Sean Davies

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Sean Davies,
a prisoner at HMP Swaleside,
on 25 February 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 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 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 Sean Davies was found hanged in his cell on 25 February 2023 at HMP Swaleside. He
was 30 years old. I offer my condolences to Mr Davies’ family and friends.
Mr Davies was the ninth prisoner to die by suicide at Swaleside in three years. Up to the
end of 2023, there had been no self-inflicted deaths since Mr Davies’ death.
Mr Davies was serving an indeterminate sentence for public protection (IPP) and had been
in prison since 2011. Until his arrival at Swaleside in 2021, his behaviour had been poor,
and he had made little progress through his sentence.
My investigation found that Mr Davies was generally well supported at Swaleside, and he
developed good relationships with key staff who were trying to help him move towards
release. However, Mr Davies’ death is a stark reminder of the difficulties for prisoners
serving IPP sentences, who feel bleak about their prospects of release. My office recently
published a Learning Lessons Bulletin highlighting the increased risk of suicide among
men serving IPP sentences.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman April 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 14
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Summary
Events
1. Mr Sean Davies had been in prison since 15 November 2011. In November 2012,
he was convicted of wounding with intent and sentenced to an indeterminate
sentence for public protection (IPP), with a minimum term of seven years (later
reduced to five years and 12 days on appeal). Mr Davies became eligible for parole
on 15 November 2017.
2. Mr Davies had a history of attempted suicide and self-harm in prison and the
community. He was also diagnosed with antisocial personality disorder (which is
characterised by impulsive, irresponsible and often criminal behaviour).
3. Prior to his arrival at HMP Swaleside in February 2021, Mr Davies’ behaviour had
been poor. There were reported incidents of assaults on prisoners and staff, and
evidence of illicit drug use.
4. On 3 February, Mr Davies transferred to Swaleside to join the Psychologically
Informed Planned Environment (PIPE) unit. (PIPE units aim to improve the
psychological health of participants, improve relationships and relationship skills
and reduce reoffending.) Mr Davies settled in well at Swaleside, engaged fully with
the clinicians on the PIPE unit and was focused on progressing towards his next
parole hearing.
5. On 9 February 2022, during a routine cell search, an adapted vape capsule was
found in Mr Davies’ cell, which tested positive for a psychoactive substance (Spice).
Mr Davies denied it belonged to him, but staff placed him on report, and he was
reduced to the basic level of the incentives and earned privileges (IEP) scheme
(meaning certain privileges were removed). Mr Davies was angry and felt that his
chance of securing release had been ruined. He was monitored under Prison
Service suicide and self-harm prevention procedures (known as ACCT) for a period.
6. On 11 April, Mr Davies was assessed as suitable for a category C prison (lower
security and indicating a progression towards release). However, on 24 August,
during a routine cell search, staff found unprescribed medication in Mr Davies’ cell.
He was placed on report and subsequently awarded seven days loss of privileges,
suspended for three months. He was re-assessed and found unsuitable for a
category C prison in October.
7. At 8.50am on 25 February 2023, a prisoner went to Mr Davies’ cell, looked through
the observation panel of the cell door and saw Mr Davies hanging by a ligature
around his neck. The prisoner alerted staff who started cardiopulmonary
resuscitation (CPR). Nurses attended and concluded that Mr Davies was dead and
that resuscitation attempts should stop. Paramedics arrived shortly afterwards and
confirmed that Mr Davies had died.
Findings
8. There were no apparent changes in Mr Davies’ behaviour in the time before his
death that indicated he was at any increased risk of self-harm.
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9. When an officer completed the routine roll check on 25 February, they made no
attempt to speak to Mr Davies and continued with the roll count, and an officer who
was tasked with unlocking prisoner’s cells did not check on the welfare of each
prisoner before unlocking the doors as they should have done, which is not in line
with national policy.
10. There were several missed opportunities to refer Mr Davies for substance misuse
support.
Recommendations
• The Governor, Head of Healthcare and Service Manager for Change, Grow,
Live should work together to ensure that referral processes to the service are
clear and established and that all staff understand when and how to refer a
prisoner to the service.
