Shaine Tester

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Shaine Tester,
a prisoner at HMP Gartree, on
1 November 2022
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 His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate, our
recommendations should be focused, evidenced and viable. This is especially the case if
there is evidence of systemic failure.
Mr Shaine Tester died from catastrophic haemorrhage after he made multiple cuts to his
body on 1 November 2022 at HMP Gartree. He was 34 years old. I offer my condolences
to Mr Tester’s family and friends.
Mr Tester was a complex man who had regular thoughts of suicide and self-harm.
Generally, he received efficient multi-disciplinary support from staff at Gartree. Staff ended
suicide and self-harm prevention procedures a few days before he died. While it was not
obvious that his risk of suicide had significantly increased before his death, some aspects
of his mental health had not yet been assessed.
Staff who responded when Mr Tester was found on 1 November, tried hard to save him
despite the extremely distressing circumstances.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
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 February 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 13
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Summary
Events
1. On 3 January 2022, Mr Shaine Tester was remanded to HMP Lewes charged with
making threats to kill, possession of offensive weapons and assaulting police
officers. He was later sentenced to 27 months imprisonment.
2. While at Lewes, Mr Tester spent extended time in the segregation unit as staff
considered his risk of violence to others could not be managed on a standard wing.
From June onwards, Mr Tester was supported through Prison Service suicide and
self-harm monitoring procedures (known as ACCT). On 23 September, Mr Tester
transferred to HMP Gartree.
3. Prison staff stopped ACCT procedures on 11 October, and after being briefly
restarted, they were stopped again on 27 October.
4. At 1.35am on 1 November, the night orderly officer (the most senior officer on duty)
found a voicemail message on the safer custody hotline from Mr Tester’s mother
that she had left several hours earlier asking for Mr Tester to telephone her. The
night orderly officer asked a member of staff to check Mr Tester and she found him
lying on his cell floor in a pool of blood. She radioed a medical emergency code.
5. The night orderly officer responded and found that Mr Tester had barricaded his cell
door. Once the door was pushed open the nurse went into the cell followed by an
officer, and they started cardiopulmonary resuscitation (CPR).
6. Paramedics arrived at 2.49am and at 2.53am, confirmed that Mr Tester had died.
Findings
7. Generally, Mr Tester received suitable multidisciplinary support from staff at
Gartree. However, the prison lost a vital component of the ACCT plan that was
closed a few days before he died, so we were not able to assess some of the
decision making involved. As Mr Tester was refusing to take anti-psychotic
medication and had not yet seen the psychiatrist, we consider that it would have
been prudent to continue ACCT monitoring until this had happened.
8. The clinical reviewer concluded that the clinical care Mr Tester received at Gartree
was partially equivalent to what he could have expected to receive in the
community. Mr Tester did not receive an appropriate level of mental health care
during his time at Gartree and a formal safety plan should have been devised to
help manage him more effectively.
Recommendations
• The Head of Healthcare at Gartree should ensure that safety plans are written
for all prisoners who have self-harmed.
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• The Head of Healthcare at Lewes should ensure that a formal clinical handover
is arranged for all complex mental health prisoners before transfer to a new
prison.
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The Investigation Process
9. HMPPS informed us of Mr Tester’s death on 1 November 2022. The investigator
issued notices to staff and prisoners at HMP Gartree, informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded.
10. The investigator visited Gartree on 15 November. He obtained copies of relevant
extracts from Mr Tester’s prison and medical records.
11. The investigator interviewed 13 members of staff at Gartree from 16 to 20 January
2023. He interviewed one other witness in March by video link.
12. NHS England commissioned a clinical reviewer to review Mr Tester’s clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews with the
clinical staff.
13. We informed HM Coroner for Rutland and North Leicestershire of the investigation.
The Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
14. The Ombudsman’s family liaison officer contacted Mr Tester’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Tester’s mother said the following:
• She did not understand why her son had remained so long in the segregation
unit at HMP Lewes.
