Roy King

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Independent investigation into
the death of Mr Roy King,
a prisoner at HMP Littlehey,
on 30 January 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 HM 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 Roy King died in hospital from a pulmonary embolism on 30 January 2023 while a
prisoner at HMP Littlehey. Mr King’s death followed his deliberate overdose of sodium
valproate (prescribed medication) in prison on 27 January. He was 61 years old. I offer my
condolences to his family and friends.
Mr King had a history of impulsive behaviour and harmed himself, including by overdose of
prescribed medication, following inappropriate behaviour, altercations or when his
employment status changed. Despite his history of deliberate overdose, Mr King was
considered suitable to hold and administer his medication himself (known as in-possession
medication).
Following an incident on 27 January during which Mr King was moved to a different wing,
faced disciplinary charges and lost his job, staff did not consider Mr King’s known pattern
of behaviour following such incidents and did not start suicide and self-harm monitoring,
known as ACCT. As a result, no one considered taking his medication away from him.
The independent clinical review into Mr King’s death concluded that Mr King’s access to
in-possession medication, which he subsequently used in overdose, reflected poor
healthcare monitoring arrangements to assess his suitability to hold in-possession
medication.
The clinical reviewer also concluded that healthcare staff did not demonstrate good clinical
practice when Mr King reported having taken an overdose of medication: they did not
establish the potential extent or seriousness of the overdose, call an ambulance or return
to check on Mr King. As a result, the clinical reviewer raised his concerns about two
nurses’ fitness to practise with the Nursing and Midwifery Council.
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 November 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 14
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Summary
Events
1. On 25 January 2007, Mr Roy King was convicted of rape and was sentenced to
Imprisonment for Public Protection (IPP, an indeterminate sentence). Mr King had a
personality disorder and following a period in a medium secure psychiatric hospital,
he was transferred to HMP Littlehey in 2015.
2. At Littlehey, Mr King frequently harmed himself by cutting, making ligatures and
telling staff that he had overdosed, often following incidents of his inappropriate
behaviour, altercations or a change in employment status. Prison staff monitored
him under ACCT monitoring procedures on many occasions. During such times,
staff sometimes removed Mr King’s in-possession medication and on other
occasions did not.
3. On the morning of 27 January 2023, Mr King responded angrily when staff
discussed with him serious allegations that another prisoner had made about him.
Given their severity, Mr King was told that he would be moved to another prison
wing and was suspended from his job pending further investigation.
4. At around 3.00pm, Mr King was moved to another wing. Around half an hour later,
he told staff that he had he had taken an overdose of his medication. Nursing staff
attended but Mr King, who was verbally aggressive, refused to have his
observations taken or go to hospital. The nurses spent around ten minutes with him
before leaving. They had no further contact with him that day.
5. Prison staff started ACCT monitoring and arranged for Mr King to be constantly
supervised. Mr King agreed to go to hospital at around 5.00pm, following
encouragement from officers. Shortly afterwards, his health began to deteriorate.
Prison staff arranged for him to be taken to hospital by taxi rather than wait for an
ambulance. Just before his transfer to hospital, Mr King’s health deteriorated
further.
6. When he arrived at hospital, Mr King was admitted to the intensive care unit and
was placed in a medically induced coma. Life support was withdrawn in the early
hours of 30 January and Mr King died shortly afterwards.
Findings
7. Mr King had a history of repeated self-harm following inappropriate behaviour, when
he lost his job or after staff told him to do something he did not want to do. Although
this was clearly recorded in his prison records, staff did not consider starting ACCT
monitoring immediately on the morning of 27 January, which would likely have led
to consideration of removing Mr King’s in-possession medication.
8. Mr King’s suitability for holding in-possession medication was not consistently
reviewed in line with the prison’s medication in-possession policies. The reasons
that he was allowed to continue accessing in-possession medication were not
adequately reflected in his medical records and his risk was not consistently
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managed effectively following incidents of self-harm or other occasions which
potentially increased his risk.
9. Mr King had surplus medication in his cell at the time of his overdose. The clinical
reviewer reported that since 2018, Mr King had kept and administered his own
medication, and this had not been reassessed since then. Healthcare staff had
missed an opportunity to identify potential compliance issues, including the
hoarding of medication.
10. Officers were unable to confirm with hospital staff the type and quantity of
medications Mr King had taken as healthcare staff had not reconciled the empty
medication packets to establish what he had taken.
11. When healthcare staff found that Mr King had taken an overdose, they did not
immediately call for an ambulance, they did not contact a GP operating at Littlehey
or the national poisons unit for guidance and they did not return to check on Mr King
before they finished their duties. They appear to have become desensitised to the
risks of overdose. Their response was not in line with prison guidance for dealing
with prisoners who have taken an overdose. The clinical reviewer raised concerns
with the Nursing and Midwifery Council about the nurses’ actions, their interactions
with Mr King and their fitness to practise.
Recommendations
• The Governor and Head of Healthcare should ensure that staff consider all
relevant risk information about prisoners when assessing their risk of suicide
and self-harm and start ACCT procedures when appropriate.
