Steven Hart

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Steven Hart,
a prisoner at HMP Bedford,
on 29 March 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 Hart died on 29 March, having been found hanging in his cell at HMP Bedford four days
earlier. He was 37 years old. I offer my condolences to Mr Hart’s family and friends.
Mr Hart had a history of anxiety and paranoia and had been supported several times
through prison suicide and self-harm monitoring procedures while at Bedford, including
when he died. An officer found Mr Hart tying a telephone cord around his neck a few hours
before Mr Hart hanged himself. The officer took the cord away, but staff did not re-assess
Mr Hart’s risk to himself or consider increasing the frequency of their checks on him. There
was also a five-minute delay in staff going into the cell when they could not get a response
from Mr Hart. This may have been critical.
The clinical reviewer concluded that staff did not update Mr Hart’s mental health
assessment or create a care plan in response to his increased risk of suicide and self-
harm.
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 July 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 14
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Summary
Events
1. On 30 November 2022, Mr Steven Hart was remanded to HMP Bedford charged
with breach of a non-molestation order.
2. Mr Hart was briefly supported through prison suicide and self-harm monitoring
procedures (known as ACCT) on three occasions between December and mid-
March 2023. On each occasion, Mr Hart either self-harmed or said he would self-
harm due to anxiety and hearing voices.
3. On 18 March, Mr Hart’s wing was locked down as there was intelligence that there
might be a firearm in the prison. Mr Hart grew anxious that he was going to be
attacked and at around midnight on 19 March he made cuts to his arm and neck. At
an ACCT review the following morning, he also said that he had taken an overdose.
He was sent to hospital for assessment and on his return to Bedford, was moved to
the healthcare unit and placed under constant supervision.
4. Mr Hart remained under constant supervision until 23 March, when staff reduced his
observations to four an hour.
5. At 5.02pm on 25 March, an officer saw Mr Hart placing a telephone cord around his
neck. The officer took the cord away and made an entry in Mr Hart’s ACCT. The
officer did not report the incident to the officer in charge and no further actions were
taken.
6. At 8.59pm, another officer found that Mr Hart’s observation panel was locked or
jammed. He thought Mr Hart might be using the toilet, so he first checked all the
other prisoners on the unit and he also collected a key to unlock the panel. The
officer returned to Mr Hart’s cell at 9.04pm, and noticed a shoelace attached to the
panel. When the officer forced the panel open, he saw Mr Hart in a seated position
below the door with the shoelace around his neck. The officer radioed a medical
emergency code, went into the cell, and cut the ligature. A nurse started
cardiopulmonary resuscitation (CPR).
7. Paramedics arrived at 9.19pm and established a pulse. They took Mr Hart to
hospital where he died on 29 March.
Findings
8. The decision, on 23 March, to reduce Mr Hart’s ACCT observations to four an hour
was reasonable: he said at the review that he was feeling well, was noted to have
cleaned his room, had been for exercise that morning and interacted with other
prisoners.
9. However, when staff removed a ligature from Mr Hart on the evening of 25 March,
they should have recognised that his risk to himself had increased and held an
immediate ACCT review. The officer should have also ensured that he informed the
officer in charge of the prison.
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10. When an officer could not open Mr Hart’s observation panel or get a response from
him, there was a five-minute delay before they went into the cell.
11. Mr Hart received good support from a number of the staff at Bedford, in particular
from a supervising officer who chaired the majority of his ACCT reviews and from
the bicycle workshop manager.
12. We did not receive all the information we requested for this investigation and there
were delays to receiving some information.
13. Healthcare staff did not update Mr Hart’s mental health assessment in response to
his apparent increased risk of suicide and self-harm or create a care plan.
Recommendations
• The Governor should ensure that ACCT reviews are held whenever an event
occurs that could mean a prisoner is at increased risk and improve the quality
assurance process that confirms this learning has been embedded.
• The Governor should ensure that all information requested by the PPO following
a death in custody is provided promptly.
• The Head of Healthcare should ensure that mental health assessments are
updated when there are changes in a prisoner’s clinical presentation and
circumstances.
• The Head of Healthcare should ensure that a care plan is created for prisoners
who are at increased risk of suicide or self-harm.
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The Investigation Process
14. HMPPS notified us of Mr Hart’s death on 30 March 2023. The investigator issued
notices to staff and prisoners at HMP Bedford informing them of the investigation
and asking anyone with relevant information to contact him. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Hart’s prison and
medical records.
16. The investigator interviewed nine members of staff and one prisoner at HMP
Bedford on 30 and 31 May. He interviewed nine further members of staff between
May and August through video-link.
17. NHS England commissioned a clinical reviewer to review Mr Hart’s clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews with
clinical staff.
18. We informed HM Coroner for Bedfordshire and Luton of the investigation. She gave
us the results of the post-mortem examination. We have sent her a copy of this
report.
