Russell Irvine

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Russell Irvine,
a prisoner at HMP Durham,
on 7 November 2022
A report by the Prisons and Probation Ombudsman
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2024
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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 Russell Irvine was found hanged in his prison cell at HMP Durham on 7 November
2022. He was 51 years old. I offer my condolences to Mr Irvine’s family and friends.
Mr Irvine had been at Durham for three days when he died, after he was recalled for
breaching the conditions of his licence. He had not been identified as at an increased risk
of suicide and was not subject to any additional monitoring.
My investigation found issues with access to, use of and sharing of risk information
amongst prison and healthcare staff completing Mr Irvine’s initial risk assessments. Staff
were reliant on Mr Irvine’s presentation, rather than an objective assessment of his risk
factors.
Durham is receiving additional support from HMPPS headquarters as a result of the
number of self-inflicted deaths there in the last 12 months. The learning from this
investigation can usefully inform considerations about staff training and suicide and self-
harm risk management.
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 September 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
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Summary
Events
1. Mr Russell Irvine was convicted of murder in 1994 and sentenced to life
imprisonment. He was managed under Prison Service suicide and self-harm
prevention procedures, known as ACCT, on several occasions. Mr Irvine was
released on licence in October 2022, but on 4 November 2022 he was recalled to
HMP Durham for breaching his licence conditions.
2. In reception, Mr Irvine said that he was unhappy about his recall but had no
thoughts of harming himself. He had been in prison before and understood how to
access support. Mr Irvine told a nurse that he had not eaten for two days, which
was noted on his medical record but not on his prison record. Prison staff were not
made aware. A mental health nurse assessed Mr Irvine and found no evidence of
mental illness. In the first night centre, Mr Irvine said he did not want to share a cell
or use the telephone system.
3. Mr Irvine saw various members of staff as part of his reception and induction. No
suicide or self-harm risks were identified based on Mr Irvine’s presentation, and no
additional monitoring was put in place. On 5 November, a healthcare assistant
checked Mr Irvine’s basic clinical observations, which were normal.
4. On 7 November, Mr Irvine told a healthcare support worker that once he knew
whether his partner was going to stand by him, he would consider eating again. His
clinical observations were slightly abnormal. That afternoon, Mr Irvine went to the
wing office in an agitated state and said that he was unable to use the telephone
system. Staff checked and told him that he had declined access on arrival but told
him how he could apply.
5. During a routine check that evening, a prison officer found Mr Irvine hanging. She
called for assistance and went into his cell, cut the ligature and worked with
colleagues to try to resuscitate Mr Irvine. Ambulance staff arrived and took over. At
9.34pm they confirmed that Mr Irvine had died.
Findings
Assessment of risk
6. Some staff who saw Mr Irvine in reception were unaware of his history of
management under ACCT processes or that he had been recalled to prison (which
is a known risk factor for suicide). Healthcare staff did not have access to records
and prison staff did not use them to inform initial risk assessments.
Mr Irvine’s food refusal
7. When Mr Irvine told a reception nurse that he had not eaten for two days, she noted
the disclosure in his medical records but did not follow the food refusal policy to
manage the risks or monitor his food or fluid intake. There is no evidence that the
information was passed to prison staff.
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8. Mr Irvine did not collect any food during his time at Durham. Prison staff did not
notice this and were unaware of policy requirements for prisoners refusing food.
Mr Irvine’s healthcare
9. The healthcare Mr Irvine received at Durham was only partially equivalent to what
he might have expected to receive in the community. The healthcare management
of his not having eaten for several days was not sufficient. In addition, when Mr
Irvine complained of feeling unwell and his observations were outside normal limits,
no action was taken.
Recommendations
• The Governor and Head of Healthcare should review reception procedures to
ensure that all staff have access to and consider relevant information, including
digital PERs and prison records when assessing the prisoner’s risk.
• The Governor and Head of Healthcare should ensure that staff do not rely on a
prisoner’s presentation alone when assessing suicide and self-harm risks.
