple reports suggesting he was the main supplier of
hooch on Dixon wing.
83. On 7 June, staff found 42 litres of hooch in Mr Marchant’s cell on Dixon wing, and
he returned to the CSU the next day for a security review. The review took place on
10 June, and it was decided that Mr Marchant would remain in the CSU and
transfer to another prison because of his persistent hooch brewing. Mr Marchant
said he was happy with a move and asked if he could go to Rochester as it was
closer for his family to visit. His prison telephone calls (PIN calls) from this period
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indicated that he had wanted to move to a different prison and had intended to
misbehave until being granted a transfer. Mr Marchant’s prison record for the
remainder of June showed that he remained on the CSU, his mood was good, and
his behaviour was stable.
84. On 24 June, the well-being worker visited Mr Marchant in the CSU for their meeting.
He said he was doing well and spending his days eating, training and sleeping. He
said he was waiting for a transfer to another prison. Mr Marchant acknowledged his
continued hooch brewing and said he would continue to brew it. He said he had
trouble looking beyond the present but was getting tired of ‘smashing up and
fighting’.
85. The well-being worker said she thought Mr Marchant always did well in the CSU
because he could not get hold of PS and because he responded well to the daily
contact afforded to him by the mandatory checks (prisoners in the CSU are seen
daily by the duty governor, the chaplaincy, the IMB and healthcare and there is a
higher staff to prisoner ratio than on a standard wing).
86. A CSU planning meeting on 28 June noted that Mr Marchant was due to be
transferred to another prison and set the next review for 8 July. On 29 June, a
senior prison manager told Mr Marchant he had been accepted at HMP Coldingley
and would return to a standard wing to wait transfer.
87. On 30 June, a prison GP saw Mr Marchant for a follow up assessment. He said Mr
Marchant seemed well and told him he had been accepted by Coldingley. They
discussed a further reduction in quetiapine. Mr Marchant was initially reluctant, but
the GP reassured him that it would not affect his sleep.
88. On 4 July, Mr Marchant moved to Fowler, a standard wing. It is not clear from the
records why Mr Marchant was moved before the scheduled CSU planning meeting
on 8 July.
89. On 20 July, the well-being worker met with Mr Marchant. He said he was concerned
at the length of time it was taking for him to transfer to Coldingley. He said he was
still abstinent from PS and felt his mental health was getting better. They talked
about the death of another prisoner, Mr B, from PS on 14 July. Mr Marchant said he
had known Mr B and was shocked by his death. He said it showed that the PS in
the prison was “strong”, and it had “made him think”. Mr Marchant said spending a
lot of time in cell made prisoners more inclined to use PS. She reiterated how
tolerance levels reduced after periods of abstinence and this increased the risk of
harm from using it.
90. Later the same day staff found nine litres of hooch in Mr Marchant’s cell. The well-
being worker visited him the day after on 21 July. He said he had brewed the hooch
to sell not to use. He said he had had a conversation with his mum that day and that
had made him feel happier. They completed the Forward Trust’s in-cell pack on PS
together.
91. On 23 July, Mr Marchant was moved to Nash A wing. Mr Marchant’s prison record
did not show why he was moved, although the prison clarified at initial report stage
that this was because, due to his history of starting cell fires, the prison was
required to allocate Mr Marchant to an anti-barricade cell (a cell with a door that can
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be opened outwards in order for staff to gain access in case of fire). In July 2022,
The Mount had 28 such cells on the standard wings at the top end of the prison (on
Fowler, Brister, Lakes and Ellis wings), 486 such cells on the standard wings at the
bottom end of the prison (on Howard, Dixon and Nash wings) and 24 in the CSU.
We do not know how many such cells were available on each wing on 23 July.
92. A prisoner said he had known Mr Marchant since they were at school together. He
was already on Nash A wing when Mr Marchant moved there in the late afternoon
of 23 July. He said Mr Marchant looked well, seemed happy and had put on some
weight. He helped him move his property into his cell. He said there was a lot of PS
on Nash A at that time and he and other prisoners thought a member of staff was
bringing the drugs into the prison.
