Terence Devereux

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Independent investigation into
the death of Mr Terence
Devereux, a prisoner at
HMP Channings Wood, on 24
May 2020
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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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 Terrence Devereux was found hanged in his cell at HMP Channings Wood on 24 May
2020. He was 31 years old. I offer my condolences to his family and friends.
Staff monitored Mr Devereux under suicide and self-harm prevention procedures (known
as ACCT) three times at Channings Wood. Although staff generally managed ACCT
procedures well, I am concerned that caremap actions were not properly recorded. It is
not the first time that I have identified deficiencies in Channings Wood’s ACCT procedures.
The Prison Group Director for Devon and North Dorset will need to address this issue
urgently.
I note that it is possible that the very restricted regime imposed during the COVID-19
pandemic may have affected Mr Devereux’s mood and would have made it more difficult
for staff to pick up on any signs that his mood might have been deteriorating.
I am also concerned that when staff found Mr Devereux hanging, they did not call a
medical emergency code or provide the correct location of the cell. This caused an
unnecessary delay in Mr Devereux receiving emergency medical treatment, although this
is unlikely to have affected the outcome for him.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman March 2021
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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 2 March 2019, Mr Terrence Devereux was remanded into custody at HMP
Exeter, charged with attempted robbery. (He was subsequently sentenced to three
years in prison on 7 August.) Mr Devereux had schizoaffective disorder and
frequently harmed himself in prison. He also had a history of substance misuse and
took psychoactive substances (PS).
2. On 6 September, Mr Devereux moved to HMP Channings Wood. Over the next six
months, his mood fluctuated frequently and resulted in several incidents of self-
harm. He continued to use PS and prison staff managed him under suicide and
self-harm prevention procedures (known as ACCT) on three occasions.
3. On 30 March 2020, a supervising officer chaired an ACCT case review. He noted
that Mr Devereux did not report any thoughts of suicide or self-harm and said that
his PS use had decreased. Attendees assessed him as a low risk of suicide and
closed the ACCT document. Over the next eight weeks, prison staff monitored Mr
Devereux on a weekly basis as part of his post-closure planning.
4. At 8.27pm on 24 May, an officer who was completing prison officer entry level
training (POELT) looked through Mr Devereux’s cell observation panel to conduct a
roll check and saw him apparently kneeling on the floor. He moved to the next cell
but returned around 20 seconds later to check on Mr Devereux again. He then
noticed a ligature around his neck. At 8.29pm, the POELT officer requested
assistance and provided his location. He then opened the cell door and assessed
the situation before cutting the ligature.
5. In the meantime, a custodial manger and three officers went to the location
provided by the POELT officer and found that the cell was empty. They made their
way across the house block to where they suspected he was and found Mr
Devereux on the floor of his cell. The custodial manager requested an ambulance
and asked officers to move Mr Devereux onto the landing. He started
cardiopulmonary resuscitation (CPR) and applied a defibrillator.
6. Paramedics arrived and continued with resuscitation efforts but at 9.21pm,
pronounced that Mr Devereux had died.
Findings
7. Mr Devereux had a history of mental ill health and substance misuse problems and
his mood fluctuated frequently. We are satisfied that the prison showed concern
and compassion and tried to support his best interests.
8. While staff mostly managed Mr Devereux’s ACCT procedures well and continued to
monitor him in the post-closure period, we are concerned that they did not always
set clear or meaningful caremap actions. We have raised concerns about ACCT
management at Channings Wood before and urgent action is now required to
address the issue.
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9. We note that, like other prisoners, Mr Devereux was subject to a very restricted
regime at this time because of the COVID-19 pandemic and was spending up to 23
hours a day alone in his cell. This may have affected his mood and would have
made it more difficult for staff to pick up on any signs that his mood might have
been deteriorating.
10. While we are satisfied that the POELT officer acted appropriately by returning to
check on Mr Devereux and entering the cell, we are concerned that he failed to call
a medical emergency code and provided an incorrect location. This caused a four-
minute delay in calling an ambulance. Although calling an ambulance sooner is
unlikely to have changed the outcome for Mr Devereux, in other cases, it could be
critical.