• The Governor and The Head of Healthcare should review the arrangements in
place to ensure that information about changes to a prisoner’s risk and
management is communicated promptly between operational and healthcare
staff.
• The Head of Healthcare should ensure that medication in possession
arrangements are reviewed and audited so that appropriate safety measures are
in place to identify and address non-compliance with medication promptly.
• The Head of Healthcare should ensure that effective arrangements are in place
to escalate concerns about patients at risk who do not cooperate with healthcare
interventions and to respond appropriately following reports of overdose.
• The Head of Healthcare should ensure that when a prisoner reports an
overdose of prescribed medication, healthcare staff follow a recognised process
to urgently establish what medications, and how much, might have been taken.
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The Investigation Process
12. The Prisons and Probation Ombudsman (PPO) was notified of Mr King’s death on
30 January 2023.
13. The investigator issued notices to staff and prisoners at HMP Littlehey informing
them of the investigation and asking anyone with relevant information to contact
him.
14. The investigator obtained copies of relevant extracts form Mr King’s prison and
medical records.
15. NHS England commissioned a clinical reviewer to review Mr King’s clinical care at
the prison.
16. The investigator interviewed twelve members of staff and one prisoner at HMP
Littlehey, some jointly with the clinical reviewer. Three prisoners wrote to the
Ombudsman with information about Mr King’s death.
17. We informed HM Coroner for Cambridgeshire of the investigation. They provided us
with a copy of the post-mortem and toxicology reports. We have sent Them a copy
of this report.
18. We contacted Mr King’s next of kin to explain the investigation and ask if they had
any matters they wanted us to consider. Mr King’s next of kin had no specific
questions.
19. Mr King’s next of kin received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Littlehey
20. HMP Littlehey is a category C training prison for men convicted of sexual offences.
It holds approximately 1,200 men. Northamptonshire NHS Foundation Trust
provides healthcare services at the prison. The prison healthcare centre is open
from Monday to Thursday from 7.30am to 7.30pm, on Fridays from 7.30am to
5.20pm and at weekends from 8.00am to 5.50pm. A local practice provides GP
services, and there is a range of nurse-led clinics. There are no inpatient beds at
the prison.
HM Inspectorate of Prisons
21. Inspectors carried out a full unannounced inspection in August 2019. They noted
that Littlehey continued to be an overwhelmingly safe prison, with little violence.
They found that relationships between staff and prisoners were relaxed and helpful
but not always proactive. Inspectors reported that although self-harm had increased
in recent years, it remained low. They noted that prisoners were generally positive
about health services and clinical governance was stronger than it had been at their
previous inspection.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its annual report for the year to January 2023, the IMB reported that the
prison continued to be generally safe and secure and that prisoners were treated
with respect and decency. They reported that previous PPO recommendations had
been accepted and implemented.
Previous deaths at HMP Littlehey
23. Mr King was the third prisoner to take his life at Littlehey since August 2020. There
were no similarities between our investigation findings for Mr King’s death and
those of the two previous self-inflicted deaths at the prison. There were 42 deaths
from natural causes at Littlehey between January 2020 and Mr King’s death. There
were three further deaths from natural causes since Mr King’s death up to the end
of 2023.
Assessment, Care in Custody and Teamwork
24. 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 prisoners. As part of
the process, a care plan which includes support and intervention, should be in
place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. Guidance on ACCT procedures is set out in Prison Service
Instruction (PSI) 64/2011 on safer custody.
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Indeterminate Sentences for Public Protection
25. An indeterminate sentence for public protection (IPP) is a sentence where the court
sets a minimum term of imprisonment, after which the person will be released once
they can satisfy the Parole Board that their risk of reoffending has sufficiently
reduced. In September 2023, the Prisons and Probation Ombudsman published a
learning lessons bulletin which highlighted findings from our investigations into the
self-inflicted deaths of IPP prisoners to provide learning for HMPPS about the
specific risk factors associated with IPP sentences.
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Key Events
Background
26. On 25 January 2007, Mr Roy King was convicted of rape. He received an
indeterminate Imprisonment for Public Protection (IPP) sentence due to his risk to
the public. Mr King was sentenced to a minimum of five and a half years before he
could be considered for release. It was not his first time in prison.
27. Mr King had a diagnosis of personality disorder and bipolar disorder. He also had a
number of physical health concerns for which he was prescribed medication,
including sodium valproate for bipolar disorder and epilepsy. In 2010, he was
admitted to the Bethlem Royal Hospital, a medium secure psychiatric hospital. In
2014, Mr King was transferred to HMP Thameside.
28. Mr King had a long history of self-harm by cutting, making ligatures and telling staff
that he had overdosed on prescribed medications. He had frequently been
managed under Prison Service suicide and self-harm prevention procedures,
known as ACCT. (Mr King’s medical records contain little detail about the alleged
overdoses as Mr King frequently quickly denied that he had overdosed.)