93. The Nash A wing observation book showed more than 20 entries relating to
prisoners being found under the influence of PS between 19 and 24 July. A CM told
the investigator that there was a lot of PS on Nash A at the time. He said he
understood that PS had become cheaper since Mr B died on 14 July, and so more
people had access to it.
94. Information provided by the prison’s security department showed intelligence that
PS was being distributed throughout the prison from Nash A and Nash B wings via
kitchen workers and other prisoners in trusted jobs.
Events of 24 - 25 July
95. CCTV showed that an officer unlocked Mr Marchant for evening medication at
4.51pm. Mr Marchant returned to his cell from an upstairs landing four minutes later
and an officer locked him into his cell for the night. A prisoner said Mr Marchant had
visited him just before he was locked into his cell. He thought Mr Marchant did not
look well and appeared under the influence of something. CCTV showed Mr
Marchant appeared to walk steadily and was not obviously unwell.
96. Operational Support Grade (OSG) A, the night patrol officer, completed the evening
roll check at the start of his shift. CCTV showed he checked Mr Marchant twice, at
8.15pm and 8.20pm. CCTV shows that no one checked Mr Marchant again during
the night.
97. At about 5.25am, the OSG A started the early morning roll check. CCTV showed he
looked through Mr Marchant's observation panel at 5.30am. He said Mr Marchant
was laying on the floor of his cell with his head facing the window and it was
obvious that something was not right. He banged on the cell door and called Mr
Marchant's name but received no response. He said it was his understanding that in
this situation he should call for assistance from the night orderly officer.
98. CCTV and radio traffic showed the OSG radioed the communications officer and
asked for assistance at 5.32am. He said, “X-ray 2 (the call sign of his radio) can I
have some assistance on Nash wing A side on the twos, over.”
99. OSG B, the night patrol on Nash Wing B side, heard the radio transmission and
joined his colleague outside Mr Marchant's cell. OSG B said he also tried to get a
response from Mr Marchant but was unable to. He said Mr Marchant was in an
unnatural position on the floor.
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100. The night orderly officer also heard OSG A’s call and asked for more information.
The communications officer asked OSG A twice for more information, but he did not
respond. He said at interview that he did not remember hearing the requests. Two
minutes later at 5.35am, the communications officer asked OSG A if he could see
the prisoner. He said, “I can absolutely see the prisoner I’m just not getting any
response from him”.
101. At 5.36am, OSG A asked the night orderly officer for permission to enter Mr
Marchant's cell using the cell key in his sealed pouch. He said he felt safe to go in
because he knew something was wrong and he had OSG B with him. The night
orderly officer said he could not enter the cell until staff arrived.
102. OSG B said that when the night orderly officer told them not enter the cell, he
decided to collect the defibrillator from the wing office. CCTV showed he left to
collect the defibrillator at 5.37am and returned with it at 5.39am. Neither of the
OSGs radioed a code blue emergency (indicating that a prisoner is not breathing or
unconscious and requiring an ambulance be called).
103. The night orderly officer said he denied OSG A permission to enter the cell because
he had said he could see Mr Marchant and he had not called an emergency code.
He assumed that if a member of staff could see a prisoner and had serious
concerns about him, he would call an emergency code. He said the original call had
been for assistance and there was no indication that the situation was an
emergency. Due to the amount of PS on Nash A, he had responded to several
requests to attend cells that week when prisoners were under the influence and
there was no indication that this was anything other than a routine request.
104. Just before 5.41am, the night orderly officer arrived at Mr Marchant’s cell with two
officers. (He was at the gate end of the prison and Nash is the farthest wing away
from the gate. The Mount is large site, and it takes approximately ten minutes to
walk from one end of the prison to the other.)