• She did not understand why her son was not on a list for the PIPE unit or
personality disorder unit at Gartree as she had been led to believe that that
was the reason for his move there.
• She wanted to know why he remained so long on the induction unit at
Gartree.
• There was a four hour delay before staff acted on the message she left on
Gartree’s safer custody helpline on 31 October.
• She received mixed messages about whether or not her son had left behind
letters written just before his death.
15. Mr Tester’s mother also asked about her son’s medical care and these questions
have been addressed in the clinical review.
16. We shared the initial report with Mr Tester’s mother and HMPPS. HMPPS identified
no factual inaccuracies.
17. Mr Tester’s mother’s solicitors raised a number of issues relating to our
investigation which we have addressed in separate correspondence. We have also
amended the wording in the penultimate paragraph of our foreword to say that Mr
Tester had regular thoughts of suicide and self-harm rather than that such thoughts
were quite normal for him.
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Background Information
HMP Gartree
18. HMP Gartree, near Market Harborough in Leicestershire, holds up to 700 male
prisoners mainly sentenced to life imprisonment and other indeterminate sentences.
Nottinghamshire NHS Trust provides healthcare. Nursing staff are available 24
hours a day.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Gartree was in January 2023. In his
introduction, the Chief Inspector wrote that Gartree was a well-led institution that
generally provided good outcomes for those detained. Inspectors noted that Gartree
now received long-term prisoners much earlier in their sentences and while the
prison had risen to the challenge, there was still work to do to manage the
expectations of prisoners who were understandably focused on meeting the
objectives of their sentence plans as early as possible.
20. Inspectors also found that while ACCT processes had improved since the previous
inspection, delivery was inconsistent in quality. In particular, care plans were weak,
and issues raised in reviews were not always added to plans. Inspectors found that
mental health services had improved since the previous inspection. They noted that
twice-weekly multidisciplinary referral meetings provided oversight of the team’s
workload and ensured that patients received the most appropriate care. In addition,
a daily duty worker attended all initial ACCT reviews.
Independent Monitoring Board
21. 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 November 2022, the IMB found
that on the whole, prisoners at Gartree were treated fairly and humanely and that
relationships between prisoners and staff were generally positive. The IMB noted
that there had been a ten percent increase in the recorded incidents of self-harm
compared to the previous reporting year and that 27 of the 242 incidents, were
classed as serious ‘near-miss’ incidents.
Previous deaths at HMP Gartree
22. Mr Tester was the 17th prisoner to die at Gartree since April 2019. Of the previous
deaths, four were self-inflicted and 12 were from natural causes. In a death of a
prisoner at Gartree in September 2021, we found deficiencies in the management
of the prisoner’s ACCT plan, but the deficiencies were different to those we
identified in Mr Tester’s case. There were no other similarities between this
investigation and the previous deaths.
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Assessment, Care in Custody and Teamwork
23. Assessment, Care in Custody and Teamwork (ACCT) is the care planning system
the Prison Service uses for supporting and monitoring prisoners assessed as at risk
of suicide and self-harm. The purpose of the ACCT process is to try to determine
the level of risk posed, the steps that might be taken to reduce this and the extent to
which staff need to monitor and supervise the prisoner. Levels of supervision and
interactions are set according to the perceived risk of harm. There should be regular
multidisciplinary case reviews involving the prisoner. Checks made on prisoners
should be at irregular intervals to prevent the prisoner anticipating when they will
occur. Part of the ACCT process involves assessing immediate needs and drawing
up a care plan to identify the prisoner’s most urgent issues and how they will be
met. Guidance on ACCT procedures is set out in Prison Service Instruction (PSI)
64/2011.
