Simon Lightfoot

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Independent investigation into
the death of Mr Simon Lightfoot,
a prisoner at HMP Dovegate,
on 29 April 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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The Prisons and Probation Ombudsman aims to make a significant contribution to safer,
fairer custody and community supervision. One of the most important ways in which we
work towards that aim is by carrying out independent investigations into deaths, due to any
cause, of prisoners, young people in detention, residents of approved premises and
detainees in immigration centres.
If my office is to best assist 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 Simon Lightfoot was found hanged in his cell at HMP Dovegate on 29 April 2023. He
was 52 years old. I offer my condolences to his family and friends.
Mr Lightfoot spent just two weeks at Dovegate. He appeared to have settled well but in
telephone calls and texts to his partner, he became increasingly stressed and expressed
worries about his family, the running of his business and the possibility of spending many
years in prison. However, there is no evidence that Mr Lightfoot shared his concerns with
prison staff.
The clinical reviewer concluded that the healthcare Mr Lightfoot received at Dovegate was
equivalent to that which he might have expected to receive in the community. However,
the nurse who helped staff try to resuscitate Mr Lightfoot did not feel confident enough to
stop resuscitation efforts, even though it was clear that he had already died.
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 June 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
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Summary
Events
1. On 14 April 2023, Mr Simon Lightfoot was remanded to HMP Dovegate. It was his
first time in prison.
2. During his short time at Dovegate, Mr Lightfoot seemed to settle quickly. He
appeared to get on with his cellmate, participated in the prison regime, worked
daily, mixed with other prisoners, went to the gym, and received a visit from his
partner.
3. In telephone calls and text messages to his partner, family and friends, Mr Lightfoot
sounded increasingly stressed and anxious about his family’s welfare, his business,
court proceedings and the possible length of his sentence. Staff did not know about
these concerns.
4. At around 8.00am on 29 April, Mr Lightfoot’s cellmate woke to find him hanging
from the ladder of their bunk bed and raised the alarm. Mr Lightfoot had tied a
ligature, made of a blue nylon rope, around his neck. Although the officer who
responded first did not call an emergency code blue, staff responded quickly to his
call for assistance, went into the cell, cut the ligature, and called a code blue.
5. The officers and emergency response nurse tried to resuscitate Mr Lightfoot,
despite the presence of rigor mortis. Paramedics arrived at around 8.26am and
confirmed Mr Lightfoot’s death two minutes later.
Findings
6. Mr Lightfoot did not display any behaviour that indicated that he was at risk of
suicide or self-harm and did not present with any new risk factors in the days before
his death. Although Mr Lightfoot expressed anxiety about his family’s welfare,
business and court proceedings with his family, he never shared his feelings with
staff. Staff at Dovegate therefore reasonably concluded that Mr Lightfoot did not
need to be monitored under suicide and self-harm monitoring procedures (ACCT).
7. When Mr Lightfoot was found, staff immediately started cardiopulmonary
resuscitation (CPR). These attempts continued after the emergency response nurse
arrived. Although the nurse quickly recognised that rigor mortis was present, she
did not feel confident enough to stop resuscitation efforts, even though it was clear
that Mr Lightfoot had already died.
Recommendations
• The Head of Healthcare should ensure that all agency staff commissioned by
Practice Plus Group (PPG) have sufficient training and competency to stop or not
attempt CPR when it is evident it is futile.
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The Investigation Process
8. The Prisons and Probation Ombudsman (PPO) was notified of Mr Lightfoot’s death
on 29 April 2023.
9. The investigator issued notices to staff and prisoners at HMP Dovegate informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Lightfoot’s prison and
medical records.
11. NHS England commissioned a clinical reviewer to review Mr Lightfoot’s clinical care
at the prison.
12. The investigator interviewed eleven members of staff at HMP Dovegate, some
jointly with the clinical reviewer.
13. We informed HM Coroner for Staffordshire South of the investigation. He provided
us with a copy of the post-mortem and toxicology reports. We have sent him a copy
of this report.
14. We contacted Mr Lightfoot’s next of kin to explain the investigation and to ask if they
had any matters they wanted us to consider. They asked why he had access to a
rope in his cell and why he was not checked overnight. Mr Lightfoot’s next of kin
said that they had spoken to a man released from Dovegate (we were not told his
name) who told them that Mr Lightfoot had asked to speak to someone about his
mental health, but his requests were ignored. (We found no evidence that Mr
Lightfoot had raised concerns about his mental health with healthcare staff.)