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The Investigation Process
11. HMPPS notified us of Mr Davies’ death on 25 February 2023.
12. The investigator issued notices to staff and prisoners at HMP Swaleside informing
them of the investigation and asking anyone with relevant information to contact
him. Three prisoners contacted him, all of whom shared their concerns about
welfare checks.
13. The investigator obtained copies of relevant extracts from Mr Davies’ prison and
medical records.
14. The investigator interviewed seven members of staff at Swaleside on 11 and 12
May.
15. NHS England commissioned a clinical reviewer to review Mr Davies’ clinical care at
the prison.
16. We informed HM Coroner for Kent and Medway of the investigation. The coroner
gave us the results of the post-mortem examination. We have sent the coroner a
copy of this report.
17. The Ombudsman’s family liaison officer contacted Mr Davies’ family to explain the
investigation and to ask if they had any matters, they wanted us to consider. They
said:
• They thought that Mr Davies had self-harmed in September/October 2022
and had attended hospital as a result and asked why he had not been kept
on suicide and self-harm monitoring following this? (We found no evidence
that Mr Davies had self-harmed at this time or that he was hospitalised.)
• Mr Davies was an IPP prisoner and had little luck at receiving positive
responses regarding his release from custody. What impact did being an IPP
prisoner have on Mr Davies?
• Mr Davies had been asking his family to send him large amounts of money,
which he said was to buy vapes. They were concerned that he might have
been in debt to other prisoners or was being bullied by other prisoners.
We have addressed these concerns in this report.
18. Mr Davies’ family received a copy of initial report, but no response to our findings
had been received.
19. HMPPS responded to the initial report, no factual inaccuracies were identified, and
all recommendations were accepted.
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Background Information
HMP Swaleside
20. HMP Swaleside, on the Isle of Sheppey, is part of the Long-Term and High Security
Estate. It holds up to 1,090 men serving sentences of four years or more. Integrated
Care 24 Ltd provides primary healthcare. There is 24-hour nursing cover and a 17-
bed inpatient unit. GPs work at the prison Monday to Friday, and Medway on Call
Care provides an out of hours GP service. Oxleas NHS Foundation Trust provides
mental health services. Forward Trust provides substance misuse treatment.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Swaleside was in October 2021. Inspectors
reported that incidents of self-harm had almost doubled since the last inspection.
The quality of support delivered through ACCT case management for prisoners at
risk of suicide and self-harm was variable, with some inconsistent case
management and care plans that lacked meaningful or completed actions. They
found that only just under half of prisoners with experience of being on an ACCT
said that they had felt cared for by staff.
22. Inspectors noted that in their survey, more respondents than at the time of the last
inspection said that they had a named officer or key worker, with around half saying
that this officer was helpful or very helpful. However, the key worker scheme had
almost stalled as a result of more of the already stretched prison officer resource
being required to manage prisoners during the increased time out of their cells. With
the notable exception of the specialist wings, such as the psychologically informed
planned environment (PIPE) unit and the drug support wing, few case notes
evidenced any meaningful contact and support from key workers.
23. HMIP carried out an Independent Review of Progress (IRP) in July 2022. Inspectors
found that the shortage of officers was worse than at the previous inspection
leading to very limited time out of cell. The rate of self-harm had declined
considerably but there had been five self-inflicted deaths, four since the last
inspection and a fifth death two months after the IRP visit.
Independent Monitoring Board
24. 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 30 April 2023, the IMB noted that
continued staff shortages had resulted in a lack of meaningful activity for prisoners
on all but two wings. The IMB said that this was clearly having an impact on the
mental health and general well-being of the prisoners and the incidence of self-
harm, serious incidents and attacks on both prisoners and staff were likely to have
been exacerbated by the restrictions. The IMB also noted that self-inflicted deaths
were at very worrying levels. Staff were frustrated by their inability to implement
anything approaching a full regime. However, the Board also said that the senior
leadership team recognised the problems and had taken positive action, with the
support of regional and national safety teams, to improve the situation.