Psychologically Informed Planned Environment
24. Psychologically Informed Planned Environments (PIPEs) form a key part of the
Prison Service’s offender management strategy. PIPEs are specifically designed
living areas where staff trained in psychological understanding aim to create a
supportive environment that can facilitate the development of prisoners with
challenging behavioural needs. PIPEs are not a treatment intervention, instead they
are designed for those who have recently completed high intensity offending
behaviour and treatment programmes and aim to enable progress through the
maintenance and development of previously achieved learning.
Offender Personality Disorder Pathway
25. The Offender Personality Disorder (OPD) pathway programme is a jointly
commissioned initiative between NHS England and Improvement and HM Prison
and Probation Service. The pathway is aimed at supporting and managing high-risk
high-harm offenders with complex mental health needs. The need for offenders to
access appropriate services is a key principle of the pathway with offender
managers having a key role in the early identification of an individual’s needs and
the identification of appropriate intervention programmes.
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Key Events
26. On 25 September 2005, Mr Tester was arrested and charged with attempted
robbery, possession of an offensive weapon and common assault. He was 17 years
old. Mr Tester was later convicted and sentenced to an indeterminate sentence for
public protection (IPP) and received a minimum term of 18 months.
27. By July 2014, Mr Tester had moved to an open prison. On 9 July, Mr Tester
absconded with another prisoner: this was the second time that he had absconded
from an open prison. The next day, Mr Tester was arrested and charged with a
further offence of robbery and possession of an offensive weapon. He was
sentenced to a further term of four years and six months.
28. In August 2016, Mr Tester was moved to a medium secure mental health hospital
where he remained for four months before returning to prison. He went back to the
mental health hospital in June 2017, and this time he remained there until August
2020, when he was released back into the community. Mr Tester had been
diagnosed with dissocial personality disorder with schizoid and paranoid traits. He
also had periods of high anxiety and recurrent depression. There were conflicting
views from professionals about whether Mr Tester had other possible diagnoses for
other conditions, including schizophrenia.
29. On 1 January 2022, Mr Tester was arrested for making threats to kill, possession of
offensive weapons and for assaulting police officers. He was remanded to HMP
Lewes on 3 January and was later sentenced to 27 months in prison. In addition to
this new sentence, Mr Tester was still subject to his original IPP sentence.
30. On 15 June, Mr Tester smashed his television and used a plastic shard to make
several deep cuts to his wrists, arms and torso. His medical record noted that he
also tied a ligature to a shower fitting in his cell, but the fitting broke and came away
from the wall. As Mr Tester was behaving violently, officers placed him under
restraint so they could move him to a different cell. Nurses cleaned and treated his
wounds. Mr Tester was taken to hospital and was sedated due to his agitation. Staff
started ACCT procedures. (Mr Tester had been supported through ACCT on many
previous occasions while in prison, usually following incidents of minor self-harm.)
31. On 19 June, Lewes submitted a request to the Prison Service’s long term high
security estate (LTHSE) population management team to request that Mr Tester be
transferred to a new prison. In the referral, Lewes explained that in his six months at
the prison, he had stayed either in the healthcare unit or the segregation unit. They
explained that moving him to a standard prison wing had not been an option as he
refused to take his prescribed anti-psychotic medication, which meant that his
behaviour was unpredictable and his propensity for violence was a risk that could
not be managed on a standard wing. Lewes wrote that it was not equipped to deal
with Mr Tester’s needs. Lewes also explained that Mr Tester and his legal team had
been trying to pursue a hospital order (which would allow him to transfer to a mental
health hospital), but all avenues had been exhausted and he had been told that he
would be spending his sentence in prison.
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32. Mr Tester returned from hospital to Lewes on 27 June and was placed under
constant observation in the healthcare unit. At an ACCT assessment interview, Mr
Tester said that the incident of self-harm had been “a moment of madness”.
33. At an interview with his key-work officer on 30 June, Mr Tester said that he did not
want to harm himself and he was scared that he had almost killed himself. He said
that he was frustrated because he could not get the mental health treatment he
needed in prison and wanted to go back to hospital.