15. Mr Lightfoot’s next of kin received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Dovegate
16. HMP Dovegate is a category B prison in Staffordshire, managed by Serco, holding
remanded and sentenced adult male prisoners. There is also a therapeutic
community, separate to the main prison. Practice Plus Group (PPG) provides 24-
hour healthcare services. South Staffordshire and Shropshire Foundation Trust
provides mental health services.
HM Inspectorate of Prisons
17. Inspectors carried out a full unannounced inspection from September to October
2023. They noted that there had been instability at Director level, with seven
Directors over a 10-year period. A new Director had taken over in January 2023 but
the instability had meant that the prison had not progressed as much as expected in
ensuring purposeful activity for prisoners. However, levels of violence were lower
than in comparable prisons. Inspectors found ongoing difficulties with recruiting
healthcare staff. Staff worked hard to support prisoners to maintain family ties and
key work was strong. Inspectors found that Dovegate was reasonably safe. PPO
recommendations were monitored but progress in addressing some of them was
too slow.
18. Following the previous inspection in October 2019, inspectors noted that Dovegate
had improved since their last inspection in 2017. They noted the positive and polite
interactions between staff and prisoners, that officers demonstrated a good
knowledge of prisoners in their care and that the support prisoners were given to
maintain family ties was encouraging, with enhanced family visit arrangements.
Inspectors reported that prisoners received good support during their early days at
the prison and initial interviews with new prisoners were sufficiently focused on
safety.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its annual report for the year to September 2022, the IMB reported that
staff treated prisoners with respect, there were generally positive relationships
between them, and staff had good knowledge of prisoners in their care.
Previous deaths at HMP Dovegate
20. Mr Lightfoot was the third prisoner to take his life at Dovegate since January 2020.
Between then and Mr Lightfoot’s death, there were eight deaths from natural
causes. There were no similarities between our findings in these investigation
reports and those in our investigation of Mr Lightfoot’s death. Up to the end of 2023,
there has been one self-inflicted death at Dovegate and one drug-related death
since Mr Lightfoot’s death. There was also one drug related death in July 2020. In
our investigation into this death, we identified that staff had attempted CPR, despite
evidence that the prisoner had died.
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Assessment, Care in Custody and Teamwork
21. ACCT is the Prison Service care planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise prisoners. As part of
the process, a care plan which includes support and intervention, should be in
place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. Guidance on ACCT procedures is set out in Prison Service
Instruction (PSI) 64/2011 on safer custody.
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Key Events
22. On 14 April 2023, Mr Simon Lightfoot was remanded to HMP Dovegate. He had no
previous convictions, and it was his first time in prison.
23. At around 6.30pm, Mr Lightfoot arrived at Dovegate. At his reception interview, Mr
Lightfoot told a Prison Custody Officer (PCO) that he had never harmed himself
before and he denied thoughts of doing so. Mr Lightfoot was not considered a risk
to himself or others and was assessed as suitable to share a cell. He was moved to
the Vulnerable Prisoners’ Unit.
24. At around 8.40pm, a nurse completed an exceptional safety assessment (rather
than an initial health screen) because it was late in the day. He noted Mr Lightfoot
was fully engaged but was nervous and felt “slightly dejected” about being in prison.
Mr Lightfoot told the nurse that he had never had mental health concerns, he
denied substance misuse issues and “categorically” denied thoughts of self-harm.
The nurse told him how to access support at the prison, including from Listeners
(prisoners trained by the Samaritans to provide confidential and emotional support).
He told Mr Lightfoot that he would be checked regularly overnight, and he should
use his cell bell to alert staff if he was struggling with his mental or physical health.
He said that Mr Lightfoot presented with no risk to suggest that he should be
monitored under suicide and self-harm prevention procedures, known as ACCT.
25. During his first night in custody, Mr Lightfoot was checked hourly. Staff raised no
concerns about him.
26. On 15 April, a PCO completed a first 24-hour review. The PCO noted that Mr
Lightfoot raised no issues or concerns, and he was reminded of the support
available. When asked to score his mood out of ten, with 10 indicating that he was
extremely content, Mr Lightfoot assessed his mood as eight and said he was okay.