19. We contacted Mr Hart’s mother to explain the investigation and to ask if she had
any matters she wanted us to consider. Mr Hart’s mother did not respond. Mr Hart’s
father contacted us and asked:
• Why was Mr Hart not under constant supervision?
• Was Mr Hart being bullied?
• Where was Mr Hart located when he harmed himself?
• Did Mr Hart leave a suicide letter?
• How long was Mr Hart on life-support?
20. We shared the initial report with Mr Hart’s parents and with HM Prison and
Probation Service (HMPPS). Mr Hart’s mother identified an incorrect date in
paragraph nine of the report, which we have corrected. Bedford notified us of an
error with the identity of the officer who witnessed the telephone cord being taken
from Mr Hart. We have corrected reference to this officer in paragraph 75.
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Background Information
HMP Bedford
21. HMP Bedford is a local inner-city Victorian prison. Northants Healthcare NHS
Foundation Trust provides all healthcare services. There is an inpatient unit with
nine single cells and a four-bed dormitory. There is 24-hour healthcare provision.
HM Inspectorate of Prisons
22. Following an unannounced inspection of HMP Bedford in January and February
2022, the Chief Inspector wrote that real progress had been made at the prison
since the last inspection in 2018.
23. However, following a further unannounced inspection in October and November
2023, the Chief Inspector found that standards had fallen badly. He noted that many
officers at Bedford were inexperienced and did not have a clear idea of their role
and this was impacting on the delivery of core services. The inspection found that
prisoners spent too long locked in their cell with not enough to do.
24. Inspectors found that the rate of self-harm had increased by 84% since the last
inspection and was among the highest in the male estate. Inspectors were also
troubled to find that the prison had failed to identify learning opportunities from
incidents of suicide and self-harm occurring both within the prison and at other
institutions.
25. Inspectors noted that only 41% of prisoners who had been supported through
ACCTs said that they felt cared for and many perceived ACCT reviews to be
unproductive. Inspectors also found that too many ACCTs lacked a multi-
disciplinary approach and care plans were frequently left incomplete.
26. Inspectors found that mental health services were not meeting the needs of patients
with little evidence of delivery of meaningful evidence-based interventions. One-to-
one interventions lacked structure and did not reflect patient need. In addition, care
plans lacked sufficient detail to inform interventions and were not person centred.
27. Inspectors were also damning of some of the accommodation at Bedford, which the
Chief Inspector noted was the worst he had seen.
Independent Monitoring Board
28. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to June 2022, the Board identified
some areas for improvement in ACCT management. However, their overall view
was that genuine progress had been made in remedying previous deficiencies in
implementation of the process. The IMB found that staff/prisoner relationships were
of a mixed quality.
29. The Board found some good interactions on the wings and during formal settings,
such as at ACCT reviews, but most of the feedback in the prisoner survey was
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negative. The IMB reported that the mental health team lacked the capacity to meet
the needs of prisoners with an overreliance on one-to-one interventions. The IMB
noted that without significant investment, the provision of effective mental health
services was likely to remain a challenge.
Previous deaths at HMP Bedford
30. Mr Hart was the eighth prisoner to die at Bedford since April 2020. Of the previous
deaths, three were self-inflicted and four were from natural causes. In our
investigation into a self-inflicted death in July 2020, we found that nurses failed to
make ACCT observations appropriately on the night before the prisoner’s death.
There have been three deaths since that of Mr Hart, up to 16 February 2024. Of
these deaths one was self-inflicted and two due to unknown causes.
Assessment, Care in Custody and Teamwork
31. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
32. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. Guidance on
ACCT procedures is set out in Prison Service Instruction (PSI) 64/2011.
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Key Events
33. On 30 November 2022, Mr Steven Hart was remanded to HMP Bedford charged
with breach of a non-molestation order by communicating with his ex-partner and
going within 50 metres of her home.
34. A nurse assessed Mr Hart. She noted that he had deliberately banged his head
while in police custody the previous day. The nurse also noted that he was now
bright in mood with no current thoughts of suicide or self-harm. She did not start
suicide and self-harm support procedures, known as ACCT.
35. Following the health screen assessment, a prison GP prescribed Mr Hart 30mg of
mirtazapine (an antidepressant). Mr Hart said that he had been prescribed
antidepressants in the community but had not taken his medication for the previous
month or two as his depression had been stable.
36. On 2 December, Mr Hart moved to a cell on A Wing.
37. On 5 December, a nurse saw Mr Hart for mental health screening. She noted that
he had a history of deliberate self-harm through cutting and making ligatures. She
also noted that, in the previous month, he had attempted to set fire to himself and
had gone to a multi-storey car park with thoughts of jumping until he was escorted
down by security staff. She noted that Mr Hart said he had no current thoughts of
suicide or self-harm. She noted that Mr Hart had no indications of acute mental
illness, although he presented as a little anxious. He said he believed he might have
attention deficit hyperactivity disorder (ADHD): people with ADHD can seem
restless, may have trouble concentrating and may act on impulse. Mr Hart said that
he had been waiting for a diagnosis for two years. (His medical record confirmed
that this was the case.) The nurse noted that Mr Hart would not be taken onto the
mental health caseload but would be managed with medication. She also sent a
referral to the chaplaincy team for emotional support.