• The Head of Healthcare should ensure that staff are aware of their responsibilities
under the food refusal policy, including sharing information with prison staff and
completing an incident report.
• The Governor should implement a process for monitoring food collection, to ensure
follow up action can be taken where necessary.
• The Head of Healthcare should ensure that clinical checks on prisoners who are
refusing food and/or fluids are carried out and recorded appropriately to ensure
risks are managed.
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The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Durham informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. The investigator visited Durham in February 2023. He obtained copies of relevant
extracts from Mr Irvine’s prison and medical records.
12. The investigator interviewed eight members of staff at Durham.
13. NHS England commissioned an independent clinical reviewer to review Mr Irvine’s
clinical care at the prison. She joined the investigator remotely for interviews of
healthcare staff.
14. We informed HM Coroner for Durham of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
15. The Ombudsman’s family liaison officer contacted Mr Irvine’s father, his next of kin,
to explain the investigation and to ask if he had any matters he wanted us to
consider. Mr Irvine’s father had no specific questions.
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Background Information
HMP Durham
16. HMP Durham is a local prison, serving the courts of Tyneside, Durham and
Cumbria. It has a maximum capacity of 985 men. Spectrum Community Health CIC
provides primary healthcare services. Tees, Esk and Wear Valleys Foundation NHS
Trust provides mental health services.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Durham was in November 2021. Inspectors
reported that serious staff shortages had affected all aspects of healthcare provision
and caused delays for prisoners trying to access support. Although the Head of
Healthcare had a clear vision, oversight and strategic management had been
affected by the lack of a deputy and the need for her to be involved in clinical
delivery.
18. Inspectors also found that reception was a busy environment, with late admissions
affecting the quality of provision. Similarly, the first night centre was busy, which
affected the regime there.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 October 2022, the IMB
reported that Durham was a safe prison, with safety a priority for staff at all levels.
However, Prisoners were not satisfied with the speed of healthcare processes. The
Board noted that reception was a very busy area. Incidents of self-harm had
reduced since the last annual report.
Previous deaths at HMP Durham
20. Mr Irvine was the seventh prisoner at HMP Durham to die since the beginning of
2021. The other deaths were all due to natural causes. There have been three
further apparently self-inflicted deaths since Mr Irvine’s, including one that occurred
three days after Mr Irvine’s. As a result, the prison is receiving additional support
and monitoring from HMPPS headquarters.
Assessment, Care in Custody, and Teamwork (ACCT)
21. 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.
22. 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
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regular multi-disciplinary review meetings involving the prisoner. As part of the
process, a caremap (plan of care, support and intervention) is put in place. The
ACCT plan should not be closed until all the actions of the caremap have been
completed.
23. 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
24. In 1994, Mr Russell Irvine was convicted of murder and sentenced to life
imprisonment. During his time in prison, he refused food on several occasions. Mr
Irvine had also tied ligatures during his sentence and had been managed under
suicide and self-harm monitoring procedures known as ACCT. Mr Irvine was
released on licence in October 2022, but was recalled to Durham on 4 November
after breaching his licence conditions. (This meant that he would restart the parole
application process and once again have to work towards release.)
25. In reception, Mr Irvine was interviewed by two supervising officers (SOs), who
completed an initial risk assessment. They did not check Mr Irvine’s prison record
so were unaware of his history of self-harm. Mr Irvine said that he was unhappy
about the reasons for his recall but had no thoughts of harming himself. One of the
SOs explained the support that was available in the prison, including chaplaincy,
the Samaritans, and Listeners (prisoners trained by the Samaritans to provide peer
support). Mr Irvine said that he had been in prison before and understood how to
access support but did not need any at the time. Mr Irvine had previously resided on
the vulnerable prisoners’ unit (VPU), which prisoners can apply to for their own
protection. He told the SOs that he did not wish to apply at the time.