105. Officer A opened the cell and he and Officer B went in. At 5.42, the night orderly
officer radioed a code blue emergency. He said it was obvious as soon as he
arrived that Mr Marchant had died. Officer A said he touched Mr Marchant’s leg to
try to get a response from him and it was stiff and cold. He and Officer B turned Mr
Marchant over and saw that rigor mortis had set in. Mr Marchant had a vaping
device in one hand and a vape capsule in the other. He said they did not start
cardio-pulmonary resuscitation (CPR) as Mr Marchant had clearly died.
106. Radio messages showed that that the communications officer asked the night
orderly officer if he wanted her to call an ambulance. He confirmed that he did.
About a minute later he told the communications officer that Mr Marchant was dead
and to call the duty governor. The communications officer asked if he wanted her to
call the ambulance or the duty governor first. He told her to call the ambulance.
Ambulance records showed the prison called an ambulance at 5.45am and the call
was triaged as a category one with a response time target of 15 minutes.
107. The call handler asked the communications officer to attach a defibrillator if one was
available. The night orderly officer said he could hear the call over the radio. He had
decided not to start CPR as Mr Marchant had died, but changed his mind when he
heard this request. Both officers put the defibrillator on Mr Marchant and Officer A
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started CPR. The defibrillator checked for a heartbeat and instructed them to carry
on with CPR.
108. Paramedics arrived at Mr Marchant’s cell at 6.12am and immediately confirmed Mr
Marchant had died.
109. Later the same day, the police arrested a member of staff on Nash A wing. At the
time of writing the police are still investigating whether they were involved in
bringing drugs into the prison. We understand that their investigation has not been
evidentially linked to Mr Marchant’s death.
Contact with Mr Marchant’s family
110. The prison appointed a family liaison officer (FLO). The FLO and the prison
chaplain informed Mr Marchant’s next of kin of his death in person at their home at
lunchtime that day. The prison made a financial contribution to Mr Marchant’s
funeral in line with national guidance.
Support for prisoners and staff
111. There was no formal debrief for the staff involved in the emergency response. The
night orderly officer said he did not receive any support from managers or the
prison’s Trauma Risk Management (TRiM) team. Officer B said the Deputy
Governor and the TRiM team spoke to him that morning.
112. The prison posted notices informing other prisoners of Mr Marchant’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 his death.
Post-mortem report
113. The post-mortem report showed that Mr Marchant died from synthetic cannabinoid
toxicity.
Inquest
114. The Coroner’s inquest held in March 2025 gave the medical cause of death as
synthetic cannabinoid toxicity and concluded Mr Marchant’s death was drug related.
Actions taken after the deaths of Mr Marchant and Mr B
115. When Mr Marchant died the prison was in the process of taking a number of actions
in response to the death of Mr B on 14 July, including:
• On 14 July the Governor issued a Prisoner Information Notice (PIN) on PS
awareness, warning prisoners that the ingredients of PS changed constantly
and listing warning signs of intoxification.
• An amnesty on illicit substances was brought in for the remainder of 14 July
and all-day 15 July. No one handed anything in.
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• On 17 July, the prison resumed intelligence-led and random drug testing.
• Prisoners found under the influence had their cells searched without
supporting intelligence, on the grounds of safety.
• The Forward Trust prioritised checking all prisoners suspected of using drugs
and delivered direct harm minimisation advice.
• Between 19 July and 11 August, nine prisoners were removed from their jobs
following intelligence that they were conveying drugs.
• On 28 July, the prison conducted a lockdown search of Nash Wing.
Fermenting liquid, paper suspected to contain PS and other evidence of illicit
substances was found.
• The windows of the Annexe were sealed after intelligence indicated that
drugs were being sent in through them via drone.
116. In August, the HMPPS regional drug lead requested a full diagnostic review of the
prison’s drug strategy by HMPPS Substance Misuse Group. The diagnostic team
made 20 recommendations to improve the prison’s drug strategy. Significantly they
found that:
• Evidence indicated an extensive supply of PS in the prison.
• The drug strategy was not fully developed and was not a ‘live’ document.
• There was no specific PS strategy.
• The approach to debt was not dynamic or linked to the drug strategy or
intelligence reports.