38. On 8 December, Mr Hart started work in the prison’s bicycle repair workshop. That
afternoon, Mr Hart told a prison GP that that he wanted an increase in his
mirtazapine dose as he had been feeling “down” for the past four days. The GP
increased the dose to 45mg, and he emailed the mental health team manager to
ask for the mental health team to see him again.
39. On 9 December, the mental health team manager replied to the GP to say that
when Mr Hart was reviewed on 5 December, he had been signposted appropriately
and the mental health team would not be reassessing him at that time.
40. On 15 December, an officer started ACCT procedures after Mr Hart scratched the
word “wanker” on his hand. Mr Hart said that he felt under threat from other
prisoners due to his offence.
41. On 16 December, a Supervising Officer (SO, SO A), from the safer custody team
chaired an ACCT review with Mr Hart. Another SO, who carried out the ACCT
assessment interview, and a mental health nurse, also attended. Mr Hart said that
he had spoken to a friend on the wing and now felt safe. He said that he used
cutting as a coping mechanism and he did not want to die as he had four children.
The SO A noted that everyone at the review agreed that an ACCT was
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unnecessary and that Mr Hart would be better supported through a Prison Service
Challenge, Support and Intervention Plan (CSIP): a process to support and manage
prisoners who pose a risk of being violent or are at risk of violence. Staff closed the
ACCT.
42. The SO A told the investigator that there were three SOs in the safer custody team
and they chaired almost all of the ACCT reviews with the aim that case managers
were consistent. The exception to this practice was that custodial managers (CMs)
chaired reviews for prisoners under constant supervision.
43. On 17 December, SO A referred Mr Hart for a CSIP, noting that he was very
vulnerable, could be the victim of bullying and required extra support through the
CSIP process. Over the following weeks, staff recorded daily CSIP entries of
conversations they had with Mr Hart, listening to his concerns and reassuring him.
44. On 28 December, the bicycle workshop instructor made an entry in Mr Hart’s
records about his positive attitude, good behaviour, good work ethic and attention to
detail. She told the investigator that Mr Hart attended the workshop each morning
from Monday to Friday and he worked hard but was slow to complete jobs as he
was meticulous with his work. She also said that he was a person who needed
routine, so he found weekends difficult when the workshop was closed.
45. At around 10.00pm on 26 January 2023, Mr Hart rang his cell bell. An officer
responded and found Mr Hart bleeding from his thumb. He called a nurse and the
Orderly Officer (officer in charge of the prison at night). Mr Hart said that he had
harmed himself as he believed he was under threat from other prisoners who
thought he was a sex offender. He also said that he was hearing voices outside his
cell. The Orderly Officer opened an ACCT and directed that Mr Hart be observed
three times an hour through the night. A nurse treated the cut to Mr Hart’s thumb
that she noted was not too deep.
46. On the morning of 27 January, SO A went to Mr Hart’s cell to collect him for an
ACCT review. Mr Hart had barricaded his door, but he removed the barricade when
he saw her. She saw that he had scratched the word “nonce” onto his hand. Mr Hart
named another prisoner who he said had been shouting on the wing the previous
evening about him being a sex offender. She told Mr Hart that the other prisoner
had had a cell search in the evening and that was why his cell had been unlocked
during the night-time patrol period. She noted that the other prisoner came to Mr
Hart’s cell at that point to reassure him that no-one had been talking about him. She
noted that Mr Hart calmed down slightly and agreed to come out of his cell for an
ACCT review with her and a nurse.
47. At the ACCT review, Mr Hart said that being in prison was taking a toll on his mental
health. He said again that he believed prisoners were spreading rumours about him.
However, when SO A reminded Mr Hart what the other prisoner had said, he
acknowledged that he could become paranoid at times, that he struggled with
anxiety and then self-harmed as a release. Staff set Mr Hart’s observations at one
an hour and arranged his next ACCT review for 31 January.
48. SO A told Mr Hart that he could move to C Wing if he wanted. He agreed to move,
and in the interim he moved that day to a cell with his friend. By the time she started
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arrangements to move Mr Hart to C Wing, he said that after speaking to his friend,
he wanted to remain on A Wing in a cell with him.
49. The friend told the investigator that he and Mr Hart got on well. He said that Mr Hart
was well liked by other prisoners, and interacted with others when he was on the
landing. However, he said that when Mr Hart was locked in his cell, he believed that
the other prisoners were talking about him. He also had other strange thoughts
such as believing people were tampering with his vape. He said that he would
distract Mr Hart by playing cards with him and turning up the volume of the radio.