26. In interview, one SO said that although she was not aware that Mr Irvine had
previously been managed under ACCT procedures, she knew he was serving a life
sentence and had been recalled to prison, which she noted was a potential trigger
for suicide and self-harm. She assessed that there was no imminent risk of harm at
the time.
27. A nurse completed Mr Irvine’s initial health screening. She did not have access to
any information about Mr Irvine’s time in police custody or previous time in prison.
Mr Irvine told her that he had not eaten or drunk any fluids while in police custody
because he was unhappy about being recalled. She incorrectly recorded that there
had been no change in custodial status (such as recall). She said in interview this
was the answer Mr Irvine gave her. She referred him for a mental health
assessment and noted on his record that his food and drink intake and basic
medical observations (such as blood pressure, pulse, and temperature) should be
monitored. In interview, she said that she told a member of prison staff that Mr
Irvine had not been eating, but she could not remember who she told. She did not
note this on Mr Irvine’s records. It was her understanding that the officer would
begin a food refusal sheet for Mr Irvine, in accordance with local policy. Mr Irvine
told her that he had no thoughts of harming himself. She told Mr Irvine that if he had
any concerns, he should see the nurse on the wing.
28. Mr Irvine also met with a nurse from the mental health team, who completed an
initial mental health consultation. Mr Irvine said he had no thoughts of harming
himself and had a friend outside prison who was supportive. He said he had not had
anything to eat but could not remember for how long. In interview, she said that
based on the consultation, she did not think Mr Irvine was refusing food as a form of
control or self-harm, more that he was frustrated about his recall and had no
appetite. She assessed that there were no signs of mental illness and no imminent
risk to Mr Irvine’s safety at the time. She concluded that he did not require the
support of ACCT processes, but the decision should be reviewed if he continued to
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refuse food. She recorded that Mr Irvine did not need the support of the mental
health team.
29. Mr Irvine was taken to the first night centre, where an officer explained the support
available and provided an induction pack. Although anxious, Mr Irvine said that he
had no thoughts of harming himself. He declined access to the telephone system.
The officer said in interview that she explained the consequences of this, but Mr
Irvine did not raise any concerns. She noted on Mr Irvine’s record that he was in a
good mood and presented well. Mr Irvine refused to share a cell and was charged
with a disciplinary offence as a result. He was allocated a double cell but as a single
occupant.
30. The following morning, on 5 November, Mr Irvine met with a member of the
chaplaincy as part of his induction. He said that he was okay and had no issues. He
also met with an officer for an introduction to key work session (where prisoners are
given a named officer as a first point of contact and with whom they meet regularly).
She explained the purpose of key work and that Mr Irvine would be allocated a
named key worker in due course. Mr Irvine said that he had been in prison before
so understood the system. She was not aware of Mr Irvine’s lack of food and would
not usually have access to such information unless a prisoner told her, which he did
not. Mr Irvine did not raise any issues with her.
31. A healthcare assistant saw Mr Irvine that afternoon and took his National Early
Warning Score (NEWS, a tool developed by the Royal College of Physicians to
detect clinical deterioration in adult patients) as part of the process for monitoring
the impact of his food refusal. She recorded that Mr Irvine’s score was zero,
meaning his health had not deteriorated. She did not record anything about his food
or fluid intake. Mr Irvine’s records do not show any interaction with healthcare
services on 6 November.
7 November
32. On the morning of 7 November, Mr Irvine saw a healthcare clerical support worker
for a health assessment. His NEWS score was 1, meaning there was a low risk of
deterioration in his health, but he said that he had “aches and pains” and an on/off
cough. Mr Irvine said that he wanted to know if his partner was going to stand by
him while he was in prison. He said he would ask his solicitor to contact her on his
behalf, though he did not know if he had any credit to make a telephone call. Mr
Irvine said that once he knew if his partner was going to stand by him, he would
know whether to continue with his food refusal. Mr Irvine’s body temperature was
lower than average, and his blood pressure was higher than is normal. The support
worker did not record any information on Mr Irvine’s food or fluid intake, or take any
further action as regards his temperature or blood pressure.