• Intelligence analysis was good.
• The prison’s significant staffing issues undermined their efforts to reduce
supply and demand and made a ‘whole prison approach’ extremely difficult.
In particular, the lack of prison regime fuelled the demand for drugs.
• Mandatory drug testing was suspended due to lack of staff. (This has since
resumed but at the time of writing a maximum of 17 tests had been
completed each month.)
• Wing Intelligence Liaison Officers (WILOs) who might plug the intelligence
gap caused by the lack of mandatory drug testing were not operating due to
staff shortages.
• Conveyance of drugs by staff was a considerable risk due to their
inexperience and vulnerability to organised crime (over 70% of staff had less
than two years’ experience).
117. The drug strategy manager appointed in November 2022, provided us with the
prison’s current drug strategy and their action plan in response to the diagnostic
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report. The Head of Safety provided us with the prison’s debt strategy and
confirmed that it was currently under review.
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Findings
Drug strategy at HMP The Mount
118. We acknowledge the huge challenges inherent in preventing drugs entering The
Mount. PS is especially prevalent in category C prisons because their lower security
measures and stable population allows for the maintenance of distribution networks.
The Mount also has a large perimeter and is situated in an open and accessible
rural area vulnerable to ‘throw-overs’ and drones. The proximity of the M25 places it
at the junction of prominent County Lines routes. The illicit drugs market in prison is
controlled by organised crime gangs and the scale of the problem requires a co-
ordinated approach. Although it is clear that some things are being done very well
at The Mount, including the analysis of intelligence and the system for checking the
validity of legal mail, the threat from drugs is constantly evolving and more can
always be done.
119. We are extremely concerned that there was an unacceptably high supply of PS in
the prison when Mr Marchant and Mr B died in July. Some drug testing re-started
after Mr B died but fewer than half the requested cell searches were being
completed. HMPPS Substance Misuse Group concluded that the prison could do
much more to reduce supply and demand, especially for PS. The prison accepted
all 20 recommendations from the diagnostic report and has produced a ‘live’ action
plan to drive progress towards achieving them. The newly appointed drug strategy
manager is now working to coordinate a whole prison approach. Although it is too
early to see the impact of these new measures, we are satisfied that the prison is
trying to make meaningful progress to reduce supply and demand. In particular, we
note they have:
• Added counter-corruption training to the monthly staff training schedule.
• Issued a protocol for prisoners found under the influence of illicit substances.
• Started reviewing all prisoners in high-risk roles every six months.
And are planning to:
• Ban staff from bringing in paper other than their official diaries.
• Require legal visitors to bring in laptops and not paper records.
120. We are concerned that the prison’s efforts are fatally undermined by their chronic
staffing issues. Staffing was highlighted as a key concern by HMIP with 40% of staff
unable to be deployed to operational duties and a high number of staff left within
their first year. The diagnostic report also highlighted staff retention as a key issue,
as 70% of staff had under two years’ experience. The Mount is currently 30 officers
below their profile of 180. At the time of writing, 50% of officers were not available
for operational duties. In October, they introduced an emergency regime based on a
re-profile of 150 staff. This has allowed consistent delivery of some work and
activities but is by no means a permanent or desirable long-term solution. A
consistent regime is critical to reducing the demand for drugs by alleviating
boredom through purposeful activity.
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121. Crucially, the lack of staff has limited the operation of drug testing programmes.
Random and suspicion testing was re-introduced a few days before Mr Marchant
died. Mandatory drug testing resumed in October for the first time since the COVID-
19 pandemic. However, the highest number of mandatory tests completed in a
single month at the time of writing was 17 out of a population of just over 1,000
men. This means that information reports relating to substance misuse are not
being properly tested and there is a consequent intelligence gap. The WILO role
that might help to plug this gap is not operating due to lack of staff.