34. On 12 July, Mr Tester was moved to the segregation unit where he continued to
remain under constant observation. The psychiatrist at Lewes noted his agreement
with a senior prison manager that the segregation unit was “the best and safest
place to manage [Mr Tester’s] likely increase in risk to [himself] and others …”
35. At an ACCT review on 14 July, Mr Tester asked if he could move to Lewes’
healthcare unit (he felt that he needed to be in a mental health setting and preferred
smaller units). Staff at the review meeting told him that he was not suitable to move
to the healthcare unit or a mental health unit, instead Lewes was seeking to transfer
him to another prison that could meet his needs. A note was added for staff to
continue to speak to Mr Tester about a move to a prison with a psychologically
informed planned environment unit (PIPE unit).
36. Following receipt of the request from Lewes, the LTHSE approached HMP Gartree
about taking Mr Tester. Gartree’s Deputy Governor asked the prison’s Head of
Psychology if Mr Tester was suitable for Gartree. The Heald of Psychology told the
investigator that while Mr Tester met some of the criteria for Gartree’s PIPE unit,
there were other criteria he did not meet: in particular, that he had not engaged in
medium to high intensity treatment in the last two years. However, she considered
that he would be suitable for a place within the prison’s general therapeutic
community where he would undertake the Kaizen high risk violence programme.
She said that if Mr Tester had completed Kaizen, or whatever other treatment was
identified to reduce his risk of re-offending, that he might in due course have moved
to Gartree’s progression PIPE unit.
37. The Head of Psychology said that a video conference was arranged for Mr Tester to
speak to her and other staff at Gartree to discuss his transfer. She said that this
was not something that Gartree normally did, but she recognised that the move
would be difficult for him.
38. The video conference between Gartree and Lewes was arranged for 16 September,
but, on the day, Mr Tester refused to attend. An officer at Lewes noted that it was
disappointing that Mr Tester had not taken part as he had spoken with him about it
a number of times and that Mr Tester had said that he would attend. The officer told
Mr Tester that his failure to attend the conference would not change the fact that he
would be transferring to Gartree.
39. Mr Tester’s last ACCT review at Lewes was on 22 September. Mr Tester said that
he was “good” and that he had no intention of harming himself. He said, however,
that he did not want to go to Gartree. His ACCT observations were increased to one
an hour as a precaution ahead of his transfer. (For the previous four weeks, Mr
Tester’s observations had been set at three during the day and three at night.)
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40. On 23 September, Mr Tester transferred from Lewes to Gartree.
HMP Gartree
41. When he arrived, he saw a nurse for a reception health screen. The nurse noted
that Mr Tester had a history of self-harm, but that he was settled in mood that day
and had no current thoughts of self-harm.
42. Mr Tester was moved to G wing where a Custodial Manager (CM), a Supervising
Officer (SO) and a mental health nurse saw him for an ACCT review. Mr Tester said
that he did not intend to take his life but said that his parole review was due within
the next four months, so he did not understand why he had been transferred to
Gartree. The review team set Mr Tester’s observations to three an hour with two
conversations a day.
43. The nurse told the investigator that, at times, Mr Tester would look at the ceiling
while talking, but he was able to concentrate, his speech was normal in rate, rhythm
and tone and there was no evidence of delusionary beliefs.
44. On 24 September, Mr Tester had a follow-up health screen. The nurse noted that
Mr Tester had enduring mental health problems and a history of self-harm, and she
referred him for assessment by the mental health team.
45. On 27 September, an SO chaired Mr Tester’s next ACCT review. Mr Tester said
that he was “okay”, but that he did not understand why he had moved to Gartree as
he had no family nearby. He also said that he should have been sent to a mental
health unit as he had paranoia and schizophrenia. The SO noted that Mr Tester
was very restless: Mr Tester said that if he did not keep some part of his body
moving, he would struggle to concentrate and would “zone out”. The SO asked Mr
Tester if he had any thoughts of suicide or self-harm and Mr Tester said that he had
never been truly suicidal and that he did not want to die. Mr Tester agreed with the
SO’s suggestions to reduce the observations to two an hour.