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Previous deaths at HMP Swaleside
25. Mr Davies was the twenty-third prisoner to die at Swaleside since September 2020.
Of the previous deaths, eight were self-inflicted (five of which were during 2022) two
were drug-related and twelve were from natural causes. Up to the end of 2023,
there had been no self-inflicted deaths at Swaleside since Mr Davies’ death.
26. As a result of the number of self-inflicted deaths during 2022, Swaleside was
receiving additional support from HMPPS headquarters.
27. In an investigation into the death of a prisoner at Swaleside in June 2022, we made
a recommendation about staff completing routine checks appropriately. The prison
responded to our recommendation and said that routine checks were reported to
the orderly officer as per the local security strategy which would be assured through
ad-hoc checks carried out by supervising officers and covert testing by the security
department. The prison also said that multiple safety briefings had been delivered,
the latest in December 2022, to highlight the importance of carrying out routine
checks and to re-iterate the actions required when staff find an observation panel
covered.
Assessment, Care in Custody and Teamwork
28. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide and self-harm. The purpose of ACCT is to try to determine the level of
risk, how to reduce the risk and how best to monitor and supervise the prisoner.
After an initial assessment of the prisoner’s main concerns, levels of supervision
and interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
Indeterminant sentence for Public Protection (IPP)
29. Indeterminant sentence for Public Protection (IPP) sentences, began in 2005 and
were abolished in 2012 under the Legal Aid, Sentencing and Punishment of
Offenders Act. They were introduced to protect the public against offenders whose
crimes were not serious enough to merit a normal life sentence, but who could only
be released once they had served their minimum tariff and had demonstrated to the
satisfaction of the independent Parole Board that they had sufficiently reduced their
risk. There are currently about 3000 IPP prisoners, of which half have never been
released.
30. Since June 2022, all Parole Board recommendations for the transfer to open
conditions and release of IPP prisoners must be approved by the Secretary of State
for Justice.
31. In September 2023, we published our Learning Lessons Bulletin (LLB) on Self
Inflicted Deaths of IPP Prisoners. The LLB was prompted by the increase in deaths
amongst those serving IPP Sentences in 2022. The LLB noted that an IPP
sentence should be considered as a potential risk factor for suicide and self-harm
because of the uncertain nature of the sentence, which can lead to feelings of
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hopelessness and frustration. Our investigations indicated that parole hearings,
transfers, changes in security categorisation and upcoming release could all act as
risk triggers, increasing the risk of suicide among this group of prisoners.
Incentives and Earned Privileges (IEP) Scheme
32. Each prison has an Incentives and Earned Privileges scheme which aims to
encourage and reward responsible behaviour, encourage sentenced prisoners to
engage in activities designed to reduce the risk of re-offending and to help create a
disciplined and safer environment for prisoners and staff. Under the scheme,
prisoners can earn additional privileges such as extra visits, more time out of cell,
the ability to earn more money in prison jobs and to wear their own clothes. There
are three levels: basic, standard and enhanced.
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Key Events
33. On 15 November 2011, Mr Sean Davies was remanded to prison charged with
Section 18 wounding with intent. He was sentenced on 2 November 2012 to an
indeterminate sentence for public protection (IPP) with a minimum term of seven
years. This was later reduced to five years and 12 days on appeal. Mr Davies’
minimum term expired on 15 November 2017, when he became eligible for parole.
34. Mr Davies had a history of attempted suicide and self-harm in the community, and
substance misuse. He was also diagnosed with antisocial personality disorder.
35. Mr Davies transferred to several different prisons before moving to Swaleside on 3
February 2021. Mr Davies had been subject to suicide and self-harm prevention
measures known as ACCT on two occasions; in July 2019 after he had refused
food and August 2020, after he had made cuts to his forearm with a razor blade.
HMP Swaleside
36. Mr Davies transferred to Swaleside to join the Psychologically Informed Planned
Environment (PIPE) unit. The units have dedicated staff made up of prison staff and
psychologists (clinicians).