11. The clinical reviewer concluded that the clinical care that Mr Devereux received at
HMP Channings Wood was equivalent to that which he could have expected in the
community. However, we are concerned that healthcare staff did not conduct a
secondary health screen within a week of his arrival.
Recommendations
• The Governor should ensure that staff manage prisoners at risk of suicide and
self-harm in line with national guidelines, including that staff set effective
caremap actions that are specific and meaningful, aimed at reducing risk, and
update them at each review.
• The Prison Group Director for Devon and North Dorset should assure herself
that meaningful action is being taken to ensure that ACCT procedures at
Channings Wood improve.
• The Governor should ensure that all prison staff are made aware of and
understand their responsibilities during medical emergencies, including that staff
promptly use an emergency code to communicate the nature of the emergency
and provide their correct location.
• The Head of Healthcare should ensure that healthcare staff offer all prisoners a
full general health assessment within a week of their arrival, in line with PSO
3050.
• The Governor should ensure that a copy of this report is shared with the POELT
officer and a supervising officer and that a senior manager discusses the
Ombudsman’s findings with them.
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The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Channings Wood
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Devereux’s prison and
medical records.
14. The investigator interviewed eight members of staff between 7 and 8 July. NHS
England commissioned a clinical reviewer to review Mr Devereux’s clinical care at
the prison. The investigator and the clinical reviewer jointly interviewed healthcare
staff. All the interviews were conducted by telephone because of the restrictions in
place during the COVID-19 pandemic.
15. We informed HM Coroner for Exeter and Greater Devon District of the investigation.
He gave us the results of the post-mortem examination. We have sent the Coroner
a copy of this report.
16. The Ombudsman’s family liaison officer contacted Mr Devereux’s mother to explain
the investigation and to ask if there were any matters they wanted the investigation
to consider. Mr Devereux’s mother wanted to know
• how did this manage to happen;
• what was known about Mr Devereux’s state of mind before his death;
• was there evidence of drug misuse before his death;
• when was his medication last given;
• why was his medication stopped;
• why was he not on suicide watch; and
• should he have been in the medical unit?
We have addressed these concerns in this report.
17. Mr Devereux’s mother received a copy of the initial report. She did not raise any
further issues or comment on the factual accuracy of the report.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out a factual inaccuracy and this report has been amended
accordingly. The action plan has been annexed to this report.
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Background Information
HMP Channings Wood
19. HMP Channings Wood is a medium security prison near Newton Abbot in Devon. It
holds approximately 700 men. Care UK provides healthcare and substance misuse
services. There is nursing cover from 7.30am to 6.00pm on weekdays and from
8.30am to 5.30pm on weekends. Devon Doctors provide an out of hours GP
service.
HM Inspectorate of Prisons
20. The most recent full inspection of HMP Channings Wood was in September 2018.
Inspectors reported that some efforts had been made to improve standards since
their last inspection in October 2016 but they were not co-ordinated, and previous
recommendations had not been implemented. Inspectors assessed the prison
outcomes as not sufficiently good in all four areas of their healthy prisons test –
safety, respect, purposeful activity, and rehabilitation and release planning.
21. HMIP carried out an independent review of progress at Channings Wood on 1 to 3
July 2019. Inspectors found that the prison had responded positively to the findings
and recommendations from the September 2018 inspection and had moved ahead
in the great majority of areas, where weaknesses had been identified. Good
progress had been made on understanding the drivers of self-harm and an action
plan had been produced. However, the actions were not consistently carried out or
updated regularly.
Independent Monitoring Board
22. 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 31 August 2019, the IMB
reported that although the prison had made reasonable progress to identify and
support prisoners who self-harmed, they remained concerned by the number of
self-harm incidents. The IMB welcomed the addition of several drug supply
reduction measures but remained concerned about the availability of PS and the
limited number of suspicion-based drug tests due to resourcing issues.
Previous deaths at HMP Channings Wood
23. Mr Devereux was the eighth prisoner to die at Channings Wood since May 2018.
Of the previous deaths, two prisoners took their own lives, three died from natural
causes and two were drug-related. We have previously made a recommendation
about the management of suicide and self-harm prevention procedures which
Channings Wood agreed to implement.
