Paul Bryant

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Independent investigation into
the death of Mr Paul Bryant,
a prisoner at HMP Stocken, on
19 April 2023
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 Paul Bryant died from a catastrophic haemorrhage after he made a deep cut to his
carotid artery on 19 April 2023 at HMP Stocken. He was 38 years old. I offer my
condolences to Mr Bryant’s family and friends.
Mr Bryant had been in prison since July 2021 and was due for release in May 2023. He
had been supported through the Prison Service suicide and self-harm prevention
procedures for a month in April and May 2022, but had then settled.
Mr Bryant experienced difficulties in his personal life in 2023 but was dismissive when staff
tried to help him and he insisted that he had no thoughts of suicide or self-harm. We are
satisfied that there was little indication that Mr Bryant was at imminent risk of suicide at the
time of his death.
Staff who responded when Mr Bryant was found on 19 April, tried hard to save him despite
the extremely distressing circumstances.
We have not made any recommendations but have identified an area of learning that the
Governor will want to consider.
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 April 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
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Summary
Events
1. Mr Paul Bryant was recalled to custody in July 2021 after he was arrested for
burglary. He moved to HMP Stocken in January 2022 and had a conditional release
date of 14 May 2023.
2. In early January 2023, Mr Bryant damaged his cell furniture to engineer a move to
the segregation unit. He said that he had problems in his personal life and needed
some time alone. He would not tell staff about his problems but said that he had no
thoughts of suicide or self-harm. Mr Bryant’s mother died later that month after a
period of ill health.
3. In early April, Mr Bryant’s partner told the prison that she was concerned about his
welfare. Staff spoke to him, and he told a nurse that he was upset with one of his
sisters. He said he believed his partner was having an affair. He told the nurse that
he had no thoughts of suicide or self-harm, and he declined an offer of counselling.
4. At 2.35am on 19 April, a prisoner rang his cell bell after hearing a strange noise
from Mr Bryant’s cell. The night officer saw Mr Bryant lying on the cell floor, partly
obscured by his bed. The night officer saw a lot of blood and he radioed a medical
emergency code. The night officer went into the cell and when he pulled Mr Bryant
away from his bed, he saw he had a gaping wound to his throat. The night officer
pressed a towel to Mr Bryant’s neck and gave chest compressions with his other
hand. Other officers arrived at the cell and took turns in giving chest compressions.
5. Ambulance paramedics arrived at 3.10am and took charge of Mr Bryant’s
treatment. At 3.23am, they confirmed that Mr Bryant had died.
Findings
6. While Mr Bryant had concerns about his personal life, he declined offers of support
and he gave no clear indications that he was at risk of suicide or in need of
additional monitoring.
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The Investigation Process
7. HMPPS notified us of Mr Bryant’s death on 19 April 2023. The investigator issued
notices to staff and prisoners at HMP Stocken informing them of the investigation
and asking anyone with relevant information to contact him. One prisoner
responded.
8. The investigator obtained copies of relevant extracts from Mr Bryant’s prison and
medical records.
9. The investigator interviewed ten members of staff at Stocken on 6 and 7 June 2023.
He subsequently interviewed two further staff and one prisoner by video-link and
telephone.
10. NHS England commissioned a clinical reviewer to review Mr Bryant’s clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews with
healthcare staff and with the officers who responded to Mr Bryant’s discovery.
11. We informed HM Coroner for Rutland and North Leicestershire of the investigation.
She gave us the results of the post-mortem examination. We have sent her a copy
of this report.
12. The Ombudsman’s family liaison officer contacted Mr Bryant’s partner to explain the
investigation and to ask if she had any matters she wanted us to consider. It would
appear however that she did not receive the letter.
13. Separately, Mr Bryant’s sister forwarded us an email she sent to the prison which
referred to two emails she had sent the previous year in which she raised concerns
about her brother’s mental health at the time of their mother’s death. She wrote that
despite raising these concerns, her brother was nevertheless able to take his life.
Mr Bryant’s sister also complained that it took almost seven hours for the family to
be told of her brother’s death. We have tried to address these concerns in this
report.
14. We shared our initial report with Mr Bryant’s family via their solicitors and with HM
Prison and Probation Service (HMPPS).
15. Mr Bryant’s sisters commented on part of the evidence given by Officer A about
their mother’s funeral. They said that they both approached their brother at the
funeral and that he interacted with one of them.
16. Mr Bryant’s partner said that in their final telephone conversations, Mr Bryant made
a number of comments to suggest that he intended to harm himself. She also said
that she reported her concerns a number of times to his community offender
manager.
17. HMPPS pointed out two factual inaccuracies on the background information about
Stocken and these have been corrected.
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Background Information
HMP Stocken
18. HMP Stocken is a category C training prison in Rutland which holds up to around
1,070 men. Practice Plus Group provides all healthcare services. Healthcare is
provided from 7.30am to 6.30pm during the week and from 8.30am to 5.30pm at
weekends.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Stocken was in January 2023. Inspectors found
that staff were knowledgeable about prisoners receiving support through ACCT
(Prison Service suicide and self-harm reduction procedures) and the quality of
ACCT documentation had improved since the previous inspection. Inspectors found
that mental health staff contributed effectively to ACCT reviews. However,
inspectors noted that there remained some deficiencies, including inconsistent case
managers. Inspectors noted that 63% of prisoners said that most staff treated them
with respect although many prisoners said that staff were detached and kept their
distance.
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 April 2022, the IMB found that
Stocken was a safe environment and that in general, prisoners were treated fairly
and humanely. The IMB noted that the Governor prioritised safety and violence
reduction, supported by a well-resourced and enthusiastic safer custody team. The
IMB noted that quality assurance checks showed improvements in ACCT
documentation but identified some areas of concern.
Previous deaths at HMP Stocken
21. Mr Bryant was the seventh prisoner to die at Stocken since January 2019. Of the
previous deaths, two were self-inflicted, three were from natural causes, one was
drug-related and in one case, no cause of death was established. We have found
no similarities between Mr Bryant’s death and the previous deaths.
Assessment, Care in Custody and Teamwork
22. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses for supporting and monitoring prisoners assessed as at risk
of suicide and self-harm. The purpose of the ACCT process is to try to determine
the level of risk posed, the steps that might be taken to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Levels of supervision and
interactions are set according to the perceived risk of harm. There should be regular
multidisciplinary case reviews involving the prisoner. Checks made on prisoners
should be at irregular intervals to prevent the prisoner anticipating when they will
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occur. Part of the ACCT process involves assessing immediate needs and drawing
up a care plan to identify the prisoner’s most urgent issues and how they will be
met. Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011.
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Key Events
23. In July 2021, Mr Paul Bryant was arrested for burglary and was later sentenced to
12 months in prison. He was also subject to a life sentence recall so received an
additional 18-month sentence to run concurrently with his new sentence. His
conditional release date was 14 May 2023.
24. On 18 January 2022, Mr Bryant was moved to HMP Stocken.
25. Mr Bryant saw a nurse for a first reception health screen on arrival at Stocken. The
nurse noted that Mr Bryant engaged well, reported that he had no history of mental
health problems and had no thoughts of suicide or self-harm.
26. When Mr Bryant’s cell was unlocked on the morning of 3 April, an officer noted that
he was covered in blood. He told the officer that he had used a razor blade to cut
his neck. A nurse was called who noted that Mr Bryant had numerous cuts to his
throat, although they were not deep cuts. The nurse cleaned and dressed the cuts.
27. Staff started Prison Service suicide and self-harm monitoring procedures (known as
ACCT) and a supervising officer (SO) chaired an ACCT review later that morning.
Mr Bryant, an officer and a mental health nurse attended. Mr Bryant said that he
had not been getting much sleep recently due to the noise from a neighbouring cell
and he also believed people were pumping gas into his cell. He said that he thought
he could hear his brother’s voice outside his cell window, although he knew his
brother was not there and he accepted he was becoming paranoid. Mr Bryant said
that when he cut himself, he had done it before he realised what he was doing. He
said that he had not harmed himself in the past and had no intention of doing so in
the future. He said that he had good support from his family and had made some
friends in prison. Mr Bryant’s observations were set at two an hour.
28. The nurse who attended the ACCT review noted that while Mr Bryant said that he
had no past mental health issues, it was possible that he had a potentially
undiagnosed mental health condition. He referred him to the prison psychiatrist.
29. Mr Bryant’s next ACCT review was on 6 April. The SO asked Mr Bryant about his
report of hearing voices, the other thoughts that had prevented him sleeping and
whether he had any history of anxiety, paranoia or depression. Mr Bryant said that
he had no such history and he denied taking illicit drugs. Mr Bryant again said that
he had no intentions of suicide or further acts of self-harm. The SO reduced Mr
Bryant’s observations to one an hour. A mental health nurse who attended the
review told Mr Bryant that he had an appointment with the prison psychiatrist later
that morning. She encouraged him to be open about his situation.
30. Mr Bryant did not attend his appointment with the psychiatrist. The mental health
team sent Mr Bryant a letter to ask why he did not attend and whether he wanted a
new appointment.
31. On 8 April, two officers and a chaplain separately spoke to Mr Bryant in response to
concerns that had been raised by his family. Mr Bryant told one of the officers that
he was fine, but he complained to the chaplain and the other officer about the men
in the cell above his, including that they were talking about him. Mr Bryant declined
an offer of support from the safer custody team.
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32. Mr Bryant’s next ACCT review was on 13 April. He said that he was doing very well
and was enjoying his prison job which kept him distracted. He also said that he was
no longer hearing voices, although the SO noted that he was not necessarily
convinced by Mr Bryant’s answer. A mental health nurse at the review asked Mr
Bryant about his missed psychiatric appointment and he said that he was alright
and did not need to see anyone. The nurse noted that Mr Bryant appeared well-
kempt, he maintained good eye contact, his speech was normal in rate and rhythm,
and he was showing no overt signs of psychotic illness. Mr Bryant again said that
he had no thoughts of suicide or self-harm, and his observations were reduced to
one every three hours.
33. At his next ACCT review on 20 April, Mr Bryant appeared dismissive of the process.
The SO noted that he did not consider that Mr Bryant’s risk was raised compared to
the previous review, but he decided to keep the ACCT open due to his poor
interaction with the review. The SO maintained Mr Bryant’s observations at the
same level.
34. Nothing of concern arose during Mr Bryant’s next two ACCT reviews and on 4 May,
the ACCT was closed.
35. On 7 January 2023, Mr Bryant damaged his television and cell furniture. He told
staff that he had difficulties with his personal life outside prison, which he did not
want to discuss. He said that he did not have any problems in the prison, he was
not having thoughts of suicide or self-harm, but he wanted some time alone in the
segregation unit.
36. Mr Bryant was moved to the segregation unit pending an adjudication hearing. He
pleaded guilty at a hearing later that day and was told he would remain in
segregation for seven days.
37. All of the entries made by prison staff, healthcare staff and chaplaincy visitors over
the following days show that Mr Bryant was polite, behaved well and engaged in
conversation. There were no entries to suggest that he might be at risk of suicide or
self-harm. A mental health nurse noted that she asked him why he damaged his
cell, but he only said that he “wanted some time out”. The nurse told him that
someone from the healthcare team would see him each day while he was in
segregation, and he could speak to them if he wanted.
38. On 14 January, Mr Bryant left segregation and returned to his usual wing. He told
one of the wing SOs that his “head [was] in a better place” and that he had learned
from his “negative behaviour”.
39. Officer A told the investigator that she had always had a good relationship with Mr
Bryant, and he spoke about his children and others in his family. She said that she
tried to speak to Mr Bryant about the problem that led to him moving to segregation,
but he would not explain. She said that after his return to the wing, he seemed his
normal self again.
40. On 23 January, Mr Bryant learned from his family that his mother had died
suddenly. Stocken’s managing chaplain told the investigator that he gave Mr Bryant
some literature about bereavement, and he was involved in the arrangements for
Mr Bryant to attend his mother’s funeral.
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41. On 2 February, a mental health nurse saw Mr Bryant for a welfare check. Mr Bryant
said that his mother had been unwell for a while and that had affected his mood and
behaviour. He said that he felt he was processing the news of her death better than
how he had dealt with her illness. He said that his partner and children were strong
protective factors for him, and he was receiving good support from the chaplaincy
team. He said that he did not have any thoughts of suicide or self-harm.
42. Mr Bryant attended his mother’s funeral on 17 March. Officer A told the investigator
that she was one of two officers who escorted him to the funeral, and she made an
entry in his records to say that he had behaved impeccably and had been polite and
respectful at all times.
43. On 4 April, Mr Bryant’s prison offender manager emailed various staff to say that Mr
Bryant’s partner had contacted his community offender manager as she was
concerned about comments he had made on the telephone about never seeing her
or their children again, His partner said that she did not want him to know that she
had reported this to the prison. We understand from Mr Bryant’s partner that she
contacted the community offender manager a number of times expressing her
concerns following telephone conversation with Mr Bryant.