37. Mr Davies was initially located on the induction wing but moved to the PIPE unit on
F wing after a few days. Mr Davies had regular contact with his PIPE clinician, a
specialist forensic psychologist, and his keyworker. Although the keyworker made
regular visits to see Mr Davies, Mr Davies chose to say little about how he was
getting on and told him that if he had any issues then he would contact him. Mr
Davies engaged well with the clinicians and responded positively to the PIPE
regime. The expectation was that Mr Davies would remain on the unit for around
two years. As well as engaging in group work, Mr Davies was employed in the
prison laundry, farm and gardens.
38. In October 2021, prior to his parole hearing, Mr Davies started schema therapy (a
form of cognitive behavioural therapy that focuses on the individual’s past
behaviours and experiences to help them understand their current patterns of
behaviour). He was keen gain his category D status and transfer to an open prison
(with minimal security where prisoners can spend most of their day away from the
prison on license to carry out work, education or for other resettlement purposes).
He also volunteered as a ‘buddy’ (a designated prisoner who supports prisoners
with additional needs) for another prisoner with chronic health issues who was
located in the cell next to him.
39. In October, Mr Davies asked to defer his parole hearing by 12 months so that he
could complete his schema therapy.
40. On 9 February 2022, staff completed a routine search of Mr Davies’ cell and found
an adapted vape capsule. The capsule tested positive for a psychoactive substance
(Spice). Staff placed Mr Davies on report. At the time of the search, another
prisoner was in Mr Davies’ cell, visiting. Mr Davies denied that the capsule
belonged to him. Mr Davies was not referred to the Change, Grow, Live (CGL)
substance misuse service as he should have been.
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41. At his disciplinary hearing, Mr Davies pleaded not guilty to being in possession of
the adapted vape capsule, and as it was not possible to prove who it belonged to,
the charge against Mr Davies was dismissed, but he was downgraded to the basic
level of the Incentives and Earned Privileges (IEP) scheme for seven days and was
removed from his role as a buddy. He was reinstated to the standard level of IEP on
15 February.
42. On 16 February during a PIPE group session, Mr Davies spoke about being
downgraded to the basic regime and felt it had been unjust. Mr Davies was angry
and felt that his chances of being released on parole had been ruined. Mr Davies
said that he would get out of prison ‘one way or another’ and that staff were
sabotaging his progress on purpose.
43. A PIPE clinician asked Mr Davies what he meant by his comments. Mr Davies said
that if staff continued to ‘play games’ and jeopardise his release, then he would stab
himself in the jugular and get taken out of prison in a body bag. Mr Davies said that
while he did not feel like he was suicidal, he would do if officers did things which he
perceived as ‘playing games’. She made an entry in the wing observation book
detailing her conversation with Mr Davies, submitted an intelligence report and
started ACCT procedures.
44. A Custodial Manager (CM) chaired a multidisciplinary ACCT case review later that
afternoon. PIPE staff and Mr Davies attended. Mr Davies told the review that his
comments had been said in the heat of the moment and that he had no intention of
harming himself. Mr Davies talked about working towards his parole and said that
he was feeling positive. The review discussed Mr Davies’ previous history of self-
harm, and he said that although he had harmed himself in the past, it was a long
time ago and he had no current thoughts or intent to harm himself. The meeting
agreed to stop ACCT procedures.
45. On 22 February, an officer completed a post closure ACCT review. Mr Davies said
that he did not know why the document had been opened in the first place,
however, he understood the process. He wanted to focus on his schema therapy
group and his parole hearing, which was not too far away. Mr Davies said that he
had a good working relationship with his keyworker, and should he feel the need to
talk, he knew that his keyworker was approachable.
46. Mr Davies continued engaging with PIPE group work between March and 24
August. He attended his schema therapy sessions and had contact with PIPE
clinicians and his keyworker regularly.
47. On 11 April, Mr Davies was re-categorised from category B to category C status,
meaning he was eligible to move to a lower category prison. A move was not
sought for or requested by Mr Davies as he was still engaged with PIPE group
work.