HMP Littlehey
2015 - 2021
29. On 26 January 2015, Mr King was transferred to HMP Littlehey. Before he left HMP
Thameside, the sending prison, he made superficial scratches to his arm, in protest
at his transfer. Staff at Thameside started ACCT procedures and Littlehey
continued monitoring him until 28 January.
30. A nurse assessed Mr King when he arrived at Littlehey. He was referred to the
appropriate clinics for his various mental and physical health issues. The reception
nurse, and then the pharmacist, assessed his suitability to hold his medication in
possession and concluded that he was not suitable to do so.
31. In March, a prison GP agreed that Mr King could have a week’s supply of in-
possession medication. In June, the pharmacist concluded that he could hold a
month’s supply.
32. From August 2016, Mr King was sometimes allowed to keep medication in his cell
(normally a week’s worth at a time) but this was reviewed when he overdosed and
harmed himself and then he was required to collect his medication each day from
the medication hatch. He was monitored under ACCT procedures when staff
considered his risk of suicide and self-harm required it.
33. In November 2018, Mr King asked for a month’s supply of in-possession
medication. The pharmacist reviewed his risk, noted that his last overdose had
been eighteen months earlier and that he had said he was currently in a good
place. The pharmacist concluded that Mr King was suitable to hold a month’s
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medication in possession and told him that if he felt things were going wrong or his
mood dipped, he should tell staff so that they could review the situation.
34. On 15 August 2019, following a verbal altercation with a prisoner, Mr King told staff
he had taken an overdose, handed them empty medication packets and refused to
be taken to hospital. During the ACCT process, Mr King told staff he had not taken
an overdose.
35. On 21 August the prison pharmacist reviewed Mr King’s medication. Mr King said
he had not overdosed a week earlier but had flushed his medication away. The
pharmacist told Mr King that claiming to take an overdose was dangerous. Mr King
acknowledged this and told the pharmacist that he wanted to continue to hold his
medication in-possession. The pharmacist noted that Mr King was chatty and in a
good mood. The pharmacist concluded that Mr King could continue to hold a
month’s supply of in-possession medication.
36. On 15 November 2019, Mr King posted multiple packs of his medication under his
cell door because he was upset about a member of staff. Staff noted that he had
tried to flush some away, but Mr King would not tell staff if he had taken any and
refused treatment. Staff told healthcare colleagues and started ACCT procedures.
37. Throughout 2020, Mr King was settled, and he did not harm himself.
38. In January 2021, Mr King was told his job would change. He became extremely
irate, made superficial cuts to his arms and threw his medication out of the window.
It was later noted in his medical records that Mr King had many months of in-
possession medication which he had not taken, and the prison pharmacy was told
about this. Staff started ACCT monitoring procedures, but they were stopped later
that day when he was given his job back.
39. On 27 January, the prison pharmacy noted that Mr King would be given back his in-
possession medication. There is no record to explain the rationale for this decision.
40. Mr King was again settled during the spring and summer of 2021.
41. On 16 August, following an altercation with staff and prisoners, Mr King threatened
to take an overdose. Staff monitored him under ACCT procedures for a week.
Healthcare staff were not told of the threats. Mr King was settled over the remainder
of the year.
2022 onwards
42. In April 2022, an officer noted that Mr King appeared to cause “a lot of drama”
involving other prisoners. Mr King had recently received warnings about his
behaviour, and the officer noted that he tended to overreact. When Mr King lost his
job, he harmed himself and was monitored under ACCT procedures for several
days.
43. In May, an officer introduced himself to Mr King as his keyworker. (The scheme had
been reintroduced after the COVID-19 pandemic.) In September, the officer noted
that Mr King was pleased to be working as a wing red band (a trusted prisoner who
helps staff with tasks). In November, it was noted that Mr King had helped a
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prisoner struggling with hygiene issues to clean his cell. Staff noted this was above
and beyond his duties as a red band.
44. However, on 16 December, an officer spoke to Mr King about his attitude to other
prisoners. Mr King said he “enjoyed winding other prisoners up”. Mr King was told
his attitude needed to improve and was not that expected of a red band.
45. On 11 January 2023, Mr King was given a further 28-day supply of in-possession
medication. (There is no evidence that healthcare staff carried out regular
medication audits to confirm that Mr King was taking his medication as prescribed.)
46. During the first two weeks of January 2023, it was noted that Mr King remained in
good spirits. On 14 January, the keyworker noted that Mr King had carried out some
“great work” by cleaning another prisoner’s cell.
47. A Custodial Manager (CM), who had known Mr King for several years, said Mr King
would express extremes of emotion and could suddenly become animated and
angry. Another CM described Mr King as generally compliant but that he would
often behave in a stubborn and irrational manner. The keyworker said that for the
most part, Mr King was on an “even keel” and in good spirits.
48. A Supervising Officer (SO) said that Mr King would sometimes harm himself when
he had been asked to do something he did not agree with or when he was
disciplined but would then quickly get over it. He said he had never noticed Mr King
act inappropriately towards other prisoners but said that during Mr King’s time on A
Wing, staff had noticed that he was very friendly with Prisoner A, who had recently
moved to the wing.