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Assessment, Care in Custody and Teamwork (ACCT)
24. ACCT is the Prison Service care planning system used to support prisoners at risk
of suicide and self-harm. The purpose of ACCT is to try to determine the level of
risk, how to reduce risk and how best to monitor and supervise the prisoner. After
an initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
carried out at irregular intervals to prevent a prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
25. As part of the process, a caremap (a plan of care, support and intervention) is put in
place. The ACCT plan should not be closed until all the actions on the caremap
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
26. On 2 March 2019, Mr Terrence Devereux was remanded to HMP Exeter, charged
with attempted robbery.
27. Mr Devereux had schizoaffective disorder (a condition where psychotic and mood
disorder symptoms present together, or within a two-week period). He was
prescribed a zuclopenthixol (an antipsychotic), which he took by slow-release depot
injection every two weeks. Mr Devereux had a history of substance misuse and
frequently took illicit psychoactive substances (PS) in prison.
28. On 7 August, Mr Devereux was sentenced to three years in prison and returned to
Exeter. A nurse saw him for a review and recorded that he did not report any
thoughts of suicide or self-harm.
29. On 10 August, Mr Devereux took an overdose of paracetamol but refused to go to
hospital for treatment. He signed a medical disclaimer and prison staff started
suicide and self-harm prevention measures (known as ACCT). On 15 August,
prison staff stopped ACCT monitoring as Mr Devereux presented as more settled
and was consistently taking his medication.
HMP Channings Wood
30. On 6 September, Mr Devereux was moved to HMP Channings Wood. At an initial
reception screen, a nurse recorded that he had a history of mental health and
substance misuse problems. Mr Devereux did not report any thoughts of suicide or
self-harm and she referred him to the mental health and substance misuse teams.
However, there is no record of a secondary health screen.
31. On 10 September, a secondary care mental health nurse visited Mr Devereux to
conduct a review. She recorded his diagnosis of schizoaffective disorder and noted
that he did not report psychotic symptoms. Later that day, a drug recovery worker
conducted a welfare check after staff observed Mr Devereux under the influence of
PS. Mr Devereux told her that his cellmate was a PS user and that he found it
difficult to resist. The mental health nurse provided harm minimisation advice and
referred him to the PS support group.
32. On 12 September, a drug recovery worker reviewed Mr Devereux’s substance
misuse records from the previous six months and conducted an initial assessment.
She noted that Mr Devereux spoke openly and recognised that he needed to
change his thinking about drugs. They agreed a recovery care plan, which included
in-cell work and attending group work.
33. On 5 October, prison staff started ACCT procedures after Mr Devereux made
superficial cuts to his arms and legs. The following day, a supervising officer
chaired a first ACCT case review which a member of healthcare staff attended. He
noted that Mr Devereux said that he had self-harmed due to feeling bored,
struggling to sleep and having a PS debt of £35. Attendees assessed his risk of
suicide as low and added four actions to the caremap, which included checking his
prison employment status and arranging a mental health review.
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34. On 13 October, Mr Devereux handed a letter to staff asking to remain in his cell as
he had been assaulted. Officers reviewed the wing CCTV footage but saw no
evidence of an assault. Later that day, officers found Mr Devereux hanging by a
ligature in his cell and he was taken to hospital. He returned to prison the next day
and staff moved him to the vulnerable prisoner unit (VPU) for his own safety.
35. On 16 October, a prison manager chaired an ACCT case review. He recorded that
Mr Devereux presented with a brighter outlook and said that he would try to stay off
drugs. One action was added to his caremap: purposeful activity to keep occupied.
36. On 8 November, a supervising officer chaired an ACCT case review which a prison
psychiatrist, attended. Mr Devereux said that he had stopped taking his depot
injection in the community but had started it again in prison and felt it was helping
him to manage his psychotic thoughts. The psychiatrist suggested that Mr
Devereux should also re-start sodium valproate to help stabilise his moods.
However, Mr Devereux often failed to collect it from healthcare staff.