46. Mr Tester’s next ACCT review was on 29 September, and was chaired by SO A,
who had been appointed as Mr Tester’s ACCT case manager. Another SO and a
nurse also attended the review. SO A said that Mr Tester engaged well at the
review and spoke openly and eloquently. He said, however, that he did not like
being in a large prison wing so would prefer to move to a small unit, such as the
segregation unit, or move to a hospital. He also said that he was too far from home.
SO A reduced Mr Tester’s observations to one an hour.
47. Ahead of the review, a member of the psychology team emailed SO A to say that
Mr Tester had been discussed at the safety intervention meeting (a multi-agency
forum to discuss complex prisoners) when she asked if any intervention from
psychology would be helpful. She told SO A that she was not available to attend the
ACCT review that day but asked him if he wanted any general input from
psychology or wanted anyone from psychology to attend Mr Tester’s next ACCT
review. The psychology team member told the investigator that she did not receive
a reply to her email.
48. On 30 September, a nurse saw Mr Tester for a mental health assessment. The
nurse noted that Mr Tester had diagnoses of antisocial personality disorder,
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schizoid type personality and narcissistic personality disorder. He noted that Mr
Tester said that he had once been in receipt of aripiprazole (used to treat the
symptoms of schizophrenia), but he would not accept this medicine again unless he
was sent back to a mental health hospital or sent back to Lewes. He noted that Mr
Tester would be discussed at the next mental health allocations and discharge
meeting.
49. Mr Tester’s next ACCT review was on 4 October. SO A was not on duty so another
SO chaired the review. A nurse also attended. The SO noted that Mr Tester had not
harmed himself since being at Gartree, nor had he had any such thoughts. He
noted that Mr Tester was eating his meals and taking showers. He also noted that,
long term, Mr Tester was hoping to move closer to his family near Brighton, and
preferably to a hospital. He further reduced Mr Tester’s observations to one every
two hours.
50. On 6 October, Mr Tester was discussed at the mental health allocations and
discharge meeting. A nurse noted that Mr Tester was not suitable for the mental
health caseload, but he would be added for discussion at the psychiatrist’s next
multidisciplinary team meeting.
51. SO A chaired Mr Tester’s next ACCT review on 11 October and was accompanied
by another SO and a nurse. SO A noted that Mr Tester constantly tapped his feet
and was also making physical motions with his arms and hands. Mr Tester again
said that he coped better in small units or in special hospitals. He also said that he
had no present thoughts of self-harm and was fairly settled, provided he was left
alone. Mr Tester also spoke about his upcoming parole review and the potential
outcome from that. SO A closed the ACCT given Mr Tester’s positive attitude.
52. On 12 October, Mr Tester was discussed at the psychiatrist’s multi-disciplinary team
meeting. It was noted that there were conflicting views whether Mr Tester had
schizophrenia and that some clarity was needed. Mr Tester had been due to see
the psychiatrist on 26 October, but on 12 October the appointment was rearranged
for 16 November.
53. On 15 October, Mr Tester tested positive for COVID-19 and was told that he would
have to isolate from other prisoners for the next seven days. Mr Tester accepted
paracetamol for pain related to COVID-19 symptoms (this was the only medication
Mr Tester received at Gartree).
54. Mr Tester had a post-closure ACCT review on 20 October and said that he was
worried that he might kill himself. Staff started ACCT procedures again.
55. SO A chaired an ACCT review on 23 October and was accompanied by a general
nurse. As Mr Tester was still in isolation, the review took place at his cell door. Mr
Tester said that he found it difficult having to remain in his cell. He acknowledged
that he had made a comment about killing himself but said that this was a regular
thought for him and that he had no plans on acting on those thoughts at present.