49. Prisoner B, who knew Mr King, said that Mr King got on with most prisoners, was
polite, kind, helped other prisoners but could at times be grumpy. He said some
prisoners on the wing would “stitch” Mr King up and some of the younger prisoners
would “have a go at him”. He said he had not known Mr King ask people for sexual
favours but said he would tell people he was bisexual and was “touchy and feely” to
those that he met.
50. Prisoner B said that around three or four days before 27 January, he saw Prisoner
A ask Mr King for vapes. He said Mr King had told Prisoner A that he could not
“give vapes for nothing”. He said Prisoner A told Mr King that if he did not give him
vapes, he would tell staff that Mr King had kissed and touched him inappropriately.
(He said that two other prisoners had seen the exchange.) He said he told Prisoner
A not to lie about Mr King, but the prisoner told him “He did not care”.
Events of 26 January
51. On 26 January, Prisoner A told prison staff that at around 5.30pm the previous
evening, Mr King had gone into his cell and kissed him on the head, hugged him
and made the comment, “I want to keep you warm”. He said he wanted to report the
matter to the police.
52. An intelligence report made that day noted allegations had been made that Mr King
had bullied another prisoner who had feared Mr King would physically assault him.
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Events of 27 January
53. At around 8.00am on 27 January, a SO discussed Prisoner A’s allegations with Mr
King. The SO said Mr King shouted that the prisoner was lying and said, “I know
you lot are going to believe that liar.” Mr King then threw his red band ID away and
told the SO, “take your job” and walked away.
54. The SO said that no disciplinary procedures had yet been taken against Mr King
and he remained employed as a red band. He said he told Mr King he could still
work but acknowledged Mr King was concerned about losing his job.
55. The SO spoke to Prisoner A and asked him if he wanted to report the incident to the
police. The prisoner initially said no, but shortly afterwards, said he wanted to do so,
and the allegation of a sexual assault was reported to Cambridgeshire Police that
day. (On 30 January, the police reviewed the allegation but closed the case after Mr
King’s death. No further investigation took place.)
56. At around 9.15am, the SO discussed the allegations made about Mr King with the
Head of Residence and Safety, who decided that Mr King should be moved to B
Wing, given the seriousness of the allegations against him.
57. The SO told Mr King that he would be moved and noted that he had already packed
his property. At around 11.00am, Mr King was placed on report, pending a
disciplinary hearing and he was suspended from his job. At around 11.48am, staff
started a Challenge, Support and Intervention Plan (CSIP) for Mr King. (CSIP is a
multidisciplinary approach which focuses on those who pose a raised risk of being
violent to others and works to change their behaviour.)
58. At around 11.45am, Mr King collected his lunch but threw it away. The SO said that
it was evident that Mr King was unhappy about the allegations. Mr King was told he
would remain locked in his cell until his move to B Wing was finalised.
59. At around 3.10pm, the SO and two officers started Mr King’s move to B Wing. The
SO said Mr King shouted that B Wing was a paedophile wing and that Prisoner A
was a liar. A further two trips were made to move Mr King’s property. One officer
said Mr King was frustrated rather than aggressive.
60. The officer said that during the second trip to collect Mr King’s property, Prisoner A
appeared nearby and smiled and laughed provocatively at Mr King, in the officer’s
opinion as if to say, “I have got you.” The prisoner was warned about his behaviour.
61. Prisoner B said he told Mr King to keep calm and to submit a complaint about
Prisoner A and that he would also submit one to say what he had seen. (Prisoner B
did not submit the complaint.) He said that as Mr King was being taken off the wing,
Prisoner A walked past and said, “I told you you would get moved off the 3s, you
fucking nonce.” Prisoner B said Mr King told the SO he would take an overdose of
his medication. The SO told the investigator that Mr King never said this.
62. Another prisoner on B Wing said that when Mr King walked past his cell, he heard
him tell officers that he was going to take an overdose. (Another prisoner also
reported that Mr King had told officers that he would take his life by taking all his
medication.)
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63. Officer A said that during the move, Mr King was angry and threatened staff and
other prisoners and said, “As soon as I get to healthcare, I’m going to knife them
up.” He said that Mr King did not say he would take an overdose or harm himself.
64. At around 3.30pm, Mr King was locked in his new cell. He was told he would be
given time to calm down and would be checked again in around 30 minutes.
65. At around 3.40pm, Mr King rang his cell bell. Two officers responded. As they
approached the cell, they saw that Mr King was pushing medication blister packs
out from under the door. They turned on their body-worn video cameras at around
3.45pm. They opened the cell door and Mr King, who was standing in his cell
vaping, told them he had taken all of his medication. One officer left the cell with the
empty packaging and returned to the wing office to call healthcare staff. Officers
started ACCT procedures and Mr King was initially placed under two observations
an hour.