33. At 3.24pm that afternoon, Mr Irvine went to the wing office and spoke to a SO. He
said that he was unable to contact anybody, and no one was helping him. An officer
checked Mr Irvine’s prison record and found he had declined access to the
telephone system on arrival at Durham. The SO directed him to the induction office,
which was open at the time and could provide access. Mr Irvine was upset and
swore at her then left the office. In interview, the SO said she did not know if Mr
Irvine ever attended the induction office.
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34. At 7.30pm, an officer completed a routine check on the wing. Mr Irvine was lying on
his bed at the time. At 8.53pm, she completed a further check and saw Mr Irvine
hanging by a ligature made from the waist band of his trousers, attached to the top
bunk bed. She tried to make an emergency call on her radio, but she was not
certain that the message registered. In interview, she said that she shouted “staff”
to request immediate assistance from colleagues within earshot. She shouted,
“code blue” (meaning a prisoner is unconscious or having trouble breathing) and
told a colleague to radio a code blue emergency, which he did. At 8.54pm, the
control room called an ambulance. Hearing other staff approaching, she opened the
cell door and went in. She cut the ligature with her anti-ligature knife and she and
colleagues lowered Mr Irvine to the floor and began to perform cardiopulmonary
resuscitation (CPR).
35. A nurse responded to the emergency call and joined the officers in the cell within
two minutes. She could not detect a pulse so applied a defibrillator (a machine that
in some cases can restart the heart). The defibrillator recommended continued
CPR, which officers did. The ambulance arrived at the prison at 9.00pm and
paramedics took over CPR. At 9.34pm, they confirmed that Mr Irvine had died.
Contact with Mr Irvine’s family
36. The duty governor tried to appoint a prison family liaison officer (FLO) soon after Mr
Irvine’s death but was unable to identify an available trained FLO. To avoid a delay
in informing Mr Irvine’s family, she provided contact details for his father to the
police, who went to his home and shared the news.
37. The following morning, the prison appointed a family liaison officer. The FLO
confirmed with the police that they had contacted Mr Irvine’s father and followed up
with a call. He remained in contact with Mr Irvine’s family, to provide ongoing
support.
38. In line with HMPPS guidance, Durham offered a contribution to the costs of Mr
Irvine’s funeral. When our family liaison officer spoke to Mr Irvine’s father, he was
complimentary about the support that he received from the prison.
Support for prisoners and staff
39. After Mr Irvine’s death, the duty governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
40. The prison posted notices informing other prisoners of Mr Irvine’s death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr Irvine’s death.
Post-mortem report
41. Post-mortem tests showed that Mr Irvine died as a result of pressure on the neck
due to hanging. No illicit substances were found in Mr Irvine’s system.
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Findings
Accessing and sharing risk information
42. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm, including a history of suicide or self-
harm, violent offences against a person and recall to custody. It says all staff should
be alert to the increased risk of self-harm or suicide posed by prisoners with these
risk factors and should act appropriately to address any concerns. Any prisoner
identified as at risk of suicide and self-harm must be managed under Assessment,
Care in Custody and Teamwork (ACCT) procedures.
43. Person Escort Records (PERs) are electronic or hard copy documents used to
share risk information when individuals move between police and prison custody.
PERs are a key source of information for new receptions and should inform initial
risk assessments completed by prison and healthcare staff.
44. Mr Irvine presented a range of potential risks. His index offence was murder, for
which he had served 29 years. He had been recalled to prison for breaching his
licence conditions very shortly after release and reported that he was frustrated by
the decision. He must have known that he now faced a prolonged period in prison
while he restarted the parole process. Mr Irvine had been monitored under ACCT
procedures in prison in 2004 and 2016 and had a history of tying ligatures (a
particularly risky behaviour). He said he had a low mood, did not yet know if his
partner would stand by him, and had not eaten for a few days. Mr Irvine said that he
did not want to harm himself.