SO A noted that he would chair another ACCT review on 27 October, by which time
Mr Tester should be testing negative for COVID-19. On 26 October, Mr Tester
provided a second negative COVID-19 test and was no longer required to isolate.
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56. SO A chaired Mr Tester’s next ACCT review on 27 October and was accompanied
by a mental health nurse. SO A noted that Mr Tester engaged well at the review. Mr
Tester said that he had been frustrated during the period when he had COVID-19
and had to remain in his cell and that was why he had made the comment about
harming himself. SO A told Mr Tester that he would not be moving to I wing (a small
specialist unit that Mr Tester had asked about), but Mr Tester said that he was
happy to remain on G wing. SO A reminded Mr Tester that he had a meeting
scheduled with his probation officer in two weeks’ time and noted that this put him in
a positive mood. He noted that all at the review were content that ACCT monitoring
should stop.
57. SO A told the investigator that the review on 27 October had been “a really good
review” and he had no concerns for Mr Tester’s safety. He also explained that I
wing was for prisoners who struggled on other wings including those who were
regularly in debt. He said that Mr Tester did not fit the criteria for I wing at that time.
58. The general nurse noted that Mr Tester presented as quite unkempt, but this was
normal for him, and his speech was spontaneous and coherent with no paranoid
delusional ideas and no deficit in perception. She told the investigator that there
was nothing about Mr Tester’s behaviour to suggest he intended to harm himself.
59. On 31 October, an Operational Support Grade (OSG) started a night shift at
8.00pm. She had not previously met Mr Tester, but she noted that he rang his cell
bell three times that evening. The first time was to ask for some envelopes and the
second time was to hand her a sheet of paper with some writing, which she
subsequently gave to the police. She reminded Mr Tester that the cell bell was for
emergencies, and she asked him if he needed anything. Mr Tester responded by
apologising several times. The third time he rang the bell, the OSG noted that he
appeared to be swaying back and forth and said several times words to the effect of
“tell them that I corrected it”. She reminded Mr Tester that the cell bell was for
emergencies only and that he did not need anything. He again apologised. The
OSG said that she spoke to an officer, and he told her not to worry as that was not
unusual behaviour for Mr Tester.
60. The investigator listened to three telephone calls that Mr Tester made from his in-
cell phone to his partner and brother that evening. In the first two calls, one to his
partner and one to his brother, Mr Tester made a number of strange comments,
such as referring to a woman in a shed over the road from his window who kept on
screaming. Neither his partner nor his brother appeared overly concerned at the
comments. Mr Tester’s final call was a two minute call to his brother at 7.34pm.
They spoke about nothing in particular and there was nothing of obvious concern
about Mr Tester’s presentation.
Events of 1 November
61. On 1 November, a Custodial Manager (CM) who was the night orderly officer (the
most senior officer on duty) that night, told the investigator that the prison has an at
risk helpline which is checked by the orderly officer three times a day: in the
morning, at midday and in the early evening. He said that at around 1.35am, he
noticed that there was no record that the helpline had been checked the previous
evening before the day-time orderly officer finished his shift. He checked for
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messages and found that Mr Tester’s mother had left a message at 9.34pm. She
said that her telephone that had been out of order but was then working again and
she wanted her son to contact her as she had not heard from him for a while. The
night orderly officer asked the OSG to check if Mr Tester was awake and if he was,
to pass him the message from his mother.
62. The OSG went to Mr Tester’s cell and, when she looked through the observation
hatch, she saw him lying on his cell floor with a lot of blood on his body and
smeared around the cell. She radioed a medical emergency code blue (to indicate a
prisoner is unconscious or having breathing difficulties). She said she realised she
should have radioed an emergency code red but made a mistake due to distress at
the sight. Communications staff noted that the call was received at 1.48am and they
called an emergency ambulance. She was carrying a cell key in a sealed pouch
(which is the standard procedure at night time). She said that she tried to open the
pouch, but she could not break the seal.