66. Officer A, who had stayed with Mr King, asked him why he had taken all his
medication. Mr King said he had wanted to end his life but did not say why. When
Mr King was told that healthcare staff were on their way, he told the officer he would
refuse any treatment offered. He said he talked to Mr King about unrelated matters
to calm him down and to monitor his condition in case the medication took effect.
He said Mr King, who was irate, calmed down significantly and was not aggressive.
67. At around 3.50pm, Nurse A was told that Mr King had taken an overdose and had
refused to go to the healthcare unit. At around 4.00pm, she and Nurse B arrived at
Mr King’s cell and were shown the empty medication packets, including Epilim
(containing sodium valproate) and other medications. The nurses said they were
extremely concerned about the quantity of medication Mr King had taken.
68. Nurse B stepped into the cell. The nurses said Mr King was angry and aggressive
and told them to “fuck off” several times, refused to engage with them or have his
physical observations taken. He asked Mr King if he could call an ambulance for
him, but said Mr King repeatedly said he did not want to go to hospital. The nurse
said that Mr King had said, “I want to die, I want to die, fuck off.” Mr King was asked
to sign a medical disclaimer, but he refused. When the nurses were told about the
threats that Mr King had made against healthcare staff, they stepped back to create
distance between themselves and Mr King.
69. Nurse A said she did not think that Mr King understood the severity of his actions,
and nothing she and Nurse B said made any difference as Mr King would not listen.
Nurse B said he and Nurse A asked Mr King if there was anything else they could
do for him, but he continued not to engage with them. He said that he and Nurse A
returned to the healthcare unit with the empty medication packages. The nurses
had spent around ten minutes with Mr King.
70. The body-worn camera footage showed some of the interactions between the
nurses and Mr King. At one point, after ascertaining how much medication Mr King
had taken, Nurse B suggested to Mr King that he would “feel pretty crappy later”
and that “You won’t probably kill yourself, but you will feel like shit warmed up.”
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71. At 4.21pm, Nurse B noted his contact with Mr King in his medical records. He said
he spoke to a custodial manager by phone and was told that Mr King would be
placed under constant supervision. The nurses had no further contact with Mr King.
72. Officer A said the nurses told them to continue monitoring Mr King. He said he
stayed with Mr King to react to any change in his health. Another officer said that
the nurses had said that because the medication that Mr King had taken was
gastro-resistant, he would not notice any effects for several hours.
73. A CM said Nurse B telephoned him to say that Mr King had taken an overdose. He
said that when he asked how Mr King might feel, the nurse told him that Mr King
would “feel very groggy and would go a bit drowsy.” The CM said the nurse told him
that monitoring Mr King under constant supervision would provide additional
reassurance. He said that the nurse recommended that Mr King should go to
hospital and could go by taxi.
74. The Head of Residence & Safety said that when the CM was on the telephone to
the nurse, he asked whether Mr King’s overdose was life-threatening. He said that
the CM’s feedback was that it was not. The nurses did not consult Toxbase, an
online poisons database for clinicians, or seek any further advice about the severity
of Mr King’s overdose.
75. The CM said he and another CM then spoke to Mr King to persuade him to go to
hospital. He said that, given the information he had received from the nurses, he
considered that Mr King’s risk was low. He said that at the time, the nurses had not
seemed that concerned. Eventually, Mr King agreed to attend hospital and to move
to a constant observation cell on I Wing. He said that during the move, Mr King
continued to shout which he said was normal behaviour for Mr King when he was
upset.
76. At around 4.55pm, Officer B took over the constant supervision of Mr King from her
colleague. She said her colleague told her that Mr King had refused to eat and had
thrown his pillow and blanket out of his cell. She said Mr King was pacing up and
down his cell vaping and refused to acknowledge her.
77. The CM, aware that a taxi was returning to drop off a member of staff who had just
attended hospital, decided that it would be quicker to send Mr King, who he said
was not feeling any effect from the overdose at the time, to hospital by taxi. (He said
he decided this because in his experience, when an ambulance was called, they
often had to wait several hours.) The Head of Residence and Safety agreed with
this decision.
78. At around 5.10pm, Mr King told Officer B that he felt dizzy, and she noted that he
appeared unsteady. At around 5.40pm, Mr King asked for his pillow and blanket
back as he felt cold. She told him not to fall asleep and she noted that his speech
was slurred.
79. Between around 5.00pm and 5.30pm, the CM said he told healthcare staff that Mr
King had agreed to go to hospital. He said he could not recall what healthcare had
said to him when he updated them but confirmed that they had no further contact
with Mr King. Nurse A said that she did not speak to any officers between leaving
Mr King and the end of her shift at around 5.30pm.
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80. Officer B and another officer were told that they had to escort Mr King to hospital by
taxi. Because Mr King was drowsy and unsteady on his feet, they took him to
reception by wheelchair.
81. A CM, who had been asked to discharge Mr King, said that when Mr King arrived in
reception, he appeared under the influence of a substance, could not engage in
meaningful conversation and could not walk without assistance. However, he said
Mr King appeared aware of his surroundings and what was happening and showed
no signs of being acutely unwell or distressed.
82. It was initially decided that Mr King should be escorted to hospital with a single cuff
but because of Mr King’s presentation, this was changed to an escort chain. Officer
B and another officer pushed Mr King to the taxi in a wheelchair and helped him in.
It was noted that he struggled to keep his eyes open. At around 6.40pm, the taxi left
for Hinchingbrooke Hospital.
83. During the journey, Mr King did not speak and appeared to become drowsier. His
breathing was described as heavy. Around two minutes before Mr King arrived at
hospital, the escort officers reported that he had begun to lose consciousness.
84. At around 7.00pm, Mr King arrived at hospital, where he was assessed and treated.
The escort chain was removed, and he was taken to the intensive care unit for
further treatment. He remained unrestrained and escort officers sat in a room next
to the intensive care unit. Hospital staff told Officer B that Mr King’s next of kin
should be contacted. She told the CM.
85. Hospital staff asked Officer B about the medication that Mr King had taken, but the
officer was unable to tell them as she did not have access to the information.
86. Mr King was placed in a medically induced coma and remained in intensive care
until around 2.30am on 30 January when life support was withdrawn. Mr King was
pronounced dead soon afterwards.
Contact with Mr King’s family
87. At 8.17pm on 27 January, a family liaison officer at Littlehey told Mr King’s next of
kin that he had been admitted to hospital following an overdose. She broke the
news of his death to them at around 6.00am on 30 January. Littlehey contributed to
the funeral expenses in line with national instructions.
Support for prisoners and staff
88. As part of the prison’s post prevention procedures, a prison manager debriefed and
offered support to staff involved in the incident. He talked to prisoners who had
been affected by Mr King’s death. The prison posted notices informing other
prisoners of Mr King’s death and offered further support to those who had been
affected.
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Post-mortem report
89. A post-mortem examination found that Mr King died from a pulmonary embolism
across both lungs, which was the result of multiple organ failure due to sodium
valproate poisoning. Toxicology tests confirmed that Mr King had a high level of
sodium valproate in his bloodstream.
Inquest
90. At an inquest held on 4 March 2025, the Coroner concluded that Mr King’s death
was due to misadventure. The inquest found that whilst Mr King deliberately took
the overdose on 27 January 2023, he did not intend to take his own life.
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Findings
Assessment of risk
91. PSI 64/2011 on safer custody requires staff who have contact with prisoners to be
aware of the risk factors and triggers that might increase the risk of suicide and self-
harm and take appropriate action. Any prisoner identified as at risk of suicide or
self-harm must be managed under ACCT procedures.
92. Mr King’s prison records note his history of acting impulsively resulting in self-harm,
including by alleged overdose of his prescribed medication, following inappropriate
behaviour, altercations or when his employment status changed. Staff used ACCT
procedures to support him for relatively short periods of time after such occasions.
93. The last time Mr King harmed himself (by cutting) was in April 2022, after he lost his
job for making threatening and racist comments. Prison staff monitored him under
ACCT procedures for four days. Over the following months to January 2023, staff
reasonably considered that Mr King did not need to be monitored under ACCT
procedures.
94. On 27 January, Mr King was told of the serious allegations about him which
resulted in him being moved to another wing and losing his job. A SO said that as
no disciplinary procedures had been taken against Mr King and he was still
employed, he did not consider that there was a need to start ACCT procedures.
(We note that contrary to the SO’s comments, Mr King was placed on report, CSIP
procedures were started, and he was suspended from his job later that morning.)
95. The SO said that at no time did Mr King give him the impression that an ACCT
should be opened, and he never spoke about thoughts of suicide or self-harm. He
said he did not know if Mr King had his medication in-possession, there was nothing
to suggest he would take an overdose and there was nothing Mr King said, or did
which suggested that staff should take his medication from him.
96. Other prisoners reported hearing Mr King tell staff that he would take an overdose
of his in-possession medication when he was being escorted from wing to wing.
Staff denied hearing Mr King making such comments. We cannot establish the
factual accuracy of these differing accounts.
97. Mr King’s reaction to altercations and similar incidents was a significant and well-
documented self-harm trigger. The SO told the investigator that he was aware of Mr
King’s pattern of behaviour after such incidents. While staff judgement based on a
prisoner’s apparent mood is important, it is only one indication of risk. Staff should
also recognise the importance of patterns of previous behaviour when assessing
risk. Assessments based on behaviour and presentation must be balanced against
other available risk information.
98. Mr King’s pattern of self-harm included impulsive acts of taking in-possession
medication. Prison staff, in partnership with the mental health team, should
therefore have assessed if Mr King’s risk of self-harm had increased and
considered starting ACCT procedures to support him immediately after he was told
of the allegations about him. Opening an ACCT would likely have included
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consideration of whether to temporarily withdraw his access to his in-possession
medication in line with Littlehey’s medication in possession policy, pending a full
assessment.