He said that Mr Hart struggled with any disruption to his routine. He said weekends
were especially difficult for Mr Hart as the bicycle workshop was closed and gym
sessions and other time out of cell would be disrupted if there were staff shortages.
50. On 28 January, an officer noted a conversation with Mr Hart when he said he had
cut himself as he thought people were “out to get him” and he thought things were
being said about him on television. He said that he was feeling better following
reassurance from staff and prisoners, and he asked to attend Sunday chapel the
following day.
51. On 31 January, SO A chaired Mr Hart’s next ACCT review. A nurse also attended.
Mr Hart said that sharing a cell with his friend was helping him a lot. He also said
that his friend kept the television quite loud and that helped drown out general
shouting from other prisoners which stopped him thinking they were talking about
him. Mr Hart said that he was going to the gym, was enjoying work, felt safe on A
Wing and had no thoughts of suicide or self-harm. SO A noted that all at the review
agreed to close the ACCT.
52. On 2 February, the bicycle workshop instructor noted that Mr Hart was visibly upset
while at the bicycle workshop. He said he was struggling with not knowing what was
happening with his court case. He also said that the gym was the only place he
found “release”, but his gym sessions had been cancelled that week. She contacted
SO A to see Mr Hart.
53. SO A told the investigator that the bicycle workshop instructor contacted her many
times to go to speak to Mr Hart in the workshop. She said that Mr Hart coped poorly
if there was a break in his routine, such as closure of the gym or closure of the
workshop. When she spoke to Mr Hart that day, she noted that he said he was just
having a bad day and that he said he had no thoughts of suicide or self-harm.
54. On 21 February, the bicycle workshop instructor again called SO A to speak to Mr
Hart at the workshop. SO A noted that Mr Hart was upset because his prison phone
credit had not been topped up as it should have been, and he was still waiting for
some prison trainers. Mr Hart said that staff were laughing about him, but he again
accepted that he might be paranoid. She noted that Mr Hart struggled daily with
issues that others found easy, but he immediately felt better once he had the
opportunity to speak about his concerns. She also noted that Mr Hart said he had
no thoughts of suicide or self-harm.
55. On 28 February, Mr Hart told a prison GP that he was not happy with his medication
as he was continuing to hear voices. He said that speaking regularly with SO A was
helping him. The GP sent a referral to the mental health team asking that they see
Mr Hart urgently.
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56. On 12 March, staff re-opened Mr Hart’s ACCT after he made a comment about
slitting his throat. A Custodial Manager (CM) held an immediate ACCT review with
Mr Hart and a mental health nurse. Mr Hart said that he was struggling to sleep at
night as the younger prisoners on A Wing were too loud and he again had thoughts
that people wanted to harm him. The CM noted that Mr Hart said he was happy to
continue sharing a cell with his friend. He set Mr Hart’s observations at three an
hour and arranged a further ACCT review for the following day.
57. The mental health nurse noted that Mr Hart appeared flat in mood, and he reported
being anxious. She noted that Mr Hart had no signs of acute mental illness or major
affective disorders, and she gave him an anxiety self-help guide.
58. On 13 March, an SO chaired an ACCT review with Mr Hart. Another SO and two
mental health nurses all attended. Mr Hart said that he had been having a bad day
the day before but was now feeling well. He said that while he sometimes found A
Wing “a bit much”, he did not want to move wings as he realised he had good
support from prisoners and staff on the wing. He said that he had not harmed
himself for a while and had no present thoughts of self-harm. The SO noted that
everyone agreed that the ACCT should be closed.
59. Mr Hart remained on a CSIP. Staff continued to have daily conversations with him
about how he was feeling.
60. On 16 March, an assistant psychologist saw Mr Hart in response to referrals to
mental health from both a prison GP and SO A who were concerned about Mr
Hart’s anxiety and vulnerabilities with ADHD and potential autism spectrum
disorder. (ASD – this is a developmental disability. People with autism often have
problems with social communication and interaction and often have restricted or
repetitive behaviours and interests.)
61. The assistant psychologist told the investigator that he spoke with Mr Hart for
around 30 to 45 minutes. He said that while Mr Hart was low in mood, he was easy
to talk to and was very forthcoming. They spoke about the traits associated with
ADHD and he gave Mr Hart a screening tool to assess his own traits. He said that
he also planned to give Mr Hart a screening tool for ASD. They spoke about support
from the psychology team and Mr Hart agreed to attend an initial programme of
between two and four sessions to identify his triggers for anxiety, regulation of
emotions and development of coping strategies. He added Mr Hart to the waiting
list.
62. On 17 March, Bedford received intelligence that there was a firearm in the prison. C
Wing was locked down and at around midday on 18 March, A Wing was also locked
down. A specialist Prison Service team (the National Tactical Response Group -
NTRG) went to the prison to systematically search for the weapon and none of the
prison’s regular officers or nurses were allowed on the wings in the meantime.