37. On 9 November, a supervising officer chaired an ACCT review and recorded that
Mr Devereux engaged well. Mr Devereux said he was willing to meet with a family
support worker for support with his complex family situation and to explore the
possibility of contacting his son. However, there is no record that staff added these
actions to the caremap.
38. On 18 November, a supervising officer moved Mr Devereux to a safer cell (a cell
designed to minimise ligature points) on the VPU after he told staff that he had
thoughts of self-harm. The next day, a supervising officer chaired an ACCT case
review and recorded that Mr Devereux told attendees that he had tried to hang
himself overnight. He said that he had stopped taking PS and identified feelings of
withdrawal as a possible trigger.
39. On 13 January 2020, a supervising officer chaired an ACCT case review which the
mental health nurse attended. Mr Devereux reported feeling more settled since he
had left the main wing and said that he was doing a media studies course. The
supervising officer noted that Mr Devereux had set days for his depot injections
which really made a difference to his mood. Attendees assessed his risk of suicide
as low and agreed to stop ACCT monitoring.
40. On 14 January, the family support worker saw Mr Devereux for an initial family
support session and recorded that he had not had contact with his son for seven
years due to his drug use. The next day, she contacted Mr Devereux’s mother who
told her that he would have had contact with his son, if he had not gone back to
prison. The family support worker noted that she had told Mr Devereux that it would
take a long period of abstinence and a change in his behaviour for him to establish
contact.
41. On 21 January, a supervising officer chaired an ACCT case review which two
members of mental health staff attended. The supervising officer recorded that staff
had re-started ACCT monitoring overnight after Mr Devereux said that he was
hearing voices and wanted to ‘end it all’. Mr Devereux told attendees that he was
no longer hearing voices and that although he still had some PS debt, he should
have cleared it by the end of the week. Attendees assessed his risk of suicide as
low and set his ACCT observations at one an hour.
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42. On 22 January, a supervising officer chaired an ACCT case review. He recorded
that Mr Devereux had a good support network of staff around him and said that he
was hoping to be released on Home Detention Curfew (HDC, a scheme that allows
prisoners to be released early to a suitable address with an electronic tag) in June.
Attendees assessed his risk of suicide as low and placed the ACCT document into
an extended period of post-closure to allow him access to weekly support.
43. At 8.31pm on 2 February, a custodial manager noted that an officer had re-started
Mr Devereux’s ACCT procedures after he told him that he was going to drink water
until it caused him to self-harm. The custodial manager requested hourly ACCT
observations and a review the next day.
44. On 3 February, a supervising officer chaired an ACCT case review which a mental
health nurse attended. A supervising officer recorded that Mr Devereux said that he
felt bored in his cell and had not been showering which had annoyed him. She
contacted the activities’ department and they told her that they had removed him
from the media course for missing too many sessions. Mr Devereux told attendees
that he did not want to live in a safer cell any longer and the mental health nurse
agreed that it would be appropriate from him to move. Mr Devereux did not report
thoughts of suicide or self-harm and attendees agreed to put the ACCT procedures
into a post-closure period. He moved to a standard single occupancy cell on 26
February.
45. On 9 March, a supervising officer conducted a post-closure review and noted that
given Mr Devereux’s mental health history, the ACCT would remain in a post-
closure period until a supervising officer who worked on the wing could review it.
On 16 March, a supervising officer saw Mr Devereux for a post-closure review and
closed the ACCT.
46. On 10 March, a drug recovery worker conducted a 13-week substance misuse
review and recorded that Mr Devereux engaged well and spoke proudly about
having stopped using PS for two weeks and being debt-free. She recorded that he
had completed the relapse prevention workbook in full, attended all his counselling
sessions and completed all his in-cell work. At 12.45pm on 23 March, an officer
started ACCT procedures after Mr Devereux made several superficial cuts to both
his arms. At 2.15pm, a safer custody administrator conducted an ACCT
assessment and noted that it was the first time that Mr Devereux had harmed
himself in around four to five weeks. Mr Devereux said that he was struggling to
budget his money and became stressed when he could not buy ‘caps’ (nicotine
capsules for electronic cigarettes). He said that he was struggling from PS
withdrawal and was finding it hard to say no.