48. On 24 August, during a routine search of Mr Davies’ cell, staff found medication
which did not belong to him. Staff placed him on report. Mr Davies was
subsequently found guilty and given a suspended punishment of seven days loss of
privileges. Mr Davies was not referred to CGL substance misuse service as he
should have been.
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49. On 1 November, a manager attended F wing for a pre-arranged telephone
conference call, between Mr Davies, the psychologist, the PIPE clinician, and
community offender manager (COM). Before the call started, the manager told Mr
Davies that he had been re-assessed as unsuitable for category C conditions and
that he would remain a category B prisoner. She explained that the decision had
been taken based on the most recent proven adjudication for having unprescribed
medication and the vape capsule being found in his cell. The next review was
scheduled for April 2023. Mr Davies did not take this news well and decided not to
stay for the telephone conference.
50. After the conference call, the psychologist spoke to Mr Davies and recorded that he
was understandably frustrated and upset about decision and was concerned about
the implications for his parole hearing and progression. Mr Davies appealed against
the decision, and on 23 November, a Supervising Officer (SO) responded to the
appeal. The SO told Mr Davies that although his adjudication for the vape capsule
had been dismissed, the item had tested positive for illicit drugs and was found in
his cell. The SO encouraged Mr Davies to see that his previous involvement in drug
taking and the drug culture was a risk factor and needed to be acted upon.
However, she also noted that the manager had commended him for the good work
he was doing and that if full compliance with prison rules was maintained then
progression to category C status would be considered in April 2023.
51. Mr Davies continued to engage with PIPE and schema therapy and although he told
the clinicians that he was initially frustrated and anxious about being downgraded to
category B, he was focused on his parole hearing and regaining his category C
status. However, during further contacts with his clinicians and his keyworker, it was
recorded that Mr Davies was sometimes negative about his chances of being
granted parole, and he believed that he stood little chance, due to his past
behaviour.
52. Between 1 April 2021 and 26 December 2022, Mr Davies was named in 15 security
intelligence reports. The information included having non-prescribed medication, the
vape capsule being found in his cell and being suspected of involvement in drug
activity.
53. On 26 December, Mr Davies had injuries to his face. He told staff that he had fallen
over, that he had not been assaulted and that no one else was involved. Staff
investigated and reviewed the CCTV footage, but they found no evidence that Mr
Davies had been assaulted and submitted an intelligence report to that effect.
Although there was no evidence that Mr Davies was at increased risk of violence,
staff referred him for a Challenge and Support Intervention Plan (CSIP– a process
used to manage difficult prisoners and victims of violence or threat). The referral
was assessed and rejected on the basis that Mr Davies’ risk of violence score was
low and indicated no risk, therefore the CSIP was not deemed suitable or
reasonable.
12 January to 10 February 2023
54. On 12 January 2023, a psychologist saw Mr Davies to prepare a report for his
parole hearing, which had yet to be scheduled. Mr Davies told her that he did not
feel in the right frame of mind to be taking part in an interview as he had a lot
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playing on his mind and he was in a ‘defeatist mindset’. Mr Davies said that he felt
this was as a consequence of having his category C status taken away and his
recent adjudications. Mr Davies said that this had left him feeling hopeless about his
parole review and therefore he did not feel able to participate in the interview. She
advised Mr Davies to speak with the PIPE clinicians about how he was feeling and
to let her know once he felt able to take part in the assessment.
55. On 30 January, a psychologist spoke to Mr Davies about the parole assessment
again and he told her that he would feel more comfortable if it could be completed
on the wing. It was agreed that the assessment would take place using Microsoft
Teams on 7 and 21 February. She saw Mr Davies again the following day for an
individual session. Mr Davies told her that he felt as though he was being treated
differently to other prisoners and was worried that things from his past might be
negatively interpreted by the Parole Board. She recorded that Mr Davies ‘had such
an overwhelming sense of hopelessness and did not feel he had a chance with his
parole but was willing to go through it’. She told the investigator that when she
wrote the comment, she had no concerns about Mr Davies’ well-being or risk to
himself, and that the feelings of hopelessness were in respect of his chances of
achieving a favourable outcome at his parole hearing.
56. On 7 February, the psychologist sat in on an independent psychological
assessment with Mr Davies as part of the parole hearing process. She recorded
that Mr Davies did really well and was positive throughout the assessment. They
discussed different Approved Premises that provided PIPE and Intensive
Intervention and Risk Management services (IIRMS – designed for individuals with
high risk and high harm violent offending histories) on release. She agreed with Mr
Davies to revisit this again when the assessment process was out the way.
57. That day, staff searched Mr Davies’ cell after an intelligence report indicated he
might have been bullying another prisoner. The psychologist spoke to Mr Davies
later that afternoon and asked him what had happened. She recorded that she
reassured Mr Davies that if he had nothing to hide then nothing would come of it.
Nothing was found to support the allegations and there were no further references
or information about Mr Davies bullying other prisoners.
58. In 2022, the Justice Select Committee, appointed by the House of Commons began
a review into IPP sentences. The Committee made a number of recommendations
to the Ministry of Justice and HMPPS about how these sentences should be
managed in order to reduce the number of IPP prisoners in prison. The
Committee’s findings were published in September 2022.
59. On 10 February, the psychologist spoke to Mr Davies about the findings of the IPP
review and how it might affect him. Mr Davies told her that he did not want to speak
to anyone from the Offender Management Unit (OMU) and talked about his
frustrations in relation to his category C status. She tried to discuss the recent IPP
review, but Mr Davies did not wish to speak about it and told her that he was ‘fine’.
She reassured Mr Davies that if he changed his mind, OMU staff and the clinicians
were available to support him. (OMU staff spoke to all IPP prisoners at Swaleside
following the Justice Select Committee review.)
60. The psychologist said that on 23 February, a wing officer told her that Mr Davies
and several other prisoners had been suspected of being under the influence of an
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illicit substance the previous day. She spoke to Mr Davies and asked him about
this. Mr Davies said that he used illicit substances to manage his feelings about his
parole. She agreed with Mr Davies that they would discuss the issues further at
their therapy session booked for the following week. Mr Davies was not referred to
CGL substance misuse service as he should have been.
Events of 25 February
61. At 2.00am on 25 February, CCTV shows what appears to be a piece of fabric being
posted through the top of Mr Davies’ cell door and threaded across the top right-
hand corner.
62. At 7.15am, Officer A completed the early routine roll check on F wing, the primary
purpose of which is to count the prisoners in their cells. CCTV shows her moving
along the landing looking in all cells through the observation panel. When she
arrived at Mr Davies’ cell, she opened the observation panel and looked towards his
bed. She said that Mr Davies was not on his bed. She looked to the left side of the
door to see if he was using the toilet, but he was not. She then noticed him standing
to the right-hand side of the door. She told the investigator that the cell light was off,
but the television was on, and she assumed that Mr Davies was standing watching
the television. She did not speak to Mr Davies, had no concerns about him and
carried on with the rest of the routine check on the wing.
63. The piece of fabric was still across the top corner of the door when Officer A
completed the routine check. She said that she had not noticed anything at that
time.
64. At around 8.00am, staff began unlocking prisoners who needed to collect their
medication. CCTV shows around four staff on the landing outside Mr Davies’ cell.
The strip of fabric across the right-hand corner of Mr Davies’ door was still visible.
Once all the medication rounds had been completed, staff then began unlocking all
prisoners for association (social time) and to complete welfare checks.
65. Officer B unlocked the cells on the side of the landing where Mr Davies was
located. CCTV shows her making her way along the cells, unlocking each door. She
did not look into the cells through the observation panel, did not look in the cells
once the doors were unlocked or talk to the prisoners to check on their welfare.
When she reached Mr Davies’ cell, she unlocked the door, but did not try to open it.
66. After unlocking all prisoners, Officer A remained on the landing. At 8.50am CCTV
shows a prisoner approaching Mr Davies’ cell door and looking through the
observation panel, before calling to her, who was sitting further along the landing.
She said that when the prisoner called her, it sounded urgent, and she went straight
over to the door and looked in through the observation panel. She said that she
could see Mr Davies suspended by a ligature to the right-hand side of the door. She
shouted to her colleagues for assistance. Staff pressed a general alarm which
alerted staff to an incident on F wing, at 8.54am and at 8.55am, they then radioed a
medical emergency code blue (indicating a prisoner is unconscious or is having
breathing difficulties). Two officers responded and attempted to push the door open
with the help of prisoners who were outside the cell, but Mr Davies’ body was
stopping the door from opening fully. The officers managed to create a gap, entered
the cell and cut the ligature from around Mr Davies’ neck and lowered him to the
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floor. Mr Davies was unresponsive, and staff began CPR. Control room staff called
an emergency ambulance, with the first response arriving at 9.08am.
67. Nursing staff attended and initially assisted prison staff with CPR, but they noted
that they were unable to open Mr Davies’ airway due to rigor mortis being present.
An automated defibrillator was attached to Mr Davies but advised that no shockable
rhythm was detected. Staff moved Mr Davies onto the landing outside his cell.
Senior nursing staff attended and noted that rigor mortis was present and decided
to stop resuscitation attempts at 9.09am. The first paramedics arrived at the cell
shortly afterwards and after conducting their own observations confirmed that Mr
Davies had died.
Events following Mr Davies’ death
68. Staff recovered a note from Mr Davies’ cell, which was given to the police. The note
said, ‘Sorry for the people who find me, thank you to F wing and prison staff, I hope
my death will change things for IPP people.’
69. Staff listened to Mr Davies’ telephone calls after his death. During calls to his family
on 17 and 19 February, Mr Davies asked his family to either send him money or
deposit money into an unknown bank account. It is not clear what these monies
were in relation to and often such calls are an indication that the prisoner is being
bullied or threatened by other prisoners or is in debt due to drug use. However,
other than the nature of these calls, there was no evidence to suggest that Mr
Davies was being bullied or threatened by other prisoners.
Contact with Mr Davies’ family
70. Following Mr Davies’ death, the prison appointed a CM as family liaison officer
(FLO). A prison manager, the CM and another colleague travelled to Mr Davies’
mother’s home later that morning and informed her of Mr Davies’ death. The CM
remained in contact with the family, who asked him to arrange the funeral
arrangements locally, which he did.
71. The prison contributed towards the funeral costs in line with national guidance.
Support for prisoners and staff
72. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoners support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
73. After Mr Davies’ death, a prison manager 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 and local Samaritans were also
involved in offering support.
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74. The prison posted notices informing other prisoners of Mr Davies’ 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 the death.
Post-mortem report
75. The post-mortem gave Mr Davies’ cause of death as suspension. Toxicology results
found no illicit drugs in Mr Davies’ body.
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Findings
Indeterminate sentence for public protection (IPP)
76. When Mr Davies arrived at HMP Swaleside he was already three years over his
tariff. He had done little to address his offending behaviour and prior to this his
behaviour had been poor.
77. Mr Davies engaged well with the clinicians on the PIPE unit and responded well to
group work. His improved behaviour resulted in him being re-categorised to
category C in April 2022. His indirect involvement with a psychoactive substance
and being found with unprescribed medication resulted in him being downgraded to
category B. Mr Davies believed that his previous poor behaviour would affect his
chances of parole and saw his recategorisation as a major setback. Despite his
negative outlook towards his parole, Mr Davies continued to engage with the PIPE
regime.
78. Mr Davies mentioned his IPP sentence in the note he left in his cell. He expressed
his frustration with the slow progress of his sentence, recent re-categorisation and
concerns about his parole hearing and how the Parole Board would view this and
his past behaviour. Mr Davies had not had a date set for his parole hearing at the
time of his death.