Prison staff prepared 24-hour meal packs which were delivered to cells by NTRG
staff. Staff told the investigator that certain prisoner medication was contained in the
meal packs. Mr Hart’s mirtazapine was not included in his packs since mirtazapine
has potential for abuse. Therefore, he did not receive his mirtazapine on 18, 19 and
20 March.
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63. Mr Hart’s friend told the investigator that the security lockdown was very difficult for
Mr Hart. The NTRG had first searched the opposite side of their landing and Mr
Hart believed from the voices that there was a conspiracy to attack him.
64. During the lockdown, prison staff phoned prisoners to check on their welfare. When
an officer spoke to Mr Hart at just after midnight on 20 March, he said there were
people outside his cell who were coming for him. He then said he wanted to take his
life and he ended the call. The officer informed NTRG who checked Mr Hart and
found that he had made cuts to his arm and neck. A nurse treated the cuts and staff
restarted ACCT procedures.
65. SO A held an ACCT review with Mr Hart on the morning of 20 March. Mr Hart kept
repeating that he could not handle the voices any longer, that he would prefer to be
dead and would hang himself as soon as he could. He also said that he had taken
an overdose. She placed Mr Hart under constant supervision and staff escorted him
to hospital for checks.
66. Mr Hart returned from hospital at 4.43pm, but staff sent him back to hospital an hour
later. It is not clear from the records why they did so. Mr Hart returned again to
Bedford at around midnight and was moved to a constant supervision cell in the
healthcare unit. A nurse noted that the hospital had made no adverse findings.
67. On 21 March, a CM held an ACCT review with Mr Hart. A SO and two mental health
nurses also attended. The CM noted that when Mr Hart first came into the room he
was talking very quickly. He said that he had not had his medication during the
lockdown period and that had made him very anxious, and he had started hearing
voices again. He also said that A Wing was too big and too loud, and he was
already feeling more settled in the healthcare unit. The CM reassured Mr Hart that
his medication would recommence now that he was in healthcare. Towards the end
of the review, Mr Hart said that his mother was in the process of arranging a video
call with his children. The CM kept Mr Hart under constant supervision and
arranged a further ACCT review for the following day.
68. The CM held Mr Hart’s next review on 22 March. A nurse, an SO and a member of
the chaplaincy team also attended. The CM noted that Mr Hart was clearly agitated
when he came to the review. He said that he had been unable to sleep the previous
night as the two constant supervision officers observing him and the prisoner in the
cell next door had talked all night. He said they were talking about him, and he
feared they would switch off the cameras and let people into his cell to harm him.
The CM explained to Mr Hart that she suspected his thoughts had been triggered
by the lockdown period on A wing when NTRG staff had been going into cells. She
noted that Mr Hart then calmed down and they were able to have a more relaxed
conversation. She noted that the nurse told Mr Hart that it would take a few days for
the reinstated mirtazapine to get into his system, but he would then see an
improvement in his sleep and mental state. She noted that Mr Hart was in a much
better frame of mind by the end of the review. He told staff that his mother and a
cousin had arranged to visit him on 1 April. She again kept Mr Hart under constant
supervision and arranged a further ACCT review for the following day.
69. One of Mr Hart’s constant supervision officers noted that she had a “very
productive” conversation with Mr Hart from 4.00am to 5.00am on 23 March. Mr Hart
had spoken about how difficult he had found the lockdown period when he missed
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medication and had been kept in his cell. He said that it was difficult for staff to
understand his behaviour, as they did not understand his mental health. He also
said that he was sorry about his behaviour towards staff while he had been in
healthcare. An entry in his records the previous night noted that he had shouted
various expletives at staff.
70. The CM held a further multi-disciplinary ACCT review with Mr Hart at 11.00am on
23 March. She noted that Mr Hart seemed calmer and more settled. He said that he
was feeling great. He said that he had tidied his room, put clean bedding on his bed
and had apologised to an officer, as well as opening up to her about his mental
health. She noted that Mr Hart had followed her previous advice to start writing
down his thoughts so he could discuss them with staff rather than allowing his
thoughts to play on his mind. Mr Hart said that he had gone to the healthcare
exercise yard that morning, he had used the exercise equipment and got other
prisoners to join in. She noted that everyone agreed that Mr Hart was no longer in
crisis and that his observations should be reduced to four an hour. She set his next
review for Monday 27 March. Mr Hart was then moved from the constant
supervision cell to a standard cell in the healthcare unit.
71. On the morning of 24 March, the assistant psychologist briefly met Mr Hart and
spoke to him about starting psychology sessions. He noted that their first session
would be on 27 March, and they would meet either in the healthcare unit, or in the
bicycle workshop if Mr Hart had returned to work. He noted that Mr Hart was
engaging with education at the time of their meeting, and he appeared well.
72. At 11.15am, Mr Hart’s education instructor noted that he believed everybody was
“out to get him”. However, all of the other entries in his records that day indicated he
had had a good day. A late entry noted that Mr Hart was in a great mood, had
chatted about a range of topics and had spent the evening doing learning packs
and a jigsaw.
Events of 25 March
73. Mr Hart’s final telephone call was a five-minute call to his mother made at 12.16pm
on 25 March. Despite several requests, the investigator was not provided with a
recording of the call. He was then told that the phone calls were no longer available
as they are automatically overwritten after a period of time. Prison staff said that
they had listened to a recording of the call shortly after Mr Hart’s death and Mr Hart
had told his mother that he believed that staff and prisoners were intending to harm
him.
74. One of Bedford’s chaplains spoke to Mr Hart in the early afternoon. She noted that
he strongly believed that the food he was being given might not be fit to eat and he
also believed that other prisoners were shouting accusations against him. She
noted that Mr Hart appeared a lot calmer after she had spent time speaking with
him.
75. During the afternoon and evening, Officer A (who had been a prison officer for four
years) was responsible for Mr Hart’s ACCT checks. CCTV shows that at 5.02pm, he
pulled a telephone cord through Mr Hart’s observation panel. He told the
investigator that he saw Mr Hart beginning to put the cord around his neck, so he
thrust his arm through the panel, grabbed the cord and pulled it out. He said he
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asked Mr Hart for an explanation, but he gave none. He made an entry in the ACCT
form and said that he told his colleagues and a nurse about the cord. Other officers
confirmed they were aware of the incident, and Officer B actually observed Officer A
removing the cord, as she was carrying out constant supervision on a prisoner in a
nearby cell. However, there is no entry in the clinical record from the nurses on duty
to confirm they were told. Officer A also said that he tried to contact the Orderly
Officer by telephoning his office, but there was no answer. The investigator asked
him why he did not radio the Orderly Officer, given that he could be anywhere in the
prison and not necessarily in his office. He acknowledged that that was what he
should have done.
76. The investigator also asked Officer A about his other checks on Mr Hart that
afternoon. The investigator said that from his observation of the CCTV it was
unclear whether he made all the checks that he had signed for on the ACCT. He
said that he believed that he had made all of his checks.
77. A CM told the investigator that he was the Orderly Officer that afternoon. He said
that he was always contactable by radio and if he had been told about the ligature,
he would have spoken to Mr Hart and re-assessed his risk.
78. Officer A’s last check on Mr Hart before his shift ended was at 8.44pm. He wrote a
statement to say that Mr Hart was sitting on his bed, and they made eye contact. He
asked Mr Hart if he was okay and hoped he had no hard feelings towards him, but
Mr Hart did not respond. CCTV confirms that Officer A spent seven or eight
seconds at Mr Hart’s door before moving to the next cell. Other officers then started
a shift in healthcare. Officer A briefed Officer C on the events during his shift,
including that he had taken a ligature from Mr Hart.
79. One of the other officers then told Officer C of a potential problem with one of the
prisoners under constant supervision, so he spoke to him for a few minutes.
80. After carrying out a few administrative tasks, Officer C began a routine roll check on
all the prisoners on the unit. CCTV shows that he tried to open the observation
panel in Mr Hart’s cell door at 8.59pm, but it would not open. He tried to look
through any gaps and he then walked away from the cell. He told the investigator
that he wondered if Officer A had earlier locked the panel to stop Mr Hart throwing
objects onto the landing. He also thought it possible that Mr Hart had jammed the
observation panel as he needed to use the toilet. He said that he walked away to
check other prisoners and to give Mr Hart a few minutes’ privacy to finish using the
toilet it that was what he was doing.
81. At 9.04pm, Officer C returned to Mr Hart’s cell with a key to unlock the panel. He
said that he called Mr Hart’s name several times, without reply, and when he put his
hand on the observation panel, he saw a shoelace attached to it. He forced open
the panel and saw Mr Hart in a seated position at the bottom of the door with his
legs facing into the cell. The shoelace was around his neck and was tied to the
observation panel. He radioed a code blue emergency (to indicate a prisoner is
unconscious or having breathing difficulties). He then ran to get an anti-barricade
key so the door could be opened outwards as Mr Hart’s body was blocking the
door. He returned with the anti-barricade key, but he and another officer managed
to push the door open. He cut the ligature, laid Mr Hart on the floor and within
around 40 seconds a nurse got to the cell and started cardio pulmonary
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resuscitation (CPR). Staff took turns giving CPR and they also attached a
defibrillator.
82. At 9.09pm, staff in the control room requested an ambulance. (We asked Bedford
why there was an apparent delay between Officer A’s code blue call and the control
room calling an ambulance but did not receive any response.) Paramedics arrived
at 9.19pm. They then took charge of the efforts to resuscitate Mr Hart. At 9.29pm,
the paramedics established a pulse and at 9.48pm they took Mr Hart to hospital
without restraints.