122. The prison is also unable to undertake sufficient searching and fully support the
regional dog team. We consider that without these critical pillars of supply
reduction, the prison will be unable to gauge the true nature and scale of their drug
problem and their efforts will continue to be undermined. The prison has introduced
some new measures in response to HMIP’s recommendation on staffing, however,
almost a year later, progress has been limited and they remain some distance from
recruitment targets. It seems likely that two more prisoners have died from the
effects of PS since Mr Marchant died. We are extremely concerned that unless
more is done urgently to reduce the flow of drugs into the prison, more prisoners will
die. We recommend that:
The Director General of Prisons should consider what additional support can
be put in place to address staffing shortages at The Mount and consider, as a
matter of urgency, how it can reasonably be expected to deliver an effective
drug strategy and regime.
Mr Marchant’s PS use, hooch brewing and debt management
PS use
123. We are satisfied that Mr Marchant was well-supported by the well-being worker.
Health and wellbeing workers have a target of seeing their clients every 12 weeks
and she saw Mr Marchant at least once a month and often more frequently. She
also attended his ACCT reviews. We are satisfied that Mr Marchant knew the
dangers of PS use. He knew Mr B and had been affected by his death. The well-
being worker reiterated harm-minimisation advice and went through information on
the dangers of PS use with him only four days before he died. We have not found
any evidence that Mr Marchant intended to die on 25 July.
124. We are very concerned that shortly before he died, Mr Marchant was moved to a
wing where it was widely known that there was an exceptionally large amount of
PS. Mr Marchant was a well-known PS user in prison and was assessed as at high
risk of using PS. Mr Marchant’s autistic traits and ADHD meant he had poor impulse
control and increased the likelihood he would use PS if offered it. We understand
that the majority of anti-barricade cells were located on the wings most affected by
PS, however with hindsight, consideration should have been given to the risk
presented to Mr Marchant before moving him there. The fact that he died less than
36 hours later is stark.
The Governor should ensure that staff consider all of the prisoner’s specific
known risk factors before transferring them between wings.
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Hooch brewing and debts
125. Mr Marchant appears to have been stuck in a cycle of hooch brewing and debt
throughout his six year sentence. There is little in Mr Marchant’s records to show
what efforts the prison made to break this cycle, apart from disruption moves to
different wings and two periods in the CSU. Although Mr Marchant seems to have
done well in the CSU, partly because of the higher staff to prisoner ratio and
mandatory daily checks, segregating prisoners is not a long-term solution to
supporting behavioural change.
126. We acknowledge that Mr Marchant also admitted he enjoyed brewing and
consuming hooch. Prisoners in any type of debt are vulnerable to pressure. Mr
Marchant’s debts contributed to keeping him involved in the illegal prison economy
which in turn led to the violent and self-harming behaviour that manifested after
each hooch find. Unlike most prisoner debt, Mr Marchant’s debts were mostly a
known quantity because he was in debt to the prison. We consider it should have
been easier for the prison to help him manage them and therefore remove perhaps
the most significant reason for his persistent hooch brewing.
127. Mr Marchant’s longest period on a standard wing without either being found with
hooch in his cell or suspected of brewing hooch elsewhere, was between 24 March
and 25 April, when the prison implemented a care plan to give him a job and allow
him to keep more money each week. We have not seen this plan because the
prison lost Mr Marchant’s ACCT document (discussed below).
128. Neither have we seen any evidence of reintegration planning when Mr Marchant
returned to a standard wing after 29 days in the CSU. We do not know whether the
prison considered reinstating the previous care plan, but it seems unlikely as the
plan was not part of Mr Marchant’s prison record.
129. Mr Marchant returned to brewing hooch less than two weeks after returning to a
standard wing. We understand the prison is currently reviewing their debt strategy
in line with a recommendation from the Substance Misuse Team and this presents
an opportune moment to consider care planning for known debtors. We make the
following recommendation:
The Governor should ensure that the review of the prison debt strategy
considers care planning for known debtors and ensures that all agreed care
plans are recorded on the prisoner’s record and therefore available for all
staff to see.