27. A nurse completed Mr Lightfoot’s first night reception screen which had been
delayed due to his late arrival the previous day. Mr Lightfoot denied mental health
issues and thoughts of suicide or self-harm. The nurse described his mood as
normal. A further healthcare assessment took place that afternoon, and it was noted
that Mr Lightfoot did not take any prescribed medications.
28. On 17 April, a PCO introduced herself to Mr Lightfoot as his keyworker. She said he
was chatty but anxious about his business and being so far from his family. She told
him that she would ask about ways in which the prison could offer him additional
support. She said she had no concerns about Mr Lightfoot’s mental health and did
not consider that he was at risk of suicide or self-harm.
29. In a telephone call to his sister, Mr Lightfoot spoke about business and domestic
matters, and his alleged offending. He spoke to his partner about similar matters,
and they discussed plans for her to visit him. He later exchanged text messages,
using the prison’s texting service, about her plans to visit. (At Dovegate, prisoners
have a telephone and the ability to call and text family and friends from their cell.
Although all calls and texts are recorded, staff do not routinely monitor them and
therefore prison staff did not know the content of Mr Lightfoot’s telephone calls and
text messages while at Dovegate.)
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30. Between 18 and 25 April, Mr Lightfoot spoke to his partner 32 times and texted her
daily. They talked about domestic and business issues and arrangements for her to
visit him. Mr Lightfoot discussed his alleged offences and the length of sentence he
might receive. During this time, he also spoke to friends and other relatives.
31. In a text to his partner on 19 April, Mr Lightfoot said he did not feel good, did not
want to think about things and was worried about being moved to another prison,
where he might have less access to a telephone, and it would be harder to text. In a
telephone call to his mother, Mr Lightfoot sounded tearful and asked her to be there
for his partner and children.
32. On 20 April, Mr Lightfoot started work in the prison’s Industries Unit. (Mr Lightfoot
attended every session that he could until 28 April.) A workshop instructor gave him
an induction. He said that Mr Lightfoot was “quite jolly” and got on well with other
prisoners. He said that Mr Lightfoot never mentioned thoughts of suicide or self-
harm.
33. In a telephone call to his partner that day, Mr Lightfoot said he was not okay but
gave no further details. In a text to her, he said, “my heart is in pain and I’m
beginning to stress”.
34. On 21 April, the keyworker completed Mr Lightfoot’s 72 hours in custody interview,
noted no concerns and reminded him of the support available.
35. In texts to his partner that day, Mr Lightfoot wrote that he was “so sad thinking here
how long this is going to be after talking to solicitor so sad and afraid [sic]” and that
he would miss his sons. He later texted that his head was spinning, he was
depressed and being in prison was only going to get worse. His partner texted back
words of support.
36. In a telephone call to his partner on 22 April, Mr Lightfoot said, “I can’t do this,
babe”, and spoke again of his fear about being given a long sentence. In a further
call, he told his partner about how “hard it was” and how he missed his children. Mr
Lightfoot appeared to break down during the call. In another call, Mr Lightfoot said
he “was fucked” and despite reassurances from his partner, he repeated the
phrase, “What a fucking nightmare” three times before the call ended. Mr Lightfoot
continued to sound emotional in calls to his partner that day. During an exchange of
text messages, he said, “I’m trying in here but can’t do it, I’m trying my best but
cannot make it work, I want it finish” [sic]. His partner again provided reassurance
and support and told him he would feel better after she had visited him.
37. In a telephone call on 23 April, Mr Lightfoot told his partner that he was “burnt out”
and “might as well shut and lock the doors”. During the day, Mr Lightfoot continued
to exchange several texts with his partner about business arrangements and
domestic matters. In one text, Mr Lightfoot said he was “not really okay” and in
another, he said he had been to church but did not know why.
38. On 26 April, Mr Lightfoot spoke to his partner. They discussed her proposed visit to
see him the next day with their children.
39. On 27 April, Mr Lightfoot’s partner visited him. In a telephone call that evening, they
talked about arranging a further visit. A PCO said that when Mr Lightfoot returned
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from his visit, he was disappointed that his children had not been able to see him
but hoped he would see them the following Sunday. (Mr Lightfoot had not realised
that his children’s names needed to be put on the visiting order.) He said Mr
Lightfoot never mentioned thoughts of suicide or self-harm.