47. Immediately afterwards, a supervising officer chaired a first ACCT case review
which an officer, the safer custody administrator and a mental health nurse
attended. Mr Devereux told attendees that he had developed a low mood after
taking PS which led to him cutting his arms. He said that he was in debt to the
value of £4 but would clear it that week. Mr Devereux did not report any thoughts of
suicide or self-harm but attendees decided to keep hourly ACCT monitoring in place
for a period of stability. They identified boredom and a lack of income as an issue
and added one action to the caremap: apply for a prison job.
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48. On 30 March, a supervising officer chaired an ACCT case review which an officer
attended. Healthcare staff did not attend but a nurse provided an update before the
meeting. The supervising officer recorded that Mr Devereux engaged well and did
not report any thoughts of suicide or self-harm. He said that he had ‘sorted’ his
debt and that his PS use had declined. Attendees assessed him as a low risk of
suicide and put the ACCT into a post-closure period.
49. On 7 April, a supervising officer conducted an ACCT post-closure review and
recorded that due to Mr Devereux’s fluctuating risk of harm to himself, the ACCT
would stay in in post-closure until he, as the case manager, decided to close the
ACCT procedures.
50. On 9 April, the drug recovery worker temporarily closed Mr Devereux’s substance
misuse file due to COVID-19 regime restrictions. She noted that she would send
him a letter to explain the situation and outline his outstanding recovery plan
objectives.
51. On 14 April, a supervising officer conducted a post-closure review and extended the
post-closure review period for another two weeks to ensure there was further
stability for Mr Devereux.
52. On 28 April, a supervising officer conducted a post-closure review and recorded
that due the current COVID-19 pandemic, he had decided to extend the review
period for another two weeks. Later that day, a nurse saw Mr Devereux for a
review and recorded that he presented as stable and that he did not display signs of
intoxication. Mr Devereux did not report any thoughts of suicide or self-harm and
she gave him a distraction pack.
53. On 12 May, a physical education instructor (PEI) conducted an ACCT post-closure
review and noted that Mr Devereux would remain in post-closure for another week
as he was struggling with the reduced regime. (Prisoners were subject to a very
reduced regime at this time in response to the COVID-19 pandemic.) The PEI
suggested that he should find something to occupy his mind during the extended
period he spent in his cell and suggested that he considered reading a book.
54. On 15 May, a mental health nurse attended a CPA review meeting and the prison
psychiatrist joined by telephone. Mr Devereux told staff that he had not used PS for
two weeks and that he was having paranoid thoughts in the days leading to his
depot injection. He said that he was due to be released on HDC to a probation
approved premises in July but would prefer to live with his mother. The prison
psychiatrist recorded that Mr Devereux had failed to accept that his substance use
may have triggered his paranoia and that staff would need to refer him to a
community mental health team before release.
55. On 19 May, a supervising officer conducted an ACCT post-closure review and
noted that Mr Devereux’s risk of suicide and self-harm had been ‘fairly stable’
recently. He recorded that as Mr Devereux’s mood was liable to fluctuate, the
ACCT would remain in extended post-closure.
56. On 21 May, a nurse reviewed Mr Devereux having liaised with a probation officer.
She explained why he had to live at an approved premises and told him that if he
engaged with his licence conditions, the possibility of staying with his mother would
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be re-assessed. Later that day, a nurse gave Mr Devereux his fortnightly depot
injection.
57. On 22 May, an officer visited Mr Devereux on behalf of the prison’s safer custody
department to conduct a random check as he was classified as a vulnerable
prisoner. He recorded that Mr Devereux said that he was okay but did not want to
engage in conversation.
Events of Sunday 24 May
58. At 6.50pm, an officer looked through Mr Devereux’s cell observation panel to
conduct a roll check. She told the investigator that he was sitting on his bed and
said “yes” when she asked if he was okay.
59. At 8.27pm, an officer who was completing prison officer entry level training (POELT)
and had been assigned operational support grade (OSG) duties, looked through Mr
Devereux’s cell observation panel to conduct a roll check. He saw Mr Devereux in
a kneeling position on the floor at the back of his cell, closed the panel and moved
to the next cell. Around 20 seconds later, he returned to Mr Devereux’s cell to
check on him and saw that he had a ligature around his neck that he had attached
to the window fitting.