44. An SO told the investigator that she was copied into the email from Mr Bryant’s
offender manager, and she went to see him. She said that Mr Bryant was standing
at a friend’s cell, and they were preparing a meal. She asked him if all was well and
if he had had any recent contact with his family. He said that all was good, and he
had no problems. She told the investigator that Mr Bryant did not tend to seek help
from staff and his response that day was typical for him: he was polite, he smiled,
and he did not present as being in crisis.
45. On 5 April, a mental health nurse also saw Mr Bryant in follow-up to the email. She
noted that Mr Bryant was surprised that she had come to see him, and he was
initially defensive. However, after prompting, Mr Bryant spoke about some of his
feelings about his biological family, including that he did not consider that they had
done enough for his mother during the final stages of her life. He also said that he
believed that his partner was having an affair and he considered that he was
entitled to be angry with her about that. She asked Mr Bryant if he had made
statements implying that he wanted to die, but he said that that was a
misinterpretation and he had said instead that he was angry and he had told his
family that he did not want to see them again. She noted that Mr Bryant engaged
well, that his tone and rate of speech was good, that he had no thoughts of suicide
or self-harm and that he declined the offer of counselling.
Mr Bryant’s telephone calls
46. Most of Mr Bryant’s calls were to his partner. A lot of their conversation was about
domestic issues, including their children. From the end of March onwards, the
majority of their conversations were about Mr Bryant’s belief that his partner had
been unfaithful to him, which included events that had occurred 15 years previously.
Mr Bryant’s partner became increasingly annoyed by his repeated accusations and
his failure to accept her denials. On a number of occasions, she told him that he
was mentally unwell and needed to see a doctor. Their final conversation was an
18-second call at 8.58am on 18 April when Mr Bryant made the same accusations
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and his partner responded by saying, “I’m done with this now, I’m done with being
accused”. Mr Bryant did not make any comment in any of the conversations to
indicate that he intended to take his life, although he made a number of comments
to say that he considered their relationship to be over and he also threatened to
take her to court to fight for custody of their children.
Events of 18 and 19 April
47. At just after 10.00am on 18 April, an officer noted that she spoke to Mr Bryant about
failing to carry out his work as a wing cleaner: he had previously been warned about
this. She told him that he would receive no pay for that day, and he promised to try
harder the next day.
48. At around 8.30pm on 18 April, an Operational Support Grade (OSG) completed a
routine check on H wing. He told the investigator that he could not recall any
previous contact with Mr Bryant, and he had not recorded any concerns following
his check on Mr Bryant that evening.
49. At 2.35am on 19 April, the prisoner in the cell next door to Mr Bryant rang his cell
bell and the OSG answered the bell nine seconds later. The prisoner said that he
had heard a strange noise from Mr Bryant’s cell. When the OSG looked into the
cell, he saw Mr Bryant on the cell floor but could only see him from the waist down
as he was slumped to one side and obscured by the bed. He could see a lot of
blood and he radioed a medical emergency code red (to indicate a prisoner with
blood loss). Communications staff noted that the code red call was made at 2.36am
and that an emergency ambulance was called immediately.
50. A Custodial Manager (CM) was the senior officer on duty and was in the centre
office when the code red call was made. He went to H wing with three night support
officers, and he took emergency equipment. He said that he and his colleagues
walked quickly as the distance to H wing was at least a five-minute walk away.
51. After around two minutes of looking into Mr Bryant’s cell, the OSG decided that he
needed to go into the cell without waiting for his colleagues. Although he could not
see any injuries to Mr Bryant’s body, he considered that he needed assistance
based on the amount of blood on the floor and on the bed. He said that while he
had been looking at Mr Bryant, he had seen some movement in his hand, which
had wobbled slightly before dropping again. He said that after making a risk
assessment, he radioed the CM to say he was going into the cell.
52. The CM said that when the OSG radioed to say he was going into the cell, he and
his colleagues began running.
53. The OSG said that when he went into the cell, he pulled Mr Bryant away from his
bed and saw that he had a gaping wound to his throat. Mr Bryant did not have a
pulse. He pressed a towel to Mr Bryant’s neck and, with his other hand, began
giving chest compressions.
54. The CM and the support officers arrived around 90 seconds later. The OSG
continued to press the towel to Mr Bryant’s neck while the response officers took
turns in giving cardiopulmonary resuscitation (CPR).
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55. Ambulance paramedics arrived at 3.10am and they took over Mr Bryant’s care. All
efforts to try to resuscitate Mr Bryant proved unsuccessful and he was declared
dead at 3.23am.
56. Following Mr Bryant’s death, a broken prison issue disposable razor was found in
his cell. Two blades were found, which were not blood stained. The third blade from
the razor was not discovered.
Contact with Mr Bryant’s Family
57. An officer was appointed as the family liaison officer (FLO). Due to the distance
from Stocken to Mr Bryant’s partner’s home in London, the FLO contacted HMP
Pentonville to ask them to deliver the news. Stocken’s Governor then decided that
the local police should break the news instead. The police visited the family home
and broke the news at 10.00am. The FLO then telephoned Mr Bryant’s partner and
arranged to visit her the following day. When he visited, he also met Mr Bryant’s
father and one of his sisters.
58. Stocken contributed to the cost of Mr Bryant’s funeral in line with national
instructions.
Support for prisoners and staff
59. Stocken’s Governor spoke to the staff involved in the emergency response. The
staff care team also spoke to staff and offered support. The TRiM team also offered
specific trauma support to each member of staff on duty when the incident
occurred.
60. The prison posted notices informing other prisoners of Mr Bryant’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.
Post-mortem report
61. The pathologist found that Mr Bryant had a deep cut to his neck that extended into
the carotid sheath and carotid artery. The pathologist gave the cause of death as a
catastrophic haemorrhage. Toxicological examination had no significant findings.
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Findings
Assessment of risk
62. Mr Bryant was serving a relatively brief sentence, with a release date of 14 May
2023. He had been supported through ACCT in April and May 2022 after he had a
period of apparent psychotic thinking and made superficial cuts to his neck, but his
condition settled, and he declined an assessment with the prison psychiatrist.
63. In early January 2023, Mr Bryant deliberately damaged his cell furniture to engineer
a move to the segregation unit for a period of time alone. He said that he had
problems in his private life, but he would not say more. Nothing occurred during his
time in segregation to suggest he was at risk of suicide or self-harm.
64. Mr Bryant’s mother died later on in January, and he seemed to take comfort from
the pastoral support provided to him by the chaplaincy staff.
65. When Mr Bryant’s partner reported concern about his mental wellbeing, he was
seen on 5 April by a nurse and spoke openly about being upset with one of his
sisters about events leading up to his mother’s death. He also said that he believed
that his partner was having an affair. However, he again declined the offer of further
help and said that he had no thoughts of suicide or self-harm.
66. It was clear from his final conversation with his partner that Mr Bryant had concerns
about their relationship, but he said nothing to her to suggest he had thoughts about
taking his life.
67. An SO told the investigator that Mr Bryant was not someone who tended to seek
help from officers. Other officers gave similar evidence.
68. While it is clear that there were issues causing Mr Bryant concern at the time of his
death, he did not speak to staff about them, and we do not consider that they could
reasonably have anticipated that he was at immediate risk of suicide or of
significant self-harm. Nor do we consider that there was any reason for staff to have
recommenced suicide and self-harm monitoring procedures (ACCT).
Governor to Note
69. We understand that all custodial managers at Stocken have up-to-date first aid
training as they provide 24-hour cover at the prison. It is positive that in addition to
custodial managers, there is a further cohort of staff with up-to-date training. The
OSG told us that he had voluntarily attended a first aid training course outside the
prison but had not received first aid training from Stocken. In view of the large
footprint of Stocken and the distance and time it can take for the custodial manager
to reach an emergency, the Governor may want to encourage more of his other
regular night staff to volunteer for first aid training.
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Good practice
70. We commend the OSG in particular, as well as the other staff involved in the
response, for their concerted efforts to try to save Mr Bryant’s life in what were
highly unusual and extremely harrowing circumstances.
Clinical care
71. The clinical reviewer concluded that Mr Bryant’s care at Stocken was good and was
of a standard equivalent to that which he could have expected to receive in the
community. He found that the mental health team responded promptly to referrals
made by prison staff and was given good support.
Inquest
72. An inquest into Mr Bryant’s death held from 15 to 22 May 2025 concluded that
his cause of death was catastrophic haemorrhage following self-inflicted
laceration to the neck.
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