63. A nurse was in the healthcare unit when she heard the code blue call. She called
over the radio to ask if the patient was breathing and she was told only that there
was a lot of blood. She said that she left the healthcare unit with the emergency bag
for both code blue and code red emergencies and an officer, who was also
responding, took one of the bags for her.
64. The nurse and a number of officers arrived at Mr Tester’s cell at the same time and
around three minutes after the code blue call. The night orderly officer unlocked the
door but found that Mr Tester had created a barricade with his mattress and
cupboard. The night orderly officer was able to push open the door slightly and he
asked the nurse to squeeze through the gap and to remove the barricade. Once
she had done that, the nurse checked Mr Tester and saw that he had significant
lacerations to his neck and abdomen. She noted that he was not breathing, that he
had no pulse and that his eyes were open and fixed. She also noted that while his
hands and arms were cold to the touch, there were no signs of cyanosis (when the
skin turns blue due to lack of oxygen). As she began taking equipment from the
emergency bags, she asked an officer to start cardio-pulmonary resuscitation
(CPR). Staff took turns in giving CPR and the nurse gave oxygen and checked Mr
Tester with a defibrillator, which advised that no shock could be given, and that
CPR should continue. Staff took turns in giving further CPR.
65. Ambulance paramedics arrived at 2.49am. They noted that CPR had been going on
for an hour without success and at 2.53am, they confirmed that Mr Tester had died.
Contact with Mr Tester’s family
66. A family liaison officer (FLO) was appointed. Due to the distance to Mr Tester’s
mother’s home, the prison asked local police to visit her to break the news of her
son’s death. She was told the news at 10.50am and the FLO followed-up with a
telephone call at 2.05pm.
67. Gartree contributed to the cost of Mr Tester’s funeral in line with national
instructions.
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Support for prisoners and staff
68. After Mr Tester’s death, Gartree’s deputy 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.
69. The prison posted notices informing other prisoners of Mr Tester’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Tester’s death.
Post-mortem report
70. The pathologist gave Mr Tester’s cause of death as catastrophic haemorrhage from
multiple self-inflicted cuts. The post-mortem report noted that he had multiple cuts
to his neck as well as a deep cut to his abdomen. He also had cuts to his legs and
the pathologist noted multiple scarring from old cuts. Toxicological examination
detected no significant findings.
Events following Mr Tester’s death
71. In addition to the sheet of paper that Mr Tester gave to the OSG, various other
sheets of paper were found in his cell following his death. Much of what he wrote
suggested unusual thinking, but he did not make any comment about thoughts to
take his life. These sheets of paper had caused Mr Tester’s mother to believe he
might have left behind letters.
72. Two pieces of plastic were found in Mr Tester’s cell. One was a piece of blue plastic
broken from a dustpan and the other was clear plastic from an unknown source.
Police investigators believed that it was one or both of these that he used to make
the cuts as no other sharp items were found.
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Findings
Assessment of Mr Tester’s risk of suicide and self-harm
73. Prison Service Instruction (PSI) 64/2011, Management of prisoners at risk of harm
to self, to others and from others (Safer Custody), states that ACCT case review
teams must be multi-disciplinary where possible. It advises that the ACCT process
will operate more effectively if there is continuity in the attendance of staff from
relevant departments and services so every effort should be made to ensure the
same members of staff attend the reviews, including input from healthcare staff.
74. Mr Tester had a history of self-harm and had been supported through ACCT
monitoring at various times while in prison custody, and during his time at Lewes,
he had been supported constantly on ACCT monitoring from 15 June until his
transfer to Gartree on 23 September.
75. Staff at Gartree were aware that Mr Tester wanted to move to a mental health
hospital and wanted to move back closer to his family. In addition, staff were aware
that he had an extensive history of mental illness, that he had refused anti-psychotic
medication and that he was still waiting to see a psychiatrist. Although Mr Tester
made no explicit comment about plans to kill himself while at Gartree, he said that
thoughts of harming or killing himself were regular for him.