40. Mr Lightfoot’s cellmate said that two or three days before he died, Mr Lightfoot had
said to him, “I lost my family, my business, my everything.” He said that Mr Lightfoot
had told him, after he had spoken to his solicitor, that he might get twelve years. He
said that Mr Lightfoot had said that his alleged victim had ruined his life, and, at one
point, he had punched the cell wall in anger.
41. On the morning of 28 April, a PCO carried out a keywork session with Mr Lightfoot,
as his keyworker was not available. The officer noted that Mr Lightfoot was settled,
got on with other prisoners, maintained contact with family and friends and attended
work. He said that Mr Lightfoot was always talking to people about his family and
business and had never mentioned to him thoughts of suicide or self-harm or given
any indication that he was at risk. He said he was shocked when he learnt that Mr
Lightfoot had taken his life.
42. Later that afternoon, Mr Lightfoot spoke to his partner about his court case and her
next visit. He also spoke to his sister, told her that he felt “a bit down” and that he
might be given a six-year sentence if he pleaded guilty.
43. At around 5.00pm, Mr Lightfoot and his cellmate were locked in their cell for the
night.
44. The night officer arrived on the unit at around 7.15pm to start her nightshift. She
said that during the handover, no concerns were raised about Mr Lightfoot. At
around 7.30pm, she completed the evening routine check but said that neither Mr
Lightfoot nor his cellmate raised any concerns.
45. In a telephone call to his partner at 6.12pm, Mr Lightfoot talked about his court case
and briefly spoke to his mother. He told her he felt terrible. Mr Lightfoot and his
partner exchanged their love for one another, as they always did, and said
goodbye. Mr Lightfoot texted his partner as usual that day. He apologised for letting
people down and talked of further visits and business matters. Mr Lightfoot sent his
last text message to his partner at 11.39pm, saying goodnight. CCTV footage
shows that the light in Mr Lightfoot’s cell was turned off around ten minutes later.
46. The cellmate said that at around 11.00pm, Mr Lightfoot had asked if he could turn
the television off, which he agreed to, but that Mr Lightfoot turned it back on again,
checked his texts and went to bed at around midnight. He said that during the night,
he heard Mr Lightfoot snoring, he was quite restless, and they both got up to use
the toilet during the night.
Events of 29 April 2023
47. At around 5.05am, the night officer checked Mr Lightfoot’s cell when she completed
a routine morning check. She said that both Mr Lightfoot and his cellmate were in
their beds and that nothing in the cell gave her any concern. She handed over to a
colleague. She said she raised no concerns about Mr Lightfoot as there were none.
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48. The cellmate said that when he woke up at around 8.00am, he looked over the top
of his bunk and saw Mr Lightfoot sitting on the floor, with a rope around his neck,
which was tied to the bed. He said he rang his cell bell to alert staff at around
8.01am. (On Saturdays, prisoners are not routinely unlocked until 9.00am, unless
there is a reason to do so. It is during unlock that officers carry out a welfare check
on prisoners.)
49. PCO A said that she was in a wing office at around 8.01am, when she heard
knocking coming from one of the cells. When she arrived on the landing, she
noticed that Mr Lightfoot’s cell bell light was on. (She was not in the main office
where the cell bell panel was located and as such did not hear the bell ring.
Evidence provided shows that staff in the main office were alerted to a pressed cell
bell about 15 seconds before she arrived at the cell.) She arrived at the cell door at
around 8.03am and found the cellmate standing at the door. She said he asked for
the cell door to be opened so he could be let out. The officer told him that she could
not open it as she was on her own.
50. The cellmate stepped to one side and PCO A saw that Mr Lightfoot was in a
slumped seated position on the floor, with a ligature around his neck made from a
blue nylon rope tied to the bed’s ladder. She explained that she could not open the
door for safety reasons. (She said she did not enter the cell as she was on her own
and was not sure of the circumstances facing her.)
51. PCO A left the cell as she was the only member of staff on the landing at the time
and shouted for assistance from her colleagues. She said she also called for urgent
assistance by pressing her personal alarm but did not radio a code blue (indicating
an emergency medical response was needed). Officers responded immediately and
followed her to Mr Lightfoot’s cell. PCO B, one of the response officers, said that
PCO A sounded distressed. She said she could not recall an alarm being sounded.