45. It is clear that Durham have put efforts into ensuring reception processes are
comprehensive. Prisoners have a health check and are interviewed by two senior
prison officers and two nurses. They are assessed by a mental health nurse if
required. Mr Irvine moved through each stage of the process. However, we found
issues with information access and information sharing amongst healthcare and
prison staff. This impacted on the quality of initial assessments.
46. The nurses who completed Mr Irvine’s initial assessment did not have access to his
digital prison records and PER, which contained information on his history and
current circumstances. The Head of Healthcare told us that some healthcare staff
could not access prison records or PERs as standard because they did not have
NOMIS (the prison records system) accounts. A nurse erroneously noted on Mr
Irvine’s record that there was no change in his custodial status, despite him telling
her he was frustrated about his recall to prison. Nursing staff noted in Mr Irvine’s
medical record that he was not eating and organised follow up checks by
healthcare, which we discuss later in our findings. However, they did not share the
information with prison staff to help manage the risks.
47. The supervising officers who interviewed Mr Irvine did not check prison records or
the PER. An SO said that she was aware that Mr Irvine was a life sentenced
prisoner who had been recalled to prison and that this was a potential trigger for risk
suicide and self-harm. However, she did not see any signs that he presented a risk
to himself. Both prison and healthcare staff concluded that Mr Irvine posed no
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increased risk of harm to himself at the time of his reception and ACCT procedures
were not used.
48. In assessing a prisoner’s risk of suicide and self-harm, staff must balance what is
known and recorded about the prisoner against what the prisoner says. They must
then make a judgement on whether the prisoner’s risk of suicide and self-harm is
such that ACCT procedures are necessary. In Mr Irvine’s case staff were overly
reliant on his presentation and statements that he did not want to harm himself,
without giving sufficient weight to his history and circumstances. Staff must have
access to information, use the information available to them and share it between
them when completing initial risk assessments to ensure they take into account
historic information and current circumstances. This might have changed the
outcome of their assessment of Mr Irvine.
49. Durham is currently receiving additional support from HMPPS headquarters
because of the number of self-inflicted deaths there in the last 12 months. Risk
identification in reception has been identified as a key issue and additional training
has been provided to staff on risks, triggers and protective factors, with further
training to follow. The prison’s senior leadership team has implemented processes
to improve first night interviews and initial health screens and to ensure that every
prisoner is able to make a telephone call on their first night. These are welcome
initiatives, but the issue of appropriate access to vital digital information remains a
concern. We make the following recommendations:
The Governor and Head of Healthcare should review reception procedures to
ensure that all staff have access to and consider relevant information,
including PERs, and prison records when assessing the prisoner’s risk.
The Governor and Head of Healthcare should ensure that staff do not rely on
a prisoner’s presentation alone when assessing suicide and self-harm risks.
Mr Irvine’s food refusal
50. Guidance on prisoners who are refusing food is contained in PSI 64/2011 and the
Department of Health publication Guidelines for the clinical management for people
refusing food in Immigration Removal Centres and Prisons. The guidance says that
a thorough assessment of a person’s mental capacity and nutritional status should
be undertaken immediately and there should be regular reassessments of the
person’s physical and mental state.
51. The healthcare department at Durham’s food refusal policy says that details of food
refusal should be reported to the duty prison manager responsible for the day to
day running of the prison and the Primary Care nursing team. A prison incident
report must be completed.
52. Mr Irvine told the nurse in reception that he had not eaten or drunk anything for
some two days. She recorded this in Mr Irvine’s medical records and said that she
verbally passed the information on to prison staff, to ensure a food refusal sheet
was started. This was not recorded in Mr Irvine’s prison records. We were unable to
verify if the information was shared between healthcare and prison staff, because
the officers we spoke to did not recall the conversation. A nurse noted in Mr Irvine’s
records that if he continued to refuse food, ACCT procedures might be considered.
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Prison staff were unaware of this consideration. The nurse did not complete an
incident report in line with local healthcare policy. We make the following
recommendation:
The Head of Healthcare should ensure that staff are aware of their
responsibilities under the food refusal policy, including sharing information
with prison staff and completing an incident report.
53. Prison officers remained unaware that Mr Irvine was not eating and therefore did
not monitor his collection of meals from the servery. Durham’s local review of Mr
Irvine’s death showed that his cell was unlocked at mealtimes, but he did not collect
his food. There is no evidence of Mr Irvine eating any food during his time in
Durham, and no indication that discipline staff noticed this, so the risk was not
identified or acted on. The Department of Health’s guidance notes that custodial
settings should have a system in place that highlights when prisoners do not collect
their meals. In interview, staff said they were not familiar with the policy to monitor
whether prisoners collected meals. Some said that they relied on the prisoners
working at the servery to let them know if food had not been collected. This did not
impact on the outcome for Mr Irvine but must be addressed to ensure staff at
Durham know how to monitor food refusal and respond appropriately to mitigate the
risks. We make the following recommendation:
The Governor should implement a process for monitoring food collection, to
ensure follow up action can be taken where necessary.
Mr Irvine’s healthcare
54. The clinical reviewer concluded that the healthcare provided to Mr Irvine was not
equivalent to that which he could have expected to receive in the community. As
noted above, the fact that he had not eaten for two days prior to his arrival was not
communicated from healthcare to prison officers.
55. The clinical reviewer also found that the follow up action taken to manage the risks
of Mr Irvine’s lack of eating was not sufficient. Neither of the checks on 5 or 7
November assessed Mr Irvine’s food or fluid intake. No check was made on 6
November. On 7 November Mr Irvine complained of feeling unwell and his
temperature and blood pressure were both outside normal ranges, but no action
was taken by healthcare. We make the following recommendation:
The Head of Healthcare should ensure that clinical checks on prisoners who
are refusing food and/or fluids are carried out and recorded appropriately to
ensure risks are managed.
56. On arrival in Durham, Mr Irvine’s regular prescribed medication was recorded by
healthcare. He did not, however, collect his medication in his short time there.
There is no evidence that Mr Irvine was reminded to collect his medication. While
Mr Irvine’s medications were not prescribed for the treatment of acute or critical
conditions, continuity of medication is an important requirement for new receptions
and this practice must be improved. We bring this learning to the attention of the
Head of Healthcare.
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Governor to note
Family liaison
57. PSI 64/2011 says that following a death in custody, the prison’s family liaison officer
should visit the next of kin in person to tell them and that this should be done
quickly to ensure that the family does not find out from another source.
58. When Mr Irvine died, the duty governor was unable to locate an available family
liaison officer. In light of this, and to avoid delays, the prison accepted the police’s
offer to contact Mr Irvine’s family. We consider this was appropriate in the
circumstances.
59. Durham has a list of trained family liaison officers. We were told that this list was out
of date and included names of staff no longer in post. We found no cover
arrangements to ensure FLO provision was in place at all times. We are satisfied
that steps were taken to prevent a delay in communicating the news of Mr Irvine’s
death to his family, however we are concerned that the lack of cover arrangements
may result in delays and risks families finding out from other sources in future. The
Governor will want to reflect on our findings and assure himself that suitable family
liaison provision is available at Durham.
Inquest
60. The inquest, held from 17 to 21 June 2024, concluded that Mr Irvine died by
suicide. They jury determined:
“We believe on the balance of probabilities that Mr Irvine had the intentions and
took his own life on the evening of 7 November 2022 by hanging in his prison cell,
using a belt as a ligature, attached to his bunkbed. Mr Irvine also left a note in which
he stated he was of sound mind. Based on the evidence provided, the facts state
that a number of policies and processes were not actioned or put I place correctly. It
is evident that Mr Irvine had previously documented risk factors for suicide and self-
harm, however these factors were not identified by prison staff during the reception
screening process. It is evident that not all of the actions taken by healthcare were
in compliance with the relevant policies. It cannot be established on the evidence
that these failings caused or contributed to Mr Irvine's death.”
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