76. The majority of Mr Tester’s ACCT reviews at Gartree were multidisciplinary with
consistent case management by SO A and good attendance by general and mental
health nurses. Disappointingly, Gartree lost Mr Tester’s ACCT care plan, so the
investigator was not able to assess the adequacy of the plans drawn up to identify
and address Mr Tester’s most urgent needs, nor assess whether all of the care plan
actions had been completed when ACCT procedures were stopped.
77. While it certainly does not follow that all prisoners with mental health problems are
at risk of harming themselves, this had been a risk for Mr Tester in the past and,
given his other risks, including that he was not taking medication and had not yet
seen the psychiatrist, we consider it would have been prudent to keep ACCT
monitoring in place until staff had more information about Mr Tester’s complex
mental health and personality disorders. The Governor will wish to consider the
learning from this investigation.
Clinical care
78. The clinical reviewer concluded that Mr Tester’s care at Gartree was partially
equivalent to what he could have expected to receive in the community. She noted
that there was no formal handover of care from Lewes to Gartree, which would
have been happened between community services to ensure continuity and
comparable levels of mental health care. She noted that when Mr Tester was at
Lewes, he was on the mental health team’s caseload and was seen at least weekly
and she would have expected a comparable level of mental health care at Gartree,
even if this was just for short term support while he was awaiting assessment by the
psychiatrist at the prison.
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79. The clinical reviewer noted that the psychology team at Gartree, who were aware of
Mr Tester, had offered to attend his ACCT reviews, but they were not invited to
attend.
80. The clinical reviewer also referred to new guidance published in September 2022 by
the National Institute for Health and Care Excellence (NICE) which discusses the
use of a safety plan for the management of people who have self-harmed. She
considered that creating a safety plan would have provided a more structured and
evidence-based intervention for Mr Tester and could have been utilised by him, his
family and by prison and healthcare staff. We recommend:
The Head of Healthcare at Gartree should ensure that safety plans are written
for all prisoners who have self-harmed.
The Head of Healthcare at Lewes should ensure that a formal clinical
handover is arranged for all complex mental health prisoners before transfer
to a new prison.
81. The clinical reviewer made some recommendations about asking prisoners about
thoughts of suicide and self-harm during the reception screen and about record
keeping, which we do not repeat here, but which the Head of Healthcare will need
to address.
Governor to note
Good practice
82. We commend the staff involved in the response for their concerted efforts to try to
save Mr Tester’s life in what were clearly both highly unusual and extremely
harrowing circumstances.
At-risk hotline
83. Gartree’s website has a link for support for family and friends and a section about
the prison’s safer custody hotline where family or friends can leave a message if
they have concerns about the safety or wellbeing of a prisoner. The telephone
number given then has a standard message to say: “At-risk hotline at extension
6886 cannot be reached. You may leave a message or transfer to another
extension. To leave a message begin speaking at the tone …”. The hotline always
diverts to the message bank and there is no option to speak directly to a member of
staff instead, no matter the time of day.
84. Mr Tester’s mother left a message on the at-risk hotline at 9.34pm, that the night
orderly officer found at 1.35am.
85. In normal circumstances, the at-risk hotline would have been checked by the
orderly officer at around 7.00pm, and Mr Tester’s mother’s message would not have
been discovered until around 7.30am on 1 November.
86. Although the at-risk hotline might have some purpose in the case of non-urgent
concerns, it clearly has no value where a family member has immediate concerns,
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which is not made clear in the recorded message. While it seems that Mr Tester’s
mother’s contact with Gartree was to pass on a message rather than to raise an
urgent concern, we invite the Governor to consider whether the at-risk hotline is fit
for purpose.
Inquest
87. On 28 June 2024 an inquest into Mr Tester’s death noted that his medical cause of
death concluded that his cause of death was catastrophic haemorrhage from
multiple self-inflicted cuts to the body and that on balance of probability, he intended
to take his own life in an act of suicide.
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