Emergency response
130. Prison Service Instruction 03/2013 requires governors to have a two code medical
emergency response system based on the instruction. As is usual, The Mount use
code blue to indicate an emergency when a prisoner is unconscious, or having
breathing difficulties, and code red when a prisoner is bleeding. Calling an
emergency code should automatically trigger the control room to call an ambulance.
131. Prison Service Instruction (PSI) 24/2011 gives national guidance for entering cells
at night. The PSI says that under normal circumstances, the night orderly officer
must give authority to unlock a cell at night and a cell opened with a minimum
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number of staff (according to local risk guidelines) present. However, the PSI goes
on to say, that the preservation of life must take precedence over this. Where there
is or appears to be threat to life, staff may open and enter cells on their own if they
feel safe to do so, having performed a dynamic risk assessment and informed the
control room. The Mount’s local guidelines reflect this.
132. OSG A said he understood that, if he found a prisoner unresponsive, he should
radio for assistance. He did not give any information about why he needed
assistance and said he did not hear requests from the communications officer for
further information. He was aware that he could break his sealed pouch and enter a
cell if he believed a prisoner’s life was at risk. He said he could see that something
was not right and described Mr Marchant as laying in unnatural position. He was
sufficiently worried to ask to enter Mr Marchant’s cell once OSG B joined him,
although he did not need permission. When this was denied, OSG B was
sufficiently concerned to collect the defibrillator from the wing office.
133. We consider that the situation was sufficiently plain for OSG A to radio a code blue
emergency at the outset. He said at interview that he had felt safe to enter the cell
because OSG B was also present, but he did not do so. At the least, we consider
he should have volunteered more information to allow the night orderly officer to
make an informed decision about how to respond, both to his request for assistance
and to his subsequent request to enter the cell.
134. OSG A was the night patrol officer on duty when the other prisoner who died at The
Mount in July was found unresponsive. In that case he also failed to call a code
blue or otherwise effectively communicate the nature of the emergency to the night
orderly officer. He told the investigator that no one had spoken to him about his role
in the previous death or Mr Marchant’s death or given him any advice and guidance
about what to do if he found a prisoner unresponsive. This is disappointing,
especially as both Early Learning Reviews highlighted his response as a learning
point.
135. Staff eventually entered Mr Marchant’s cell some 12 minutes after OSG A had
found him unresponsive. The communications officer did not ring an ambulance
immediately which led to a further delay of three minutes until the emergency
services were contacted.
136. The Mount covers a very large site. The night orderly officer and the assist night
orderly officers are usually based at the gate end of the prison. Even at a fast walk,
Nash Wing is some ten minutes distant at the opposite end. This means that, if a
night patrol officer decides not to enter a cell, there is already a significant delay
built in before the cell will be entered. It also means that, if it is left to the night
orderly officer to attend the scene before a code blue is called, they (or one of their
assists) also have to return to the gate before the ambulance can enter the prison. It
is therefore imperative that a code blue is called when there are concerns for a
prisoner’s safety. This would allow the night orderly officer to consider how to best
manage the situation with the staff available to them.
137. Although the significant delay in the emergency response did not affect the outcome
for Mr Marchant, it is important that all staff understand their roles in a medical
emergency. We make the following recommendations:
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The Governor should ensure that all staff are made aware of and understand
their role and responsibilities during medical emergencies, including that
they should radio a code blue emergency if they are concerned a prisoner is
not breathing and that they should enter cells as quickly as possible if there
is reason to consider that a prisoner may be at risk.
The Head of Safety should ensure that OSG A understands his
responsibilities if he finds a prisoner unresponsive.
The Governor should review the numbers of night orderly staff and consider
stationing one or more assist night orderlies at the further end of the prison
in order to minimise delays in entering cells at night.
Resuscitation
138. In September 2016, the National Medical Director at NHS England wrote to Heads
of Healthcare for prisons to introduce new guidance to help staff understand when
not to perform cardiopulmonary resuscitation (CPR). This guidance was designed to
address concerns about inappropriate resuscitation following a sudden death in
prison. It was taken from the European Resuscitation Council Guidelines which
states, “Resuscitation is inappropriate and should not be provided when there is
clear evidence that it will be futile.” The European Guidelines were updated in May
2021, but the same principles apply.