83. Mr Hart remained in intensive care in hospital until he died at 2.10pm on 29 March.
Contact with Mr Hart’s family
84. Prison staff telephoned Mr Hart’s mother when he was first sent to hospital, and she
was able to spend time with him over the following days. A CM was appointed as
the family liaison officer, and he met Mr Hart’s family at the hospital. Mr Hart’s
mother and other family members were with him when the life support machine was
switched off and he died.
85. Bedford contributed to the cost of Mr Hart’s funeral in line with national instructions.
Support for prisoners and staff
86. After Mr Hart’s death, a CM 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.
87. The prison posted notices informing other prisoners of Mr Hart’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 Hart’s death.
Post-mortem report
88. The pathologist noted that there were no significant findings on toxicological
analysis of Mr Hart’s blood samples and gave his cause of death as asphyxiation
due to hanging.
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Findings
Assessment of Mr Hart’s risk of suicide and self-harm
89. Prison Service Instruction (PSI) 64/2011, Safer Custody, lists risk factors and
potential triggers for suicide and self-harm. It says all staff should be alert to the
increased risk of suicide or self-harm posed by prisoners with these risk factors and
should act appropriately to address any concerns. Any prisoner identified as at risk
of suicide and self-harm must be managed under Assessment, Care in Custody and
Teamwork (ACCT) procedures. PSI 64/2011 also states that any information that
becomes available which may affect a prisoner’s risk of harm to self must be
recorded and shared, to inform proper decision making.
90. Mr Hart had several risk factors. In the month before he was remanded to custody,
he had attempted to set fire to himself and had thoughts about jumping from a high
building. When he got to prison, he told staff that he felt anxious, heard voices and
was prescribed medication for depression and anxiety. During his time at Bedford,
he was intermittently subject to ACCT support after he self-harmed or, on the last
occasion, on 20 March, said he had taken an overdose. This ACCT remained open
until he died.
91. There were good examples of staff engaging with Mr Hart, trying to understand his
concerns and manage his risk. A particular SO A chaired the majority of Mr Hart’s
ACCT reviews and also provided him with support outside of this process.
92. Staff put Mr Hart under constant supervision on 20 March after a difficult three-day
period for him when the prison was on lockdown following the report of a firearm in
the prison. Mr Hart did not receive his mirtazapine in those days, which increased
his anxieties and belief that he was at risk from other prisoners.
93. At ACCT reviews on 22 and 23 March, staff noted Mr Hart was becoming more
settled and on 23 March his observations were reduced from constant, down to four
an hour. We consider that the reduction in observations was a reasonable decision
based upon the assessment of his apparent level of risk at that time.
94. However, we are concerned that when Mr Hart’s risk subsequently escalated on 25
March, this was not appropriately communicated, assessed or managed.
Events on 25 March
The telephone cord
95. At 5.02pm on 25 March, Officer A saw Mr Hart placing a telephone cord around his
neck. He took the cord from him and made an appropriate entry in his ACCT form.
Other officers were aware of the incident, but it is unclear whether he told a nurse,
as there is no entry about this in the medical record. He also said that he tried to
contact the Orderly Officer by telephoning his office, but without success.
96. By the nature of the role, the Orderly Officer can, at any time, be anywhere in the
prison. Even if Officer A did attempt to telephone the Orderly Officer’s office, this
was not an efficient way to try to contact him. He should have radioed the Orderly
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Officer. The Orderly Officer said that if he had been told about the ligature, he would
have gone to the healthcare unit to speak to Mr Hart to re-evaluate his risk. It was a
clear failing on Officer A’s part not to have contacted the Orderly Officer.
97. Following Mr Hart’s death, the Governor arranged an investigation into this
omission, and Officer A was temporarily suspended from work. We are satisfied that
Bedford has taken appropriate action with regards to him. However, we remain
concerned that several other officers knew about him taking the telephone cord,
with one having witnessed the incident. No one ensured that an urgent ACCT case
review took place to find out how Mr Hart was feeling, assess his risk and decide
whether an increase in his observations was necessary. Officer A told more officers
about the incident when there was a changeover for the evening shift and again no
one took the initiative to ensure Mr Hart’s risk was reviewed. We therefore regard
the issue with risk assessment as more widespread than Officer A and make the
following recommendation:
The Governor should ensure that ACCT reviews are held whenever an event
occurs that could mean a prisoner is at increased risk and improve the quality
assurance process that confirms this learning has been embedded.
Possible missed ACCT checks
98. When the investigator reviewed the CCTV for the afternoon and evening of 25
March, he identified several occasions when ACCT checks were not apparently
made despite these being recorded in the paperwork as having been done: the
investigator separately contacted the Governor with the times of six potential
omissions, the last of which was at 6.45pm. The officer responsible for the checks
was again Officer A. The prison conducted a further disciplinary investigation. The
outcome of that investigation was that it could not be ascertained for certain
whether he failed to make any of the checks that he signed for. We therefore make
no recommendation.