79. Although it is clear that Mr Davies was frustrated and hopeless about his prospects
of release, there was no evidence of any identified changes in Mr Davies’ behaviour
or presentation leading up to his death that indicated he was at an increased risk of
suicide, or that he needed to be supported by ACCT procedures. We found
evidence that Mr Davies had a good, supportive relationship with the psychologist,
and he continued to engage fully with group work.
Staff actions on 25 February
80. HMPPS’ National Security Framework expects welfare checks to take place during
routine (roll) checks. Staff should be able to see the prisoner’s face and satisfy
themselves that they are alive and well.
81. When Officer A completed the routine check at 7.15am on 25 February, she said
that she noticed Mr Davies standing to the right-hand side of the door and assumed
that he was watching television. She did not speak to him and continued with her
check.
82. Following an unlock for medication, Officer B unlocked cells on one side of the
landing. She did not look into any of the cells using the observation panel before
unlocking the doors and did not speak with any prisoners while unlocking their cells.
In her statement, she said that when she unlocked Mr Davies’ door, it did not feel
heavy or different from normal. She also said that she thought she saw a hand at
the side of the door, trying to push it shut, and so thought that Mr Davies might have
been using the toilet, which she said was quite normal. She said that when she
responded to the calls from the prisoner and looked through the observation panel,
she could immediately see Mr Davies suspended by a ligature at the right-hand side
of the door.
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83. In an investigation into the death of a prisoner at Swaleside in June 2022, we
recommended that staff completed routine checks in accordance with policy. The
prison responded to our recommendation and said that a system for assuring the
quality of routine checks had been introduced, including ad-hoc checks by
supervising officers and covert testing by the security department. The prison also
said that multiple safety briefings had been delivered, the latest in December 2022,
to highlight the importance of carrying out routine checks and to re-iterate the
actions required when staff find an observation panel covered.
84. It is clear from the evidence gathered in this investigation that staff were not
conducting routine roll checks or welfare checks in line with policy guidance at the
time of Mr Davies’ death. The Head of Safety at Swaleside told the investigator that
managers did not conduct an internal investigation regarding staff actions on the
morning of 25 February, because managers were satisfied that the officers
responsible for checking Mr Davies thought he was alive and did not have any
concerns about his welfare.
85. The Head of Safety was asked what actions had been taken in respect of roll
checks and ensuring that staff were conducting these appropriately, since Mr
Davies’ death. He said that the following actions had been taken:
• Full staff briefings to remind staff of their responsibilities;
• Briefings via residential supervising officers / custodial managers;
• Global emails;
• Supervising officers completing quality assurance checks on their units.
While we do not think, on the evidence available, that earlier intervention would
have made any difference to the outcome for Mr Davies, it could prove critical in
future. As the Governor has taken a range of actions to address the issue, we do
not make a recommendation, but the Governor will want to continue to monitor this
area.
Clinical care and substance misuse
86. The clinical reviewer concluded that the clinical care Mr Davies received at
Swaleside, including the therapy and care delivered on the PIPE unit was of a
reasonable standard and equivalent to what he could have expected received in the
community.
87. She did note, however, that there were a number of missed opportunities for Mr
Davies to be referred to Change, Grow, Live (CGL, substance misuse services) for
support with his substance misuse. There was no evidence that referrals had been
made after staff found PS in Mr Davies’ cell in February 2022, or after the discovery
of unprescribed medication in August 2022, or after Mr Davies was suspected of
being under the influence of illicit substances on 22 February 2023. We make the
following recommendation:
The Governor, Head of Healthcare and Service Manager for Change, Grow,
Live should work together to ensure that referral processes to the service are
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clear and established and that all staff understand when and how to refer a
prisoner to the service.
Inquest
88. The inquest hearing into the death of Mr Davies concluded in August 2024, and
confirmed that Mr Davies died from suspension. The Coroner gave a narrative
conclusion of suicide.
89. The Coroner established that factors relevant to Mr Davies’ death, but could not be
concluded to have caused or contributed to his death, included a lack of
communication and handovers between staff and insufficiently completed welfare
checks.
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