139. Mr Marchant’s arms and limbs were completely stiff, which indicated that rigor
mortis (stiffness of the limbs after death) was present. Rigor mortis normally sets in
between two and six hours after death, indicating that Mr Marchant had been dead
for some time when he was found. The night orderly officer and Officers A and B all
thought Mr Marchant had died and, correctly, decided not to begin CPR. Matters
were then confused by the call-handler asking them to attach a defibrillator and they
changed their minds. Call-handlers have a set list to work through as part of their
standard response to being told a patient is not breathing, but we accept this would
not have been clear to the night orderly officer.
140. We understand the difficulty in decision-making in these circumstances. Clear
communication is impaired because the officers at the scene are not in direct
contact with the call handler. However, trying to resuscitate someone who is clearly
dead is distressing for staff and undignified for the deceased and it is important that
staff have confidence not to perform CPR when the signs of death are unequivocal.
We repeat the recommendation we made in our investigation into the death of Mr B:
The Governor should ensure that all staff are given clear guidance about and
understand the circumstances in which resuscitation is inappropriate in line
with European Resuscitation Council guidelines.
Body-worn video cameras
141. At the time of Mr Marchant’s death guidance on operating body-worn video
cameras was contained in Prison Service Instruction (PSI) 04/2017. Recording of
incident response is mandatory and staff must give reasons for any failure to record
an incident wholly or partially in their written statements. When attending incidents
where a prisoner is receiving life-saving medical intervention and there is no threat
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to the safety of others, staff must maintain audio capture but consider non-intrusive
video capture of the medical intervention. The guidance is the same in the policy
framework issued in September 2022.
142. Our investigation into the death of Mr B found that staff did not turn on their body-
worn video cameras until a late stage. In this case no one turned on their cameras
at all. We therefore repeat our recommendation that:
The Governor should ensure that staff operate their body-worn video cameras
in line with national guidance.
ACCT
143. The prison was unable to find Mr Marchant’s ACCT document and reported it as a
data loss. Summaries of ACCT reviews should be added to the prisoner’s record
(NOMIS), however there were few of these and so we have not been able to
examine Mr Marchant’s ACCT planning. The HMPPS Area Safer Custody early
learning review noted that the prison did not have a process in place to track or
store ACCT documents once they had been closed. We make the following
recommendation:
The Head of Safety should ensure that there is a process in place for tracking
and storing closed ACCT documents.
Clinical care
144. The clinical reviewer found that Mr Marchant’s mental healthcare was not
equivalent to that he could have expected in the community. The mental health
team did not take sufficient account of his neurodiversity and did not inform the
Forward Trust of Mr Marchant’s autism diagnosis. We consider that the impact of
his diagnoses of ADHD and autism on Mr Marchant’s behaviour in prison, including
his hooch brewing and PS use, was not sufficiently considered. His behaviour was
treated as a disciplinary matter, and we have seen no evidence that consideration
was given to whether he would have benefitted from mental health support. We
make the following recommendation:
The Head of Healthcare should ensure that:
• Staff use the alert function on SystmOne to include significant
conditions such as ADHD and autism on the patients record.
• All staff receive Oliver McGowan mandatory training on learning
disability and autism.
• Staff consider whether a prisoner’s neurodiversity presents a barrier to
them self-referring to services such as IAPT and psychosocial
substance misuse support.
• All referral forms include learning disability and autism in the list of
significant conditions.
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145. The reviewer also identified a lack of evidence-based risk assessment and risk
formulation for patients on the mental health team caseload. Interventions were
brief and on one occasion a mental health assessment was completed as part of an
ACCT review. The weekly multi-disciplinary team meeting was poorly attended and
lacked focus.
146. This is the third death at The Mount in 2022 where mental healthcare was found to
be inadequate. The clinical review makes recommendations about these issues
which the Head of Healthcare will need to address.
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