The jammed observation panel
99. Officer C came on duty at 8.45pm on 25 March and received a briefing from Officer
A, which included that he had taken a ligature from Mr Hart. When he tried to check
Mr Hart at 8.59pm during his routine roll check, Officer C found that his observation
panel was either locked or jammed. He tried to look into the cell, but he thought that
Mr Hart was possibly using the toilet, so he allowed him some privacy and first
checked the other prisoners. When he returned to the cell at 9.04pm, he found that
the reason the observation panel was jammed or stiff was because there was a
shoelace looped over the panel which was attached to Mr Hart’s neck and bearing
his weight.
100. We recognise the conflict between keeping prisoners safe, and the need to maintain
some degree of privacy and decency. However, Mr Hart was on a high level of
ACCT observations and had been found with a ligature just four hours earlier. We
cannot know if Mr Hart was already hanging when Officer C first got to the cell but
in such a situation, even a slight delay can have a significant impact on the chances
of a prisoner’s survival.
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101. Bedford’s Governor’s Order 671, Roll checks and accounting for prisoners, states
that staff must ensure the correct prisoners are in each cell at roll check. If staff are
unable to see a prisoner, they must instruct the prisoner to remove the obstruction.
If they still cannot see the prisoner, staff must unlock the door. We consider that
Officer C should have ensured he could see Mr Hart at 8.59pm before moving away
to check other prisoners.
102. The Head of Suicide and Self-Harm Reduction told the investigator that Officer C,
along with all other staff, had been reminded of the correct action to be taken if an
observation panel is blocked or obscured. She said that they had emphasised the
importance of swiftly getting a response, especially if a prisoner is on an ACCT. We
therefore make no further recommendation, but the Governor will want to satisfy
herself that the learning has been embedded.
Missed mirtazapine medication
103. Due to his wing being in lockdown, Mr Hart did not receive his mirtazapine
medication on 18, 19 and 20 March. It could not be included in the meal packs
delivered, due to its potential for abuse and healthcare staff were not allowed on the
wing to administer it to Mr Hart. Both the lockdown and lack of medication impacted
Mr Hart’s mental health and he self-harmed late in the evening on 20 March.
104. The Head of NTRG told us that the scale of the lockdown at Bedford was
unprecedented and truly exceptional. The need to ensure the safety of staff and
prisoners by ensuring there was no firearm in the prison needed to be balanced
against ensuring that prisoner’s critical needs were met. He explained that had staff
raised concerns Mr Hart’s missed medication with NTRG as presenting a risk to his
life, they would have assessed and responded to this. Indeed, this is what
happened when prison staff told NTRG that Mr Hart had said he wanted to end his
life.
105. We are satisfied that Mr Hart missing his medication was unavoidable in the context
of the intelligence that NTRG was investigating.
Providing information to the PPO
106. The investigator had difficulty securing the information he needed for this
investigation from the prison. He had to chase some information several times. In
addition, the prison never provided him some information, such as a download of Mr
Hart’s telephone calls or the reasons for the five-minute delay in calling the
ambulance. It is crucial to the integrity of our investigations that prisons provide
information when asked and without delay. We make the following
recommendation:
The Governor should ensure that all information requested by the PPO
following a death in custody is provided promptly.
Clinical care
107. The clinical reviewer found that the care Mr Hart received for his physical health
and substance misuse needs was of a reasonable standard, but she considered
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that the care he received for his mental health needs was only partially equivalent to
that which he could have expected to receive in the community. She noted that Mr
Hart was prescribed medication for anxiety, had mental health involvement at ACCT
reviews and was assessed by psychology. However, she noted that there was no
updated mental health assessment despite Mr Hart’s ongoing risk concerns, which
included acts of self-harm, ongoing paranoia, and the fact that he had been placed
under constant supervision. She noted that these risks should have led to the
creation of a care plan. We make the following recommendations:
The Head of Healthcare should ensure that mental health assessments are
updated when there are changes in a prisoner’s clinical presentation and
circumstances.
The Head of Healthcare should ensure that a care plan is created for
prisoners who are at increased risk of suicide or self-harm.
108. The clinical reviewer has made several other recommendations which we do not
repeat here, but which the Head of Healthcare will need to address.
Governor to note
109. We note that there was an apparent five-minute delay between the time that the
code blue call was made at 9.00pm and contact with the ambulance service at
9.05pm. The investigator asked a senior prison manager the reason for the delay
but did not receive any explanation. The Governor will wish to assure herself that
staff immediately request an ambulance when there are emergency radio calls.
Good practice
110. We consider that Mr Hart received good support from various staff at Bedford. In
particular, we note the support he received from SO A, the bicycle workshop
instructor and a prison GP. In addition, prison staff recorded almost daily entries
while Mr Hart was subject to a CSIP from 17 December onwards. Staff made
considerable efforts to reassure Mr Hart and allay his fears.
Inquest
111. An inquest into Mr Hart’s death held between 30 June and 9 July 2025 concluded
that his cause of his death was asphyxiation due to hanging.
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