52. At around 8.04am, PCO A unlocked the cell door. PCO B went into the cell,
followed by her colleagues. PCO B cut the ligature from around Mr Lightfoot’s neck,
with the help of other officers. She said that Mr Lightfoot was cold, had a mottled
appearance and she believed rigor mortis had set in.
53. The officers checked for signs of life but found none. A PCO started CPR. He said
that he also believed that Mr Lightfoot had died as his jaw was fixed. PCO B called
an emergency code blue at 8.04am, and an ambulance was called at the same
time. (The cellmate was taken from the cell at 8.04am and was supported by staff,
peers and Listeners. He later saw the prison’s bereavement services.)
54. Healthcare staff, having heard a distressed call for assistance, made their way to
the unit at around 8.02am. An agency nurse and a nursing associate arrived at the
cell at around 8.06am and helped the officers to continue CPR, including using a
defibrillator, airway and oxygen.
55. The healthcare staff said that they saw signs of rigor mortis, but they and officers
continued CPR until paramedics arrived at 8.26am. After a brief assessment, the
paramedics declared at 8.28am that Mr Lightfoot had died.
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56. Paramedics arrived at the prison at 8.12am but due to security processes, including
gates needing to be unlocked, and Mr Lightfoot’s houseblock being at the furthest
point away from the prison entrance, they did not reach Mr Lightfoot until 8.26am.
Information received after Mr Lightfoot’s death
57. At 11.59am, Mr Lightfoot’s son texted him to ask if he was okay as his partner was
worried that she had not heard from him.
58. Staffordshire Police confirmed that Mr Lightfoot left written material in his cell.
However, the police told the PPO that the contents did not refer to an intention to
take his life and did not include a letter to his family. The police confirmed that the
notes related to his thoughts and defence about the alleged offence.
Contact with Mr Lightfoot’s family
59. At 1.15pm on 29 April, two family liaison officers broke the news of Mr Lightfoot’s
death to his next of kin. Dovegate offered to contribute to funeral expenses in line
with national instructions.
Support for prisoners and staff
60. The Assistant Director invited staff individually to give an account of the emergency
and to offer support. The staff care team also offered support. A collective meeting
was not arranged.
61. The prison posted notices informing other prisoners of Mr Lightfoot’s death and
offered support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Lightfoot’s death and offered
support to other prisoners and staff.
Post-mortem report
62. A post-mortem examination found that Mr Lightfoot died from hanging and that
there was no evidence of assault or restraint. Post-mortem toxicology test results
showed no evidence of illicit substances in his system.
Inquest into Mr Lightfoot’s death
63. The inquest into Mr Lightfoot’s death was held on 16 June 2025 and a verdict of
suicide was recorded.
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Findings
Assessment of Mr Lightfoot’s risk
64. PSI 64/2011 on safer custody requires staff who have contact with prisoners to be
aware of the risk factors and triggers that might increase the risk of suicide and self-
harm and take appropriate action. Any prisoner identified as at risk of suicide or
self-harm must be managed under ACCT procedures. PSI 64/2011 recognises that
prisoners are at increased risk of suicide and self-harm during their first days in
custody.
65. Mr Lightfoot was not subject to ACCT monitoring during the two weeks he spent at
Dovegate. Although it was his first time in prison, he did not have any significant
other risk factors when he arrived and had no history of attempted suicide, self-
harm or mental health issues. When asked by staff he denied any thoughts of
suicide or self-harm. He had significant contact with his partner and others by
telephone and text. He did not display any behaviour or present with any new risk
factors to indicate to prison or healthcare staff that he was at an increased risk of
suicide or self-harm.
66. In the days leading to his death, Mr Lightfoot told his partner and family in telephone
conversations and texts that he was stressed and concerned about his family,
business matters and sentencing. However, he never shared his feelings with staff
and did not raise any specific concerns with them. With the information available to
them at the time, staff at Dovegate reasonably concluded that Mr Lightfoot did not
need to be monitored under ACCT procedures.
Emergency response
67. It took paramedics fourteen minutes from their arrival at the prison until they were
able to assess Mr Lightfoot. This was a very long time, and although in this case it
did not impact on the outcome for Mr Lightfoot, in other emergencies such a delay
could be critical.
68. We might have made a recommendation on this but on the 7 February 2024, the
PPO hosted a roundtable discussion attended by senior representatives from
HMPPS and the Ambulance Service. The PPO presented evidence that ambulance
access to prisons was a regular issue in our investigations. HMPPS committed to a
multi-agency review of their practices, and we await the outcome of that work. We
therefore make no recommendation.