99. Although we recognise that we now have the benefit of hindsight and that staff
appropriately started ACCT monitoring after it was established that Mr King had
taken an overdose, we consider that there was sufficient known evidence of Mr
King’s pattern of behaviour that staff should have begun ACCT procedures first
thing that morning. We make the following recommendation:
The Governor and Head of Healthcare should ensure that staff consider all
relevant risk information about prisoners when assessing their risk of suicide
and self-harm and start ACCT procedures when appropriate.
Clinical care
100. The clinical reviewer concluded that the physical healthcare that Mr King received in
custody was of a standard partially equivalent to that which he could have expected
to receive in the community. However, the clinical reviewer concluded that the
approach to managing Mr King’s presentation in the wake of a suspected overdose
was not reflective of good practice and did not reflect the established clinical
guidance for managing such scenarios. The clinical reviewer also noted the
inconsistency in the way staff assessed Mr King’s suitability to hold in-possession
medication.
In-possession medication
101. Littlehey’s in-possession medication policy states that since the introduction of
greater in-possession medication in prisons, there had been no increase in self-
harm or suicide due to medication overdose or abuse and prisoners should be
encouraged to self-administer their medication unless unable to due to their
physical vulnerability or mental health risks. The policy notes that National Institute
for Health and Clinical Excellence (NICE) guidance states that all prisoners should
be able to hold their medication in possession unless the prisoner fails a risk
assessment.
102. The clinical reviewer noted that the approach of positive risk taking, identifying and
balancing the potential benefit and harm which could result from a particular choice,
is an accepted practice used to manage patients with a history of self-harm.
However, the clinical reviewer also noted that the use of such an approach can only
be safe and effective when supported by an agreed plan which is implemented with
clear and effective recording of assessments, reviews and decision-making.
103. In November 2018, Mr King was assessed as suitable to keep and administer a 28-
day supply of prescribed medication. Mr King was last issued in-possession
medication on 11 January 2023.
104. On 27 January, empty medication packets of prescribed medication, including for
around 210 sodium valproate tablets, were removed from Mr King after he said he
had overdosed. The clinical reviewer noted that this suggested that Mr King had
more than four times the amount of sodium valproate than he should have been
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allowed in possession and that the quantity found indicated that he was unlikely to
have been taking his medication as prescribed in the weeks before he died.
105. The clinical reviewer reported that Mr King’s medication in-possession status should
have been suspended and reviewed following each act of self-harm or other risk-
related episode and following periods of monitoring under ACCT, in line with the
medication in possession policy. (This might have led to some lower-risk
medications being deemed suitable to be held in possession, while those that
posed a greater risk of harm in the event of an overdose being dispensed daily to
him.)
106. The clinical reviewer concluded that Mr King’s access to in-possession medication,
which he then used in overdose, was a reflection of the poor supervision and
monitoring arrangements in place. He noted this did not support a positive risk-
taking approach. The clinical reviewer stated that although the healthcare team
might have intended to reflect a positive risk-taking approach, it was not well co-
ordinated.
107. The clinical reviewer noted a lack of communication between officers and
healthcare staff, who were not always made aware of changes in Mr King’s ACCT
status or after incidents of self-harm. The clinical reviewer highlighted that the
management of Mr King’s risk of suicide and self-harm was not clearly structured.
This resulted in the appearance of a naïve understanding of his risks and a lack of
appropriate measures to manage them.
108. The clinical reviewer also reported that a regular review of Mr King’s medication
would have helped identify any potential compliance issues. His medication had not
been reassessed since 2018 and there was no evidence of medication
reconciliation exercises. We make the following recommendations:
The Governor and The Head of Healthcare should review the arrangements in
place to ensure that information about changes to a prisoner’s risk and
management is communicated promptly between operational and healthcare
staff.
The Head of Healthcare should ensure that medication in possession
arrangements are reviewed and audited so that appropriate safety measures
are in place to identify and address non-compliance with medication
promptly.
Emergency response
109. The clinical reviewer noted the inconsistencies between the reported events that
afternoon, the footage of the interaction between Mr King and healthcare staff and
the nurses’ written accounts. He highlighted three key concerns about the nurses’
response on 27 January:
• their failure to check on Mr King after their initial assessment;
• their failure to call an ambulance or otherwise arrange for Mr King to be
transferred to hospital in light of his admission; and
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• their failure to reconcile his medication to establish the amount of medication
he might have taken or to check through the national poisons’ information
service the potential risks if Mr King had taken an overdose of his prescribed
medication.
Initial response by nurses
110. At around 3.45pm on 27 January, Mr King told officers he had taken an overdose.
Nurses A and B were told soon afterwards. The timestamp on the body-worn
camera footage shows that the nurses’ interaction with Mr King ended at around
4.11pm. (The then Head of Healthcare said that healthcare provision in the prison
ended at 5.15pm.)