60. At 8.29pm, the prison officer entry level training radioed to request assistance and
to inform staff that a prisoner was hanging. He gave his location as house block 1,
Thames, cell 44. He then broke the security seal on his key pouch, opened the cell
door and stood in the doorway while he assessed the situation. Having assured
himself that Mr Devereux was hanging, he cut the ligature and checked him for a
pulse.
61. In the meantime, a custodial manager, a supervising officer and two officers arrived
at Thames, cell 44, and found that it was empty. They made their way across the
living block to Mersey, where the other cell 44 was located, and found Mr Devereux
slumped on the floor against the back wall of his cell, with the ligature that had just
been cut, still around his neck.
62. At 8.33pm, the custodial manager requested an ambulance and asked officers to
remove the ligature and to move Mr Devereux onto the landing for easier access.
He then started cardiopulmonary resuscitation (CPR) and requested a defibrillator.
The defibrillator did not identify a shockable pulse and advised to continue CPR.
Healthcare staff were not available as the emergency took place out of hours.
63. The first ambulance reached the prison at 8.40pm and paramedics arrived at Mr
Devereux’s cell at 8.46pm. The paramedics took over the resuscitation effort and
pronounced that Mr Devereux had died at 9.21pm.
64. Mr Devereux had left a note in his cell that said he was “sick of the smell of the
world” and just wanted to die.
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Contact with Mr Devereux’s family
65. That evening, the prison appointed a custodial manager as the family liaison officer.
She noted that there were security markers for the address meaning police
involvement was required. At around midnight, the custodial manger and the
governor arrived with the police at the address that Mr Devereux had provided for
his mother, who was his named next of kin, but she no longer lived there. The
police identified another address about 16 miles away and offered to ask local
police officers to attend. The custodial manager told us that they accepted the offer
because they were conscious of the time and did not want his family to find out that
he had died from prisoners with access to illicit mobile phones. The police broke
the news to Mr Devereux’s mother in the early hours of the morning.
66. At 12.25pm on 25 May, the custodial manager phoned Mr Devereux’s mother and
left her a voicemail. At 7.15pm, she returned a call from Mr Devereux’s sister and
offered her condolences and support. Mr Devereux’s sister asked to be the main
point of contact as her mother was upset and angry. The custodial manager made
several attempts to contact Mr Devereux’s mother and sister over the following
weeks and wrote to his mother on several occasions offering support. She did not
receive a response.
67. The prison contributed to the cost of Mr Devereux’s funeral, in line with national
policy.
Support for prisoners and staff
68. After Mr Devereux’s death, a prison manager debriefed the staff involved in the
emergency response to offer support. The staff care team also offered support.
69. The prison posted notices informing other prisoners of Mr Devereux’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 Devereux’s death.
Post-mortem report
70. A post-mortem examination found that Mr Devereux died of suspension by ligature.
Toxicology analysis of Mr Devereux’s blood did not identify any illicit substances,
including PS, but did find higher levels of zuclopenthixol than generally seen in
therapeutic use. However, the report concluded that the increased blood
concentration could have occurred after Mr Devereux died.
Events after Mr Devereux’s death
71. On 3 June, staff submitted an intelligence report indicating that five prisoners had
bullied Mr Devereux. It is alleged that they were selling him PS at an extortionate
rate and manipulating him to damage property.
72. On 4 June, the prisons safer custody department received an anonymous letter
from a prisoner stating that Mr Devereux was being bullied and threatened over a
PS debt he owed. The letter says that prisoners got Mr Devereux hooked on PS,
charged him twice the normal price, put pressure on him to pay and planned to
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enter his cell and assault him. It also says that the prisoners forced Mr Devereux to
damage his cell and to throw items out of the window to take £5 off his debt.
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Findings
Managing risk of suicide and self-harm
73. Mr Devereux was monitored under ACCT procedures on three occasions at
Channings Wood and spent a significant amount of time in a safer cell. For the
most part, prison staff managed the ACCT process well. The case reviews indicate
that they made concerted efