Ryan Nash

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ryan Nash,
a prisoner at HMP Bedford,
on 30 April 2020
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Ryan Nash, a prisoner at HMP Bedford, was found hanged in his cell on 30 April 2020.
He was 25 years old. I offer my condolences to his family and friends.
I am appalled by the unacceptable and inhumane cell conditions that Mr Nash was held in
for a period of five days after he damaged his cell. This is particularly concerning as he
was being monitored under suicide and self-harm prevention procedures (known as
ACCT).
I am concerned that the ACCT procedures were very poorly managed. HM Inspectorate of
Prisons had identified significant weaknesses in the management of ACCT in 2018 and
again in 2019, and this investigation suggests that the necessary improvements had not
been made by the time of Mr Nash’s death.
I am also concerned that a full roll check was not completed as required, and that this may
have been affected by the level of broken cell observation panels at the prison, an issue
affecting the health and safety of both prisoners and staff.
Although the clinical reviewer concluded that, overall, the clinical care that Mr Nash
received was of a reasonable standard, I share his concerns about deficiencies in mental
health care and that nursing staff tried inappropriately to resuscitate Mr Nash when he was
clearly dead.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman November 2021
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Contents
Summary .........................................................................................................................3
The Investigation Process ................................................................................................6
Background Information ...................................................................................................7
Key Events .......................................................................................................................9
Findings ......................................................................................................................... 19
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Summary
Events
1. In April 2017, Mr Ryan Nash was remanded into custody and was later sentenced
to eight years in prison. He had served previous prison sentences. On 16 January
2020, Mr Nash was transferred to HMP Bedford after he assaulted an officer.
2. Mr Nash had a history of mental health issues, paranoia and thoughts of self-harm
and was assessed by Bedford’s mental health team and a psychiatrist.
3. On 19 March, staff opened suicide and self-harm monitoring procedures, known as
ACCT, after Mr Nash harmed himself. On 27 March, Mr Nash damaged the fittings
of his cell, so he was moved to another one. On 29 March, he damaged his new
cell and also set fire to it. He remained in the cell for five days with no furniture or
sanitation and, for some days, with no mattress.
4. On 1 April, Mr Nash was transferred to another wing where he settled and raised no
concerns. On 7 April, arrangements were made for Mr Nash to self-isolate after he
showed symptoms of COVID-19.
5. On 14 April, ACCT monitoring stopped and several days later, he returned to his
usual wing. During this time, Mr Nash raised no concerns with staff.
6. At around 7.30am on 30 April, an officer found Mr Nash in his cell with a ligature
tied around his neck. Staff responded promptly but when paramedics arrived, he
was pronounced dead.
Findings
7. We are extremely concerned about the unacceptable cell conditions in which Mr
Nash lived for several days while being monitored under ACCT procedures. Mr
Nash’s cell conditions were degrading and unacceptable and would undoubtedly
have had an impact on his mental health.
8. We told Bedford of our concerns about Mr Nash’s cell conditions during the
investigation. The Governor issued an order which we are satisfied has remedied
the issue. However, we were concerned that the Governor did not provide us with
full information about the origins of a local order about keeping prisoners in
damaged cells.
9. Although staff appropriately started ACCT procedures when Mr Nash harmed
himself, Mr Nash’s ACCT monitoring was very poorly managed. The assessment
interview and first case review did not take place within 24 hours, reviews were not
sufficiently multidisciplinary, reviews did not take place when there was a change of
risk, and caremaps were poorly completed and not meaningful.
10. Some prisoners alleged that prison staff behaved inappropriately outside Mr Nash’s
cell on the evening / night before Mr Nash was found dead. We consider that these
serious allegations require further investigation.
11. We are concerned that a member of staff did not complete the roll check properly
on the morning that Mr Nash was found hanged in his cell. This is unlikely to have
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affected the outcome for Mr Nash as he had been dead for some time, but it could
make a critical difference in other cases.
12. The observation panel in Mr Nash’s cell was broken, as were many other
observation panels on the wing. We are concerned that the safety of staff and
prisoners is put at risk by the number of broken observation panels at Bedford.
13. When officers found Mr Nash, they thought that he had probably already died but
instinctively started cardiopulmonary resuscitation (CPR). However, we are
concerned that when nurses arrived, they continued to try to resuscitate Mr Nash,
even though rigor mortis was present.
14. The clinical reviewer concluded that the care that Mr Nash received at Bedford was
of a reasonable standard and was at least equivalent to that which he could have
expected to receive in the community.
15. However, the clinical reviewer identified a number of concerns in Mr Nash’s care,
including the need for urgent referrals to the mental health team to be assessed
within five days; that the mental health team and offender management team
should liaise with each other when prisoners are referred to other prisons as part of
their care needs; that staff receive dyslexia training; and that when prisoners are
discharged from the care of the mental health team, the reasons are fully explained
to them.
Recommendations
Special accommodation
• The Governor should ensure that all managers understand the definition of Special
Accommodation and the required protective measures set out in PSO 1700.
Cooperating with PPO investigations
• The Prison Group Director for Bedford, Cambridgeshire and Norfolk should ensure
that prisons fully cooperate with PPO requests for information and understand that
the PPO must have unfettered access to any information relevant to their
investigations, in line with PSI 58/2010.
ACCT monitoring
• The Governor should ensure that prison staff manage prisoners identified as at risk
of suicide or self-harm in line with PSI 64/2011, including that:
• the ACCT assessment interview and first ACCT case review are completed
within 24 hours of the start of ACCT procedures;
• first ACCT case reviews are multidisciplinary and always include a member
of healthcare staff and staff who have had previous contact with the
individual, such as key workers or the ACCT assessor;
• staff read the ACCT document and familiarise themselves with all relevant
issues and known risk factors before holding reviews;
• a case manager is appointed at the first case review, who should lead all
subsequent case reviews whenever possible;
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• a multi-disciplinary review is held when there is evidence of a significant
change in risk; and
• case managers should ensure that caremaps are completed at the first
ACCT case review, set specific and meaningful caremap actions, tailored to
the individual to reduce their risk and identify who is responsible for them and
review progress at each review.
Allegations made by prisoners
• The Governor should initiate an investigation into the allegations made by prisoners
about the behaviour of prison officers who were on the wing on the evening and
night of 29 April 2020 with a view to considering whether disciplinary action is
appropriate.
Roll checks and broken cell observation panels
• The Governor should ensure that staff understand the importance of conducting roll
checks as required.
• The Governor should ensure that:
• Bedford Staff Community Notice 19/2020 is updated to provide guidance to
staff about measures to take when carrying out roll checks and other welfare
checks on prisoners with damaged, broken or blocked observation panels;
and
• broken observation panels are replaced as soon as possible.
Resuscitation
• The Governor and Head of Healthcare should ensure that staff are aware of the
circumstances in which resuscitation is inappropriate.
Mental health
• The Head of Healthcare should ensure that all prisoners referred urgently to the
mental health team are assessed within five days, in line with the team’s policy.
• The Governor and Head of Healthcare should ensure that there is a communication
plan in place between OMU and the mental health team so that referrals to the
PIPE programme are progressed and prisoners are updated about the status of
their referral.
Learning lessons
• The Governor and Head of Healthcare should ensure that a copy of this report is
shared with all staff named in this report and that a senior manager discusses the
Ombudsman’s findings with them.
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The Investigation Process
16. The investigator issued notices to staff and prisoners at HMP Bedford informing
them of the investigation and asking anyone with relevant information to contact
him. No one contacted him.
17. The investigator obtained copies of relevant extracts from Mr Nash’s prison and
medical records.
18. NHS England commissioned a clinical reviewer to review Mr Nash’s clinical care at
the prison.
19. The investigator interviewed 13 members of staff and five prisoners at Bedford on
16 and 19 June, 1, 2, 22 and 28 July and 6 August, some jointly with the clinical
reviewer. All the interviews were conducted remotely either by video or by
telephone because of the restrictions imposed as a result of COVID-19.
20. We informed HM Coroner for Bedfordshire and Luton of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent her a
copy of this report.
21. We contacted Mr Nash’s family to explain the investigation and asked if they had
any matters they wanted us to consider. They had no specific questions.
22. Mr Nash’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Bedford
23. HMP Bedford is a local prison holding around 500 men. Northants Healthcare NHS
Foundation Trust provide all healthcare services at Bedford.
HM Inspectorate of Prisons
24. HM Inspectorate of Prisons (HMIP) carried out an unannounced inspection of
Bedford in August/September 2018. Inspectors reported that the number of
incidents of self-harm had increased substantially since their last inspection (in
2016) and was higher than in comparable prisons. There had also been five self-
inflicted deaths since the last inspection.
25. Inspectors reported that ACCT processes were weak, poorly managed and
ineffective, including that some care plans failed to address issues of concern, that
case reviews were often not multidisciplinary, that many entries in ongoing records
were observational and did not evidence meaningful engagement, that healthcare
did not attend all initial reviews and that prisoners subject to ACCT monitoring
experienced poor living conditions.
26. Inspectors found that many cells had broken or blocked observation panels, that
there was a huge backlog of general repairs and maintenance and that many cells
had been vandalised and assessed as not fit for habitation. Inspectors found a
prisoner located in a cell without a bed and working toilet. HMIP recommended that
all prisoners should live in clean and decent conditions.
27. Inspectors reported that there was a well-integrated mental health team that offered
a limited range of primary support but lacked capacity to provide sufficient levels of
therapeutic interventions.
28. Following the inspection, HM Chief Inspector of Prisons invoked the Urgent
Notification protocol and wrote to the Secretary of State in September 2018, setting
out his significant concerns about the treatment of prisoners, including the
management of prisoners at risk of suicide or self-harm.
29. HMIP carried out an Independent Review of Progress in August 2019. Inspectors
found that work to address weaknesses in suicide and self-harm prevention
processes had been far too slow to develop following the Urgent Notification issued
in September 2018. Inspectors noted however that there had been improvement in
reducing the number of maintenance repairs waiting to be completed.
Independent Monitoring Board
30. 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 June 2019, the IMB reported that
levels of self-harm were amongst the highest in the country and that ACCT
procedures applied at Bedford were failing to reduce levels of self-harm, partly due
to systemic weaknesses and failures of implementation. The IMB reported that
there were clear signs of improvement in the mental health provision, but that
significant problems still needed to be resolved.
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Previous deaths at HMP Bedford
31. Mr Nash was the sixth prisoner to have died at Bedford since the start of January
2017. Two of the previous deaths were self-inflicted and three were from natural
causes. In our report into the self-inflicted death of a prisoner in March 2017, we
made a recommendation about the need for healthcare staff to attend first ACCT
case reviews. In July 2020, there was a further self-inflicted death at Bedford. In
our report on that death, we made recommendations about the need for ACCT case
managers to attend and lead reviews whenever possible, that triggers should be
considered during reviews in determining levels of risk and that ACCT observations
should be carried out as directed.
Assessment, Care in Custody and Teamwork (ACCT)
32. 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. As part
of the process, a risk reduction plan, also known as a caremap (a plan of care,
support and intervention) should be put in place. The ACCT plan should not be
closed until all the actions of the risk reduction plan have been completed. After
closure, a follow-up interview should take place within seven days.
33. 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. Prison Service Instruction (PSI) 64/2011
on safer custody sets out how staff should operate ACCT procedures.
COVID-19 restrictions
34. On 24 March 2020, in response to the COVID-19 pandemic and in line with
Government advice, HMPPS issued an instruction to all prisons to introduce social
distancing and a restricted regime for staff and prisoners, wherever possible. On 27
March, HMPPS issued operational guidance to prisons on exceptional regime and
service delivery, which reflected Government restrictions following the national
lockdown of 23 March. This guidance resulted in significantly restricted prisoner
activities. Prison visits were suspended, education and non-essential work was
cancelled, and healthcare delivery was also affected. This meant that prisoners
spent up to 23 hours a day locked behind their cell doors.
35. The key worker scheme was suspended at Bedford on 20 March due to the COVID-
19 pandemic. The Exceptional Regime and Service Delivery Operational Guidance
required prisons to make every effort to ensure resources were available to support
prisoners subject to ACCT procedures on the basis that for many, the risk of self-
harm could increase as a result of prolonged periods in cells.
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Key Events
Background
36. On 11 April 2017, Mr Ryan Nash was remanded to HMP Peterborough, charged
with grievous bodily harm and aggravated burglary. On 15 December 2017, he was
sentenced to eight years in prison. He had previously served time in prison.
37. In February 2018, Mr Nash was transferred to HMP Wayland, where he told staff
that he felt unsafe due to debt. Staff offered to move him to the prison’s Vulnerable
Prisoners’ Unit, but he declined. Mr Nash was found under the influence of drugs
on at least two occasions.
38. On 15 January 2020, Mr Nash assaulted an officer with an improvised weapon and
took his keys from him. Mr Nash was re-categorised as a Category B prisoner and
was identified as posing a risk of escape. This meant that he became an E List
prisoner, who was subject to additional security restrictions.
HMP Bedford
39. On 16 January, Mr Nash was transferred to HMP Bedford due to his increased risk
of escape and was sent to the prison’s segregation unit.
40. The following day, a mental health nurse assessed Mr Nash. He said that he had a
history of depression, hearing voices and thoughts of self-harm and had used illicit
substances. It was noted that Mr Nash appeared agitated, and he was referred
urgently to the prison’s mental health team and to the prison’s substance misuse
team. Mr Nash had dyslexia (a learning disorder that involves difficulty reading,
writing and spelling).
41. Staff started suicide and self-harm monitoring procedures, known as ACCT,
because Mr Nash had made comments about feeling suicidal in a letter in 2017. At
an ACCT case review on 18 January, Mr Nash said he did not understand why he
was being monitored under ACCT procedures, as the letter had reflected his
feelings in 2017. Mr Nash denied any thoughts of suicide or self-harm and the
ACCT was closed.
42. An officer introduced himself to Mr Nash as his keyworker and a nurse from the
prison’s substance misuse team assessed him. Although Mr Nash denied the use
of illicit drugs, the nurse referred him to the Westminster Drug Project, a drug and
alcohol charity, for further support. On 20 January, a prison GP assessed Mr Nash.
No significant physical medical conditions were identified, and he tested negative
for drugs.
43. On 27 January, Mr Nash was moved from the segregation unit to a cell on A wing,
considered suitable for an E List prisoner.
44. On 28 January, Mr Nash told a worker from the Westminster Drug Project that he
did not wish to work with the team, had no drug issues and needed no further
intervention.
45. On 5 February, Mr Nash told his keyworker that he no concerns about his safety or
wellbeing. The keyworker complimented Mr Nash on the cleanliness of his cell. Mr
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Nash said he did not want to remain on the E List and that his mental health issues
had contributed to his actions at Wayland, which he regretted.
46. On the same day, a mental health nurse assessed Mr Nash, who told him that he
had had hallucinations and delusional thoughts and voices in his head from an early
age. The nurse referred Mr Nash for a psychiatric assessment and gave him a self-
help leaflet about hearing voices.
47. On 12 February, Mr Nash complained to his keyworker and a mental health nurse
about the length of time he had to wait for mental health support. He said that
although he heard voices in his head, he did not feel the need to act on them. Mr
Nash said that he had initially feared being attacked by other prisoners at Bedford
but was now making friends and felt more settled. An appointment was made for
Mr Nash to be assessed by a psychiatrist.
48. On 19 February, Mr Nash told his keyworker that he was still waiting to see the
mental health team but understood that it took time. The keyworker noted that Mr
Nash was engaging and polite and took pride in keeping his cell clean.
49. A forensic psychiatrist was unable to assess Mr Nash on 25 February, as there
were not enough staff available to escort Mr Nash to the appointment. His
appointment was rearranged for 3 March.
50. On 27 February, Mr Nash was sent a letter which explained that due to the COVID-
19 pandemic, mental health services had been streamlined, that there would be
reduced contact with prisoners until further notice, that routine appointments would
not take place and that self-help guides would be distributed.
51. On 3 March, the psychiatrist assessed Mr Nash. He told the doctor that he heard
voices in his head telling him that people were plotting against him. Mr Nash
denied thoughts of self-harm. The psychiatrist noted that Mr Nash was not
psychotic and diagnosed him with a dissocial personality disorder. He told Mr Nash
that he might benefit from therapeutic treatment and suggested that a
recommendation should be made for him to transfer to a prison with therapeutic
treatments and a psychologically informed planned environment (PIPE) unit. Mr
Nash agreed. (PIPE units run a regime and environment that enables prisoners to
progress through a pathway of therapeutic interventions, providing support to
prisoners with their personal development.) The psychiatrist told Mr Nash that
medication would not change how he felt and told him to refrain from taking illicit
drugs as they would have a negative effect on him. A mental health nurse was
tasked with referring Mr Nash to a PIPE unit and the psychiatrist discharged him
from the care of the mental health team, noting that he could be re-referred if
necessary.
52. On 8 March, Mr Nash was verbally aggressive to an officer when he collected his
meal. The following day, a weapon was found in his cell.
53. On 14 March, the keyworker was unable to meet Mr Nash for their regular
keyworker session due to time constraints. Mr Nash had no further keyworker
sessions with Mr Nash as, due to COVID-19, the keyworker scheme was
suspended at Bedford on 20 March.
54. On 17 March, a mental health nurse met Mr Nash to discuss the referral process to
a PIPE unit. Afterwards, the nurse contacted the prison offender management unit
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(OMU), responsible for considering prisoner referrals, assessments and transfers to
PIPE units as part of a prisoner’s overall sentence planning.
ACCT: 19 March to 14 April
55. On the afternoon of 19 March, staff started ACCT monitoring procedures after Mr
Nash made a cut to his face and it was noted that his behaviour was withdrawn. He
was put on hourly observations. An immediate action plan was completed, and a
Supervising Officer (SO) was allocated as the ACCT case manager.
56. On 20 March, Mr Nash was discussed at a multidisciplinary mental health team
meeting. A clinical psychologist later noted that due to COVID-19 business
continuity plans, Mr Nash should be seen every six weeks, a reduction in the
contact that he currently had with the mental health team. She noted that the team
would write to Mr Nash to tell him and noted that OMU were looking into transferring
him to a PIPE unit.
57. On 22 March, Mr Nash refused to leave his cell to attend the ACCT assessment
interview with an officer. He said that he did not want to be monitored under ACCT
procedures. A SO noted that as Mr Nash felt unsafe, it would be better to contact
him when other prisoners were locked in their cells.
58. At 2.00pm, a SO chaired Mr Nash’s first ACCT case review, with an officer, at his
cell door. It was noted that the mental health team could not attend. Mr Nash could
not explain why he had harmed himself but said he did not trust staff, did not need
mental health support and was happy to stay in his cell, watching television and
reading. Mr Nash denied having any issues relating to bullying or debt but said that
he wanted to transfer to another prison. The caremap was completed with one
action: to contact OMU about a transfer. A further review was scheduled for 25
March.
59. Later that afternoon, Mr Nash tried to climb onto the wing’s safety netting. He was
restrained and returned to his cell. That evening, Mr Nash handed over several
broken items from his cell, which officers described as homemade weapons, and a
“pole” with which he had broken his cell door observation panel. He said he had
done this because he was angry with an officer on the wing.
60. At 9.30am on 25 March, Mr Nash told an officer that he had a razor blade in his
mouth, wanted to move to healthcare for a fresh start and would go mad if he was
not moved. A mental health nurse noted that he had been unable to visit Mr Nash
for a mental health appointment. The nurse asked when Mr Nash’s next ACCT
review would take place and was told that the mental health team would be told so
they could attend. The nurse noted that he heard nothing further and assumed the
review had been completed without him.
61. At 5.00pm Mr Nash’s ACCT assessment interview took place, six days after the
ACCT was opened. Mr Nash told the assessor that he had harmed himself
“because he could”, that he did not trust anyone and wanted a move to healthcare
for a fresh start. At 6.00pm, a SO noted that due to the timing and the “situation” on
the wing, a full ACCT review would take place the following day. The SO noted that
Mr Nash had said he was okay to wait until the next day.
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62. On 26 March, an officer noted his concerns that Mr Nash was withdrawn and
paranoid. At 2.40pm, a SO tried to carry out an ACCT review but noted that as Mr
Nash was not interested, he would try again later that day.
63. On Friday 27 March, Mr Nash flooded and damaged the fittings in his cell because
he wanted to move wings and was paranoid that staff were “out to get him”. It was
agreed that Mr Nash would be moved to another cell. Because Mr Nash had
threatened staff with damaged items from his cell, officers used Control and
Restraint (C&R) techniques to move him to another cell on A Wing. After the move,
Mr Nash damaged the fittings of his new cell and again threatened staff with
improvised weapons. Prison staff again restrained Mr Nash and the debris was
cleared from his cell.
64. A CM (Custodial Manager) said that she and another CM spoke to the duty
governor about Mr Nash, and it was agreed that it would be best for him to move to
D Wing. The duty governor considered moving Mr Nash to the segregation unit, but
as the unit was full and Mr Nash was being monitored under ACCT procedures, he
did not consider that the segregation unit was suitable.
65. The duty governor sought advice from the Deputy Governor about the move. He
said that she told him that because Mr Nash had damaged his cells and there was a
lack of alternative cell space, Mr Nash’s current cell should be made safe, and he
should remain in it. (Mr Nash’s cell was cleared of debris and furniture, leaving him
with only a mattress, and he had no access to running water or sanitation as he had
damaged his toilet.)
66. A SO chaired Mr Nash’s second ACCT review alone at Mr Nash’s cell door. A
mental health nurse, who was unable to attend, provided a report about Mr Nash’s
mental health. Mr Nash calmed down when the SO told him that he would move to
D wing. Mr Nash’s observations were increased and the caremap was updated to
note that a referral to the mental health team had been made. An ACCT review
was scheduled for the following day. During the review, the SO was told that senior
management had said Mr Nash was “NOT to move cells… under any
circumstances”.
67. A nurse treated a cut to Mr Nash’s finger and noted that his trousers were stained
with faeces. That evening, Mr Nash told staff that he was cold and asked for
bedding and water. He was also given clean clothes.
68. On 28 March, a nurse was unable to assess Mr Nash as he refused to cooperate.
That afternoon, Mr Nash told his keyworker that staff were trying to poison him. His
keyworker assured him that this was not the case.
69. In the early hours of 29 March, Mr Nash was noted to be awake, standing in his cell.
He was seen holding an improvised weapon and lying on his mattress, with a towel
over his eyes. That day, he also covered his broken cell observation panel.
Despite his behaviour, officers wrote in the ACCT document that no concerns were
raised.
70. Shortly after midday, Mr Nash set fire to his mattress and staff were deployed to
extinguish it. The fire and ambulance services were also called to attend. When
the fire was put out, staff used force to take Mr Nash from his cell as he was
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threatening staff with an improvised weapon. Staff cleared further debris, including
his burnt mattress, from the cell, before Mr Nash was returned to the fire and water
damaged cell. Paramedics and a nurse assessed Mr Nash and noted that he had
no injuries, and that no treatment was required.
71. That afternoon, it was noted that Mr Nash was sitting on the floor of his cell and had
asked for a jumper, as he was worried about being cold. He also asked for hot
water. Mr Nash was given clean clothes but was not given a mattress. He
continued to have no access to running water, sanitation or other cell facilities.
Staff raised no further concerns but noted that Mr Nash was sitting on the floor of
his cell that evening.
72. In the early hours of 30 March, Mr Nash told the night officer that he had not slept.
In the morning, Mr Nash told an officer that he did not have a bed as it had been
taken away after he had set fire to his cell. Mr Nash was later seen sitting and lying
on the cell floor and at lunch time, he said that staff were against him.
73. At around 10.00am, a SO chaired Mr Nash’s third ACCT review. No one else
attended, and Mr Nash did not take part as he said he did not know the SO. A
review was scheduled for the following day but the caremap was not updated.
Throughout this time, Mr Nash continued to have no access to water or sanitation.
On the night of 30 to 31 March, an officer noted that Mr Nash had no bed or blanket
in his cell and was lying on the floor. He was seen walking around his cell in the
early hours.
74. At 8.15am on 31 March, an officer noted that Mr Nash’s behaviour was “bizarre”
and that he had no toilet, sink or furniture in his cell. Mr Nash tried to force his way
out of the cell after throwing a cup of tea at officers. He was restrained and
returned to the cell. The officer reported Mr Nash’s living conditions to a SO. He
said that he wanted to move Mr Nash as his cell was “inhumane and worse than
special accommodation”. The officer said that the cell had blackened walls and Mr
Nash was crouched in the corner. A CM was told about the conditions of the cell
and identified a new cell for Mr Nash later that morning.
75. However, later that afternoon, Mr Nash refused to move cells and he was later seen
trying to remove electric piping from the cell’s wall. A SO said that when he asked
Mr Nash where he went to the toilet, Mr Nash pointed to a hole where the pipework
would have gone.
76. That evening, Mr Nash asked staff for a mattress. A CM, the duty night manager,
contacted the duty governor and told him Mr Nash’s cell conditions were
unacceptable, he had no sanitation or running water and the walls of his cell were
blackened with smoke. Mr Nash was given a mattress and water. The CM said
that the duty governor agreed that Mr Nash should be moved to D Wing the
following morning for a fresh start.
77. At around 9.30pm, the CM chaired Mr Nash’s fourth ACCT case review at his cell
door, after she had established that the one scheduled for earlier in the day had not
taken place. She sought information from a nurse, who referred Mr Nash for an
urgent mental health assessment the following day. The CM noted that Mr Nash
was paranoid, his behaviour was bizarre, and he said that staff were out to get him.
Mr Nash was told that he would be moved to D Wing, and the CM noted he was
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pleased. The CM considered that Mr Nash’s risk of self-harm was high and raised
his observations to five an hour. She scheduled a further review for the following
day.
78. On the morning of 1 April, a SO chaired a multidisciplinary ACCT review which the
clinical psychologist attended. They noted that Mr Nash was paranoid, wanted to
move wings and said that staff and prisoners were “out to get him”. It was noted
that Mr Nash gave the impression that he had taken drugs, but he denied this. The
caremap was not updated but a review was scheduled for later that day. The
psychologist referred Mr Nash to the forensic psychiatrist for further assessment.
79. That afternoon, Mr Nash moved to a furnished cell on D Wing. He had a shower
and made a phone call. A SO carried out a further ACCT review, and Mr Nash said
that he was relieved to have moved wings. Mr Nash’s ACCT observations were
reduced, and a further review was scheduled for 6 April. Mental health nurses also
reviewed Mr Nash who asked about his move to a PIPE unit. The nurses told Mr
Nash that they had no news about his referral.
80. On 3 April, a nurse asked Mr Nash’s offender supervisor if he could be considered
for a move to a PIPE unit. He noted that Mr Nash had been given leaflets about
PIPE pathways but that the mental health team were not clear about the referral
process and sought further advice. There is no evidence the PIPE referral was
made.
81. On 6 April, a CM asked the mental health team to assess Mr Nash as she was
concerned about his bizarre and paranoid behaviour, which had been identified
during routine telephone call monitoring of conversations with his family.
82. A SO chaired an ACCT case review with the forensic psychologist. The two
caremap issues were noted as complete and a further review was scheduled for 13
April. Mr Nash said that his fresh start on D Wing was going well and the
psychologist noted that he was clearly less distressed than he had been and
interacted well and that ongoing mental health monitoring would be enough for his
needs. Mr Nash told the review that he was not at risk of suicide or self-harm and
specifically asked for this to be recorded.
83. On 7 April, a nurse assessed Mr Nash as he reported feeling unwell. The nurse
believed Mr Nash’s symptoms suggested that he had COVID-19. He was given
symptomatic relief and arrangements were put in place for him to self-isolate for
seven days. Mr Nash remained in isolation and complied with the prison regime.
84. On 13 April, Mr Nash moved to C Wing to continue his period of isolation. That
afternoon, a SO carried out an ACCT review. No one else attended. Mr Nash
denied thoughts of self-harm. A review was scheduled for the following day.
85. On 14 April, the forensic psychiatrist, who had been asked to reassess Mr Nash,
was unable to do so as he was in isolation. A SO chaired Mr Nash’s ACCT review,
with another officer and a nurse. He then completed the review on his own in
personal protective equipment (PPE) at Mr Nash’s cell door. The SO noted that Mr
Nash’s paranoia had rapidly diminished, he no longer wanted to be monitored under
ACCT procedures and that “all was good in the world”. The SO stopped ACCT
monitoring and a post-closure review was scheduled for 21 April.
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86. On 15 April, Mr Nash was discussed at a mental health team meeting after officers
raised concerns that Mr Nash was becoming more distressed and was hearing
voices. They agreed that the forensic psychiatrist would review him.
87. On 17 April, Mr Nash’s COVID-19 isolation ended, and he was moved back to A
Wing into the cell which he had previously set on fire. Mr Nash told a CM that he
was looking forward to getting back to normal and that he would tell staff if he felt
paranoid again.
88. On 23 April, Mr Nash was no longer considered at risk of escape and his E List
status was removed.
89. On 26 and 27 April, Mr Nash phoned his mother, but raised no concerns and told
her that he would behave himself when he was released from prison.
90. On 28 April, the forensic psychiatrist and a nurse reviewed Mr Nash. He denied
thoughts of paranoia, distress or thoughts of self-harm. The psychiatrist noted that
Mr Nash interacted well and concluded that there remained no evidence of
psychotic illness, his diagnosis remained the same and a move to a PIPE unit
would be beneficial. After his appointment, the psychiatrist discharged Mr Nash
from the mental health team at the multidisciplinary team meeting and noted that he
should be given a self-help leaflet about personality disorders.
91. Mr Nash spoke to his mother and grandmother by telephone that day. He told his
mother that he had spoken to a psychiatrist who he said had previously told him he
was a borderline psychotic with a split personality but now said he was sane. He
also talked about having some money sent in, told her he had enough vapes and
that he would talk to her the following day. Mr Nash’s grandmother told him that he
sounded “a bit down”, but Mr Nash told her he was okay.
92. The mental health team wrote to Mr Nash to tell him that he had been discharged
from the mental health team and that if he required further input, he should liaise
with wing staff.
93. A prisoner who knew Mr Nash said that Mr Nash had told him he was in a good
mood. He said that in the preceding days, Mr Nash had been ‘normal’, kept to
himself, was not bullied by prisoners, had no problems with staff and never talked of
self-harm. He said other prisoners would look out for Mr Nash and would give him
things if he needed them. He said that although Mr Nash had previously smoked
psychoactive substances (PS), he had only smoked vapes since he returned to the
wing.
94. Another prisoner said that although Mr Nash mixed with other prisoners, he mainly
kept to himself and never discussed thoughts of self-harm. He said that when Mr
Nash returned to A Wing, he was a lot happier and more cheerful as he had been
removed from the E List.
95. Another prisoner said that when Mr Nash returned to A wing he seemed in good
spirits and told him he had stopped smoking PS. He said he was surprised when
he heard that Mr Nash had taken his own life.
96. A prisoner who occupied a cell opposite Mr Nash said that in the days leading to his
death, Mr Nash was happy and smiling.
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29 April 2020
97. Between 8.19am and 9.49am on 29 April, Mr Nash rang his cell bell four times. The
officer who answered the cell bell said that Mr Nash was keen to know when he
would be unlocked for association so he could make a phone call and shower. The
officer said Mr Nash’s demeanour seemed similar to normal but, that he was not
smiling quite as much.
98. At around 10.00am, Mr Nash spoke to his grandparents by telephone. Mr Nash told
them he was alright, and his grandmother told him he sounded better than when
she had spoken with him the previous day and they talked about money being paid
into his prison account. At around 10.45am, Mr Nash also spoke to his mother
about money. He said that he was running out of credit on his telephone account.
Mr Nash told her he would speak to her the following day. Mr Nash then collected
his lunch.
99. That afternoon, Mr Nash rang his cell bell on four occasions between 3.30pm and
4.25pm. The investigator has been unable to establish why Mr Nash rang his cell
bell.
100. A wing cleaner who lived next to Mr Nash’s cell, said that he gave Mr Nash a packet
of vapes during the day and said that officers had ignored his cell bell because the
wing was busy. He said that when Mr Nash asked an officer for vapes, he was told
that he could not have any. Mr Nash had then told the officer that if he did not get
any, he “would do something wrong”.
101. A prisoner said that he gave Mr Nash some vapes at about 4.45pm and said that he
seemed fine and in good spirits. He said that prisoners had told him that Mr Nash
shouted out for vapes later that evening, but he did not understand why as he had
given him vapes.
102. Another prisoner said that he spoke to Mr Nash before cells were locked at around
5.30pm. He had asked Mr Nash if he wanted anything, but Mr Nash said that he
did not as he had ordered his canteen (purchases from the prison shop). He said
that Mr Nash appeared in good spirits and that he had been shocked to hear of Mr
Nash’s death.
103. Another prisoner said that Mr Nash appeared to be struggling and felt low and
depressed. He had asked Mr Nash what was wrong but did not have time to speak
to him as officers were locking prisoners in their cells.
104. At 6.33pm, several officers opened Mr Nash’s cell door to give him a pack
containing snacks, while conducting the evening roll check. An officer said that
when the officers opened his cell door, Mr Nash looked surprised.
105. At 7.06pm, an officer pushed an information sheet under Mr Nash’s cell door and at
7.19pm, another officer posted mail through the cell door. He said he could not
recall speaking to Mr Nash.
106. A prisoner said that Mr Nash had shouted out to him that evening to say that he
was watching television. Another prisoner said that he had heard Mr Nash talking
to officers at about 9.00pm about getting vapes from another prisoner, but the
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officers did not fetch them. The prisoner went to bed at about 1.00am and heard
nothing further.
107. At 8.53pm, an Operational Support Grade (OSG) carried out a further roll check.
CCTV shows that she lowered a towel that Mr Nash had used to cover his cell’s
broken observation panel in order to see into his cell.
108. A prisoner said that at about 8.30pm, he heard Mr Nash shouting out for his
medication and that he wanted a vape. He said that Mr Nash rang his cell bell at
about 9.15pm and shouted out that he could not settle down and was going to kill
himself. The prisoner said that staff told Mr Nash “to do what he had to do”.
109. Another prisoner said that Mr Nash rang his cell bell at about 9.25pm and asked
officers for vapes. He was told that this was not possible as the prison was in patrol
state. He said that Mr Nash was irate and upset that he could not smoke. He said
that Mr Nash said that if he was not given a vape, he would commit suicide. He
said that officers were standing outside Mr Nash’s cell, and that they said that he
would not kill himself and just wanted attention. He said the officers started
laughing between themselves outside his cell for about ten minutes. He said that
when Mr Nash said he would take his own life, he heard the officers say, “You have
got to do what you have got to do”. He said that he put his cell bell on and asked
the officers to give one of his vapes to Mr Nash, but they did not do so.
110. Mr Nash did not have any prescribed medication. Although CCTV footage shows
that officers attended cells close to Mr Nash’s cell that evening, Mr Nash did not
ring his cell bell after 4.25pm.
30 April 2020
111. At 12.03am, CCTV shows an OSG A appeared to carry out a check of the cells on
the threes landing but did not check Mr Nash’s cell. It is not known why the OSG
checked these cells, but there was no requirement to check Mr Nash’s cell at this
time. At 12.05am, another OSG answered a cell bell for the cell next to Mr Nash’s,
and attended the same cell several times over the following two hours.
112. At around 5.34am, OSG A completed the early morning roll check, but CCTV shows
that, although she walked past Mr Nash’s cell door, she did not check him. During
the local investigation carried out after Mr Nash’s death, she told managers that she
recalled there was a towel covering the broken cell observation panel but that she
did not move it.
113. Officer A said that he received a handover from OSG A when he arrived on the
wing at around 7.15am, and that she did not raise any issues about Mr Nash.
114. At 7.25am, Officer A started his roll check and at 7.29am, he checked Mr Nash’s
cell. The officer said that Mr Nash’s observation panel was broken and a towel,
which had been rolled up, was covering it. He pulled the towel down and looked
into the cell. The officer saw Mr Nash hanging from the cell window in a sitting
position, with a green ligature around his neck which was tied to the window.
115. Officer A immediately radioed a medical emergency code blue and asked for an
ambulance to be called. (A code blue is used when a prisoner is unresponsive or
having breathing difficulties and triggers an automatic request for an ambulance
and for healthcare staff to attend). He unlocked the cell door. Officer B arrived
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within 15 seconds and the officers went into the cell. Officer B cut the ligature from
Mr Nash’s neck. Officer A said that Mr Nash appeared stiff, and he thought that he
had already died. Officer B said that Mr Nash was grey, he was not breathing, he
appeared stiff, and the officer found no signs of life. Other officers who attended
also believed that Mr Nash was dead, and that rigor mortis had set in. Officer B
started cardiopulmonary resuscitation (CPR).
116. A nurse arrived with an emergency response bag at 7.31am, followed soon
afterwards by three of her colleagues, who were also carrying emergency
equipment. Another nurse attached a defibrillator, but it advised no shock. The
nurses said that there were no signs of life and that rigor mortis had set in. They
did not discuss whether to stop CPR. They continued with CPR until the first
paramedic arrived at 7.41am and pronounced at 7.42am that Mr Nash had died.
Contact with Mr Nash’s family
117. At 8.50am, a safer custody manager and family liaison officer telephoned Mr Nash’s
next of kin to break the news of his death. The prison contributed to funeral
expenses in line with national instructions.
Support for prisoners and staff
118. 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.
119. The prison posted notices informing other prisoners of Mr Nash’s death and offered
support. We understand that staff reviewed prisoners assessed as at risk of suicide
or self-harm in case they had been adversely affected by Mr Nash’s death.
After Mr Nash’s death
120. In addition to comments made by prisoners who spoke to Mr Nash or lived on the
same landing as him, other prisoners mentioned after his death that two female
officers working at night, and thought to be the two OSGs, had been talking and
laughing loudly with some prisoners in their cells on Mr Nash’s landing.
Post-mortem report
121. A post-mortem examination found that Mr Nash died from asphyxia due to hanging.
The toxicological tests did not identify any drugs in Mr Nash’s body.
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Findings
Cell conditions
122. PSI 75/2011 on residential services states that prisoners should have access to
furnishings, fittings, clothing, bedding adequate for warmth, decency and health and
safety.
123. Prison Service Order (PSO) 1700 on segregation defines ‘Special Accommodation’
as any cell anywhere in a prison from which furniture, bedding or sanitation have
been removed in the interests of safety. Special Accommodation is the most
austere and extreme form of custody and therefore requires special protective
arrangements. PSO 1700 says that Special Accommodation must only be used to
hold, for the shortest necessary time, a violent or refractory prisoner to prevent that
prisoner injuring others, damaging property or creating a disturbance that hinders
the maintenance of good order. It must not be used as a punishment and “every
effort must be made to keep the time a prisoner is held in Special Accommodation
to a minimum, i.e., minutes rather than hours or days”.
124. The use of Special Accommodation must be authorised by the Duty Governor who
must specify how frequently the prisoner’s continued location in Special
Accommodation must be assessed (at least once an hour) and how frequently the
prisoner must be observed (at least five times an hour). When the use of Special
Accommodation is authorised, healthcare must be informed immediately and must
complete the Initial Segregation Health Screen to determine if there are any clinical
reasons why the prisoner should not be held in Special Accommodation.
125. Prisoners identified as being at risk of suicide or self-harm must not be placed in
Special Accommodation unless they are additionally identified as violent or
refractory. Further precautionary measures must be taken based on their individual
ACCT plan and an enhanced ACCT case review must be held within two hours of
the decision to place the prisoner in Special Accommodation.
126. On 27 March, Mr Nash damaged his cell and was moved to another cell which he
also damaged. Staff considered moving Mr Nash to the segregation unit, but this
was ruled out as the unit was full and Mr Nash was being monitored under ACCT
procedures. Managers agreed that a move to another wing would be best for him,
but the Deputy Governor overruled this and said that Mr Nash should be returned to
his cell once it had been made safe. After Mr Nash set fire to his cell two days later,
the cell was cleared of debris and he was returned to it.
127. Between 27 March and 1 April, Mr Nash was located in a cell with limited facilities
and no access to sanitation and running water. For two nights after he set a fire, he
had no access to a mattress or bedding, and was expected to sleep on the floor of
his fire and water damaged cell. We note that some of the prisoners we interviewed
considered that staff kept Mr Nash in these conditions to punish him for damaging
his cell.
128. Many officers described the conditions of Mr Nash’s cell as unacceptable, with one
officer describing them as inhumane. Despite this, it took until 31 March before the
conditions were brought to the attention of senior managers, and it was only then
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that plans were made to move him to a cell with appropriate facilities.
129. We consider that the conditions that Mr Nash was expected to live in for several
days were degrading, inhumane and unsafe and fell far below the required
standards. We are appalled that Bedford could have considered that Mr Nash’s cell
conditions were appropriate for any prisoner, let alone a prisoner with mental health
issues and subject to ACCT procedures. We consider that his cell was not fit for
human habitation.
130. We are also very concerned that managers did not appear to appreciate that the
cell Mr Nash was held in had become Special Accommodation as defined in PSO
1700 and that, as a result, none of the special safeguards required by the PSO
were applied.
131. Although we consider that the appalling cell conditions were unlikely to have had a
direct impact on Mr Nash’s decision to take his life a month later, it seems very
likely that they would have affected his mental health and contributed to his
paranoia and thoughts that staff were “out to get him”.
132. We note that on 27 March, following his disruptive and destructive behaviour, Mr
Nash was not moved to the segregation unit because there was no room in the
segregation unit and because he was subject to ACCT procedures. Although
prisoners being monitored under ACCT procedures should only be sent to the
segregation unit in exceptional circumstances, we consider that Mr Nash’s actions
on 27 March would have met that criteria and, even if the segregation unit had been
full, staff should have prioritised his move. We do not accept that COVID-19
restrictions would have prevented the consideration and arrangement of such a
move. Instead, Mr Nash was held in significantly more austere conditions than
would have been the case in the segregation unit and with significantly fewer
safeguards.
133. On 1 April, Bedford issued Resident Community Notice (RCN) 30/2020 to prisoners.
It stated that:
“To reduce the risk of contamination and to protect both staff and residents we will
be taking a robust stance on any resident who deliberately damages their cell. That
is, residents will not be relocated from a cell which they have damaged and will
need to live in that cell despite the damage they have caused.”
134. Although the RCN was issued on 1 April, it would appear that the Deputy Governor
implemented its contents on 27 March before it was formally issued.
135. On 2 July, the investigator drew Mr Nash’s cell conditions to the attention of the
Governor. In response, the prison carried out a managerial inquiry into the
management of Mr Nash between 27 March and 1 April 2020. The inquiry report
made several recommendations, including that the then Deputy Governor should be
interviewed to understand the decisions she made about Mr Nash’s location, and
that formal proceedings may be appropriate, or advice and guidance given. The
Governor did not accept this recommendation.
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136. The managerial inquiry also recommended that the RCN 30/2020 should be
rescinded, and a new order issued to staff, stating that no prisoner should be left in
a cell without facilities. The Governor accepted this recommendation and issued
Order 621 on cell decency on 20 August 2020. This rescinded RCN 30/2020 and
instructed staff that a prisoner should not be left in a cell without a bed, bedding,
working toilet or sink in any circumstances and particularly when subject to ACCT
procedures.
137. Given the action already taken by the prison, we make no recommendation about
the RCN. We do, however, make the following recommendation:
The Governor should ensure that all managers understand the definition of
Special Accommodation and the required protective measures set out in PSO
1700.
138. We asked Bedford who drafted the Community Notice and ordered its issue.
Bedford did not provide the requested information. However, we identified that
HMP Leeds had issued an identical instruction. This suggested that the instruction
may be a national one and we, therefore, raised our concerns with the Director
General of Prisons. He confirmed that the instruction had not been issued
nationally but had been drawn up by senior managers at Bedford and Leeds. He
also said that the Governors of both prisons had been told that the instructions were
not acceptable.
139. We are very concerned that our attempts to establish the origin of the instruction
with senior staff at Bedford were fruitless. It is extremely important that prisons
cooperate fully with our investigations. We recommend:
The Prison Group Director for Bedford, Cambridgeshire and Norfolk should
ensure that prisons fully cooperate with PPO requests for information and
understand that the PPO should have unfettered access to any information
relevant to their investigations.
Identifying and managing risk of suicide and self-harm
140. Prison Service Instruction (PSI) 64/2011 on safer custody requires staff to start
ACCT procedures when they receive information about a prisoner which may
indicate that he is at risk of suicide or self-harm. HMPPS’s Exceptional Regime and
Service Delivery Operational Guidance to prisons during the COVID-19 pandemic
said that every effort must be made to ensure resources are available to support
prisoners at risk of suicide and self-harm. It stated that for many, the risk of self-
harm could increase due to prolonged periods in cells and that, despite any staff
shortages, ACCT was a more important tool during periods of increased cellular
confinement.
141. Prison staff appropriately monitored Mr Nash under ACCT procedures on 19 March
after he made a cut to his face and appeared to be withdrawn.
142. However, we are very concerned that the ACCT procedures were very poorly
managed and did little to support Mr Nash, particularly during a period of acute
crisis when he was living in a cell with no bed, sanitation or other amenities. We
are extremely concerned that senior managers decided that Mr Nash should remain
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in such conditions while being monitored under ACCT procedures and that they
failed to consider his vulnerabilities and address his risks during this time.
Assessment Interview
143. PSI 64/2011 states that the assessment interview should take place within 24 hours
after ACCT procedures have started and if the prisoner is unable, or refuses to
participate, the assessment should proceed based on available information.
144. Mr Nash’s assessment interview was not attempted until 22 March, three days after
the ACCT procedures started. Although Mr Nash refused to engage with the
process, the assessment should have been completed in his absence. The
assessment was not completed until 25 March, six days after the ACCT had been
opened. We find this unacceptable.
Scheduling and completion of ACCT reviews
145. PSI 64/2011 states that the first ACCT review should take place within 24 hours
after ACCT procedures have started. Mr Nash’s review did not take place until 22
March, two days after ACCT monitoring began and before the assessment interview
had been completed. A further review was scheduled for 25 March. Given the
assessment interview had not taken place on 22 March, a review should have been
scheduled for the following day and the case manager should have ensured that the
assessment was completed immediately.
146. The review scheduled for 25 March did not take place despite Mr Nash telling an
officer that morning that he had a razor blade in his mouth and would go mad if he
did not move cells. That evening, a SO noted that due to the timing and “situation”,
he was unable to carry out a review and a full review would take place the following
day.
147. On 26 March, it was noted that Mr Nash was paranoid, withdrawn and had not
eaten and that concern about his welfare was high. A SO tried to carry out a review
but noted that Mr Nash was not interested. The review was not completed, and one
was not scheduled for the following day.
148. At an ACCT review on 27 March, a further review was scheduled for the following
day. A further review did not take place until 30 March, despite Mr Nash setting fire
to his cell on 29 March. At the review on 30 March, a further review was scheduled
for the following day. This review did not take place during the day, although a
review was held late that evening in response to a CM’s concerns about the
condition of Mr Nash’s cell.
149. ACCT reviews are an essential element of the ACCT process and they should
always take place as scheduled, after acts of self-harm or when increased levels of
risk are identified, so that a prisoner’s level of risk can be considered, and
appropriate support offered, even if a prisoner refuses to participate. We are
particularly concerned that reviews were not completed appropriately when Mr
Nash was living in unacceptable cell conditions, during which time he would have
been subject to excessive levels of stress and discomfort.
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150. There has been one further death at Bedford since Mr Nash’s. In our investigation
of that death, we identified that the case manager appointed at the first case review
did not lead many of the subsequent case reviews. The case manager appointed
for Mr Nash led none of his nine reviews.
Multidisciplinary attendance at ACCT reviews
151. PSI 64/2011 requires ACCT case reviews to be multidisciplinary, where possible,
and for the ACCT assessor and a member of the healthcare team to attend at least
the first case review.
152. There were no healthcare staff at Mr Nash’s first case review and a SO held the
review with the assessor, who had not been able to complete the assessment at
that point. There is not record that there was any attempt to contact healthcare or
to seek their input.
153. The following two reviews were also not multidisciplinary. Although a healthcare
report was sought for the second review, no member of the mental health team
attended the ACCT reviews until 31 March, after Mr Nash’s unacceptable living
conditions were brought to the attention of senior managers. We also note that
there is no record that case managers tried to invite Mr Nash’s keyworker or
someone from OMU in response to the caremap action. This meant that the staff
who attended the reviews were unlikely to have fully appreciated his risk and would
only partially have been equipped to understand his difficulties and needs.
154. PSI 64/2011 says that in addition to planned ACCT case reviews, a case review
must be held where an ACCT trigger is activated or there are other concerns. We
are concerned when Mr Nash was held in unacceptable cell conditions, told staff he
had a razor blade in his mouth, or after he had set fire to his cell, staff did not hold
an ad hoc case review to re-assess his risk. We are concerned that they therefore
missed opportunities to identify if his risk was increasing, and to consider protective
measures, such as increasing the frequency of his observations, moving him to
another cell and arranging for an urgent mental health review.
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Caremap
155. PSI 64/2011 says that case managers must complete caremaps with actions aimed
at reducing the risk of suicide and self-harm and that reflect the prisoner’s needs.
156. At the first ACCT review on 22 March, the SO added an action to Mr Nash’s
caremap and noted that OMU were to be invited to the next ACCT review. OMU
did not attend the review on 25 March or any of the following reviews. Although
there is no record that Mr Nash’s concerns about wanting a transfer to another
prison and referral to a PIPE unit were addressed at subsequent reviews, the action
was noted as complete on 6 April.
157. We are also concerned that it was not until the second ACCT review on 27 March,
after Mr Nash had damaged his cell and eight days after ACCT monitoring began,
that a mental health referral was made. This is of particular concern as there was
no healthcare representation input at the first review on 22 March, even though it
was known that Mr Nash had had previous contact with the mental health team.
158. We are also concerned that even when Mr Nash’s unacceptable cell conditions
were drawn to the attention of senior management, no plan or actions for Mr Nash
to move from these conditions were noted in the caremap following ACCT reviews
on two occasions.
Post-closure review
159. PSI 64/2011 states that a post-closure review must take place within seven days of
ACCT procedures ending. Mr Nash stopped being monitored under ACCT
procedures on 14 April, but his post-closure review did not take place as scheduled
on 21 April. Although we accept that there do not appear to have been any
indications that Mr Nash was at an increased risk of suicide in the period after the
ACCT was closed, it is still essential that staff review prisoners after an ACCT to
consider how or whether they have progressed.
160. In their inspection of Bedford in 2018, HMIP identified significant weaknesses in the
management of ACCT processes at Bedford. In their Independent Review of
Progress in August 2019, they found that work to address these weaknesses had
been far too slow. We were, therefore, very concerned to find significant
deficiencies continued to exist at the time of Mr Nash’s death in April 2020. We
make the following recommendation:
The Governor should ensure that prison staff manage prisoners identified as
at risk of suicide or self-harm in line with PSI 64/2011, including that:
• the ACCT assessment interview and first ACCT case review are
completed within 24 hours of the start of ACCT procedures;
• first ACCT case reviews are multidisciplinary and always include a
member of healthcare staff and staff who have had previous contact
with the individual, such as key workers or the ACCT assessor;
• staff read the ACCT document and familiarise themselves with all
relevant issues and known risk factors before holding reviews;
• a case manager is appointed at the first case review, who should lead
all subsequent case reviews whenever possible;
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• a multi-disciplinary review is held when there is evidence of a
significant change in risk; and
• case managers should ensure that caremaps are completed at the first
ACCT case review, set specific and meaningful caremap actions,
tailored to the individual to reduce their risk and identify who is
responsible for them and review progress at each review.
Allegations made by prisoners after Mr Nash’s death
161. After Mr Nash’s death, prisoners who knew him made allegations about the actions
of staff the night before his death. Two prisoners alleged that Mr Nash had rung his
cell bell a couple of times on the evening of 29 April, asking for his medication and
shouting out that he could not cope and would take his own life if he was not given
vapes. The prisoners alleged that staff had responded by telling Mr Nash that he
should “do what he had to do”. One of the prisoners alleged that staff stood outside
Mr Nash’s cell laughing and said Mr Nash would not kill himself and was just
seeking attention. Allegations were also made that staff did not answer Mr Nash’s
cell bells.
162. Prisoners also alleged that night staff were talking to and laughing loudly with some
prisoners overnight.
163. We have considered whether there is evidence to support these allegations. Some
appear to be without foundation – for example, Mr Nash was not prescribed any
medication and the cell bell records show he did not press his cell bell after 4.25pm
- but we consider that the very serious allegations that staff taunted Mr Nash and
told him to go ahead and kill himself need to be investigated,
• The investigator was unable to speak to both OSGs about the allegations, as they
resigned on 2 and 24 June respectively. However, there were also prison officers
on the wing at various times. CCTV footage shows that staff were near Mr Nash’s
cell on the evening of 29 April at times. We make the following recommendation:
The Governor should initiate an investigation into the allegations made by
prisoners about the behaviour of prison officers who were on the wing on the
evening and night of 29 April 2020 with a view to considering whether
disciplinary action is appropriate.
Impact of COVID-19 restrictions
164. The restrictions imposed in response to the COVID-19 pandemic meant that
prisoners were spending long periods locked in their cells, with significantly less
interaction with staff and other prisoners than would normally have been the case.
165. On 20 March, the keyworker scheme at Bedford was suspended and Mr Nash had
no further contact with his keyworker. We cannot say if the long periods of isolation
affected Mr Nash’s decision to take his life. If staff had had regular daily contact
with him and had seen him interacting with other prisoners – as they would have
done in normal times – they might have identified signs of distress, a deterioration
in his mental health or an increase in his risk of suicide and self-harm. The
restricted regime meant that Mr Nash had not had the opportunity to interact with
staff and this may have limited his willingness to tell them about any concerns.
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166. A few weeks after Mr Nash’s death, the Exceptional Delivery Model for key work
was introduced nationally and aimed to ensure that a form of key work continued for
those subject to ACCT monitoring. We have not, therefore, made a
recommendation about this.
Roll checks
167. A roll check is primarily a security check to count prisoners and ensure that they are
in their cells, but it is also an opportunity for any concerns about prisoners’ safety to
be identified. The CCTV footage shows that OSG A did not check on Mr Nash
during the early morning roll check at about 5.30am on 30 April. This was both a
breach of security and a missed opportunity to check on Mr Nash’s wellbeing.
168. OSG A was suspended on 1 May, while an internal investigation into the conduct of
the roll check took place. She admitted she did not check Mr Nash. The
investigation concluded that she had failed to conduct an adequate roll check of
other prisoners and that she should face formal disciplinary proceedings. She
resigned from HMPPS on 24 June.
169. Although we cannot be sure when Mr Nash died, we know that rigor mortis was
present when he was found at 7.29am, meaning that he is likely to have been dead
for some hours. It is therefore likely that he was already dead at the time of the
5.30am roll check and that OSG A’s failure to perform her duty did not affect the
outcome for him. Nevertheless, staff should always check a prisoner’s welfare
when carrying out roll checks as early intervention in emergencies where prisoners
are found unconscious or in a critical situation might save lives. We recommend:
The Governor should ensure that staff understand the importance of
conducting roll checks as required.
Damaged observation panels
170. During the investigation, the Prison Officers’ Association (POA) contacted the
investigator to raise their concerns about broken observation panels on cell doors at
Bedford that were not being replaced. The POA said that broken observation
panels risked the safety of staff when carrying out roll checks. They told us that on
7 June, there were 19 cells with broken observation panels on A Wing, which had
risen to 22 panels on 22 July. Over a month later, the cell which Mr Nash had
occupied still had a broken observation panel.
171. We understand that staff may feel reluctant to carry out roll checks on cells without
observation panels where the panel has been covered by the prisoner, as in Mr
Nash’s case. We consider that the number of broken observation panels on A Wing
is a serious concern and puts the safety of staff and prisoners at risk.
Bedford Staff Community Notice 19/2020 issued on 29 January 2020, provides
advice to staff on the action to take when they discover a broken observation panel.
It states that staff should always be able to observe prisoners in their cells in case
they are unwell or there is an emergency situation, and they should report any
damaged panels so that they can be “fixed quickly”. The notice tells staff that they
should ask the occupant of the cell to remove any obstruction and that, if the
prisoner does not comply, they can enter the cell if it is safe to do so to remove the
obstruction. The notice does not tell staff how to check safely on prisoners in cells
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with damaged observation panels. We make the following recommendation:
The Governor should ensure that:
• Bedford Staff Community Notice 19/2020 is updated to provide
guidance to staff about measures to take when checking on prisoners
with damaged, broken or blocked observation panels; and
• broken observation panels are replaced as soon as possible.
Resuscitation
172. Resuscitation Council Guidelines say, “Resuscitation is inappropriate and should
not be provided when there is clear evidence that it will be futile”. The guidelines
define examples of futility as including the presence of rigor mortis. The British
Medical Association (BMA), the Royal College of Nursing (RCN) and the
Resuscitation Council (UK) issued guidance in October 2014 on making appropriate
decisions about resuscitation. The guidance says that every decision should be
made based on a careful assessment of an individual’s situation. These decisions
should never be dictated by ‘blanket’ policies. Trying to resuscitate someone who is
clearly dead is distressing for staff and undignified for the deceased.
173. Officer A and other officers who found Mr Nash hanging observed no signs of life
and believed that Mr Nash was dead. They described the presence of rigor mortis
but instinctively started CPR. Nurses also identified rigor mortis but continued CPR
efforts.
174. Although we understand that officers instinctively made attempts to resuscitate Mr
Nash, we agree with the clinical reviewer that healthcare staff should have
discussed the merits of continuing CPR as Mr Nash was clearly dead, there were
no signs of life and rigor mortis was present, which indicated that resuscitation was
futile. Paramedics told staff to cease CPR on their arrival. We make the following
recommendation:
The Governor and Head of Healthcare should ensure that staff are aware of
the circumstances in which resuscitation is inappropriate.
Clinical care
175. The clinical reviewer concluded that the care that Mr Nash received was of a
reasonable standard and was at least equivalent to that which would have been
received in the community. The clinical reviewer had no concerns about the
physical healthcare that Mr Nash received and noted that when Mr Nash was
identified with COVID-19 symptoms and was isolated, he was treated in line with
COVID-19 guidance. However, he identified some deficiencies in Mr Nash’s care
which we address below.
Mental health care
176. The clinical reviewer was concerned that although Mr Nash was identified in
reception on 17 January as a priority for a mental health assessment, the mental
health team did not see him until 5 February. The target for an urgent referral is five
days but Mr Nash waited for 19 days. We make the following recommendation:
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The Head of Healthcare should ensure that prisoners who are referred to the
mental health team urgently are assessed within five days, in line with the
local policy.
177. The clinical reviewer noted that although the mental health team recommended that
Mr Nash would be suitable for a transfer to a PIPE unit and the OMU was asked to
process the referral, there was no evidence of any communication between the
OMU and the mental health team to achieve a transfer and no evidence that a
referral was made. We make the following recommendation:
The Governor and Head of Healthcare should ensure that there is a
communication plan in place between OMU and the mental health team so
that referrals to the PIPE programme are progressed and prisoners are
updated about the status of their referral.
178. The clinical reviewer also made recommendations about dyslexia awareness
training for healthcare staff and the need to explain to prisoners why they have
been discharged from the mental health team’s caseload. The Head of Healthcare
and the Mental Health Lead will need to take these recommendations forward.
Learning Lessons
179. We have identified a significant number of concerns in this report. We consider that
it is important for staff to learn from the Ombudsman’s investigations and our
findings. We recommend that:
The Governor and Head of Healthcare should ensure that a copy of this report
is shared with all staff named in this report and that a senior manager
discusses the Ombudsman’s findings with them.
Inquest Verdict
180. The inquest hearing into the death of Mr Nash was held on 1 August 2024. It
confirmed that the medical cause of Mr Nash’s death was asphyxia from hanging.
The inquest concluded that this followed a period of mental stress, including the
isolation of the COVID regime and detainment in inhumane conditions for upwards
of 72 hours and that these events exacerbated Mr Nash’s pre-existing mental health
diagnosis.
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