111. In interview, Nurse B said he could not recall providing officers with any instructions
before they left Mr King. When the investigator asked Nurse A why she or Nurse B
did not go back to see Mr King before their shift ended at around 5.30pm, she said
they had told the officers that if Mr King deteriorated in any way, they could call
them, and they would return immediately. She said no one from the healthcare
team considered checking on Mr King before their shift ended. She said that officers
would have known what symptoms to look out for as they were trained in first aid,
dealt with similar matters daily and knew they should call an ambulance if they were
concerned.
112. Nurse B said that the difficulty with managing prisoners who had overdosed was
that half of them said they had overdosed when they had instead thrown or flushed
away their medication. Nurse A indicated that based on her clinical judgement in
collaboration with Nurse B, they had no real concerns about Mr King at the time as
he was awake, and his speech was not slurred.
113. The clinical reviewer noted that given his history, the uncertainty about the amount
of medication that Mr King had taken and the potential severity of the outcome for
him, nurses should have considered returning to the wing to review Mr King’s
presentation after 30 minutes. The clinical reviewer noted that the healthcare
provider was commissioned to deliver healthcare services until 5.20pm, and that not
checking Mr King was a missed opportunity to intervene as this might have
changed the outcome.
Failure to call an ambulance
114. Nurse B said that as healthcare professionals, they erred on the side of caution and
advised hospital admission. Nurse A said she discussed with Nurse B that because
the medication was enteric-coated, it would take around two or three hours for the
medication to take effect and they advised that Mr King should attend hospital if he
had taken all the medication.
115. The then Head of Healthcare said that Littlehey’s policy on managing prisoners who
had taken an overdose of medication was that a set of observations would be
taken, and the prisoner should be sent to hospital.
116. When asked why she did not call an ambulance given the circumstances, Nurse A
told the investigator that Mr King was sitting up, talking, swearing and “not in a
terrible state” and he refused any intervention so she did not consider it necessary
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to call an ambulance., The nurse said that they could not force a prisoner to attend
hospital if they did not want to go. She said that as Mr King also refused to let them
take his clinical observations, she would not have been able to give the call handler
that information.
117. When asked if Mr King could have attended hospital by taxi rather than ambulance,
Nurse B said, “absolutely not” for someone who had potentially taken 200 tablets of
sodium valproate. (A CM said that in his experience, healthcare staff always sent a
prisoner to hospital after an overdose by taxi or ambulance.)
118. The clinical reviewer found that despite Mr King’s refusal to accept healthcare
interventions, it was notable that the nurses did not call an ambulance or refer him
to a GP. He noted that earlier intervention could have led to Mr King being
assessed by paramedics and taken to hospital sooner.
Failure to explore the extent of Mr King’s overdose or the potential risk
119. The clinical reviewer noted that given Mr King’s reported overdose, there was no
evidence that the nurses considered contacting the national poisons information
service (Toxbase) for guidance. The clinical reviewer reported that the nurses’ lack
of action was contrary to clinical guidance provided in 2020 by Northamptonshire
Healthcare NHS Foundation Trust on managing potential overdoses.
120. The clinical reviewer was concerned that Nurse B told Mr King (and this was likely
within earshot of prison staff attending the incident) that his overdose could not
cause his death, but he would likely feel unwell.
121. Prison staff persuaded Mr King to attend hospital at around 5.00pm and arranged
for him to go in a taxi. A CM said that he did not believe that any of the staff
managing the incident were aware of the extent of the overdose or were aware how
ill Mr King was or that his life was in danger. We consider that prison staff’s
handling of the incident, in the absence of clear input from healthcare staff, was
appropriate. We make the following recommendation:
The Head of Healthcare should ensure that effective arrangements are in
place to escalate concerns about patients at risk who do not cooperate with
healthcare interventions and to respond appropriately following reports of
overdose.
122. The clinical reviewer noted that after Mr King had told staff that he had taken an
overdose, no one completed a detailed tally of the medication he had taken, or the
empty packets recovered from him. When Mr King arrived at hospital, escort
officers were asked what and how much medication Mr King had taken, but they
had not been given this information by healthcare colleagues.
While we cannot know if this would have made a difference to the treatment he
received in hospital, it is self-evident that those treating a prisoner suspected of
taking an overdose need to know urgently what medications a prisoner might have
taken, and how much, to provide the appropriate treatment promptly. We make the
following recommendation:
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The Head of Healthcare should ensure that when a prisoner reports an
overdose of prescribed medication, healthcare staff follow a recognised
process to urgently establish what medications, and how much, might have
been taken.
Referral of nurses to Nursing and Midwifery Council
123. The clinical reviewer concluded that the nurses’ actions might not have been in
keeping with the values set out in The Nursing and Midwifery Council’s
(independent regulator of nurses and midwives) Code of Professional Standards of
Practice and Behaviour. The clinical reviewer discussed his concerns with the then
Head of Healthcare and the Acting Head of Healthcare. The clinical reviewer
reported that the Acting Head of Healthcare did not share his concerns.
124. The clinical reviewer was sufficiently concerned about the nurses’ response on 27
January that he referred their practice to the Nursing and Midwifery Council.
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