Clinical care
69. The clinical reviewer concluded that the healthcare that Mr Lightfoot received at
Dovegate was of a standard reasonably expected and was therefore equivalent to
that which he could have expected to receive in the community.
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Cardiopulmonary resuscitation
70. Prison guidance says that resuscitation must be started on all patients who are
found not breathing and/or pulseless unless certain conditions (such as the
presence of rigor mortis) exist. The European Resuscitation Council Guidelines
state that resuscitation is inappropriate when there is clear evidence that it will be
futile.
71. CPR continued for around twenty minutes until paramedics arrived, even though it
was apparent to healthcare practitioners that rigor mortis was present. The nurse
said that she recognised quickly that rigor mortis was present but did not feel
confident enough to stop CPR. Healthcare and prison staff did not discuss whether
to continue or stop CPR.
72. In our investigation into the death of a man at Dovegate in July 2020, we identified a
similar issue about inappropriate resuscitation. The prison confirmed that all
healthcare staff had been given guidance during their initial training to ensure they
knew when it was appropriate and not appropriate to perform CPR. They told us
that additional training had been completed in February 2021.
73. However, the nurse who responded to the emergency was an agency nurse and did
not work regularly at Dovegate. The Head of Healthcare told us that all healthcare
staff, including agency staff, were trained in immediate life support. She told us that
full-time healthcare staff were confident to step down CPR when they believed it
was futile and they had received additional training to verify death. However,
agency staff had not received this training. We make the following recommendation:
The Head of Healthcare should ensure that all agency staff commissioned by
PPG have sufficient training and competency to stop or not attempt CPR
when it is evident it is futile.
Director to note
Access to ligature material
74. The Assistant Director told us that it was unclear where Mr Lightfoot obtained the
blue nylon rope that he used as a ligature. However, he said that the industries unit
had a contract to produce air bags, and the materials for this were delivered
packaged with a blue nylon rope. He told us that staff destroyed the packaging by
taking it directly to the compacter.
75. The Assistant Director confirmed that as Mr Lightfoot worked in the Vulnerable
Prisoners’ Industries Unit 1, he would not have had direct access to the rope or the
industries yard where such rope would have passed through. He told us that it was
unlikely that a member of staff would have stored rope in Industries Unit 1.
76. Dovegate concluded that it was possible that a prisoner had obtained the rope and
taken it out of the unit. The prison acknowledged that this raised serious concerns
as rope could be used to self-harm or as an escape aid.
77. The Assistant Director said that following Mr Lightfoot’s death, all staff in the
Industries Units had been briefed about the importance of vigilance in disposing of
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ropes and searching prisoners thoroughly before they left the industries units. The
prison also said that the materials involved were no longer packaged with nylon
rope but wrapped with plastic. We therefore make no recommendation about this
matter.
Calling an emergency code blue
78. PCO A said she initially did not try to radio a code blue because her radio was
faulty. She said that the battery had fallen out of her radio, and this happened
regularly. She said that as her colleagues were nearby, she shouted for help as she
believed this would be quicker.
79. The response to PCO A’s shouts for assistance were prompt and, on this occasion,
there was no impact on the emergency response or eventual outcome in a code
blue not being called. However, the Director may want to take action to ensure that
radios work so that they do not prevent staff from carrying out their duties
appropriately.
Paramedic access
80. In their report, paramedics reported on the delay in reaching Mr Lightfoot from when
they arrived at Dovegate. Paramedics arrived at the prison at 8.12am but reported
that due to security processes and gates having to be unlocked it took 14 minutes
for them to reach Mr Lightfoot’s cell. We also note, however, that Mr Lightfoot’s cell
was located on a houseblock at the furthest point from the vehicle entrance.
Although the delay did not impact on the outcome for Mr Lightfoot, the Director
should satisfy himself that all staff are aware of the procedures to ensure immediate
and swift entry to the prison by emergency services.
Hot debrief
81. Although the healthcare and prison staff who spoke to us said that they did not have
a collective immediate hot debrief after Mr Lightfoot’s death (as should take place
after serious incidents), they all said that they felt supported and knew where to
access support services.
Good practice
82. Mr Lightfoot’s cellmate was offered good support after Mr Lightfoot’s death.
12 Prisons and Probation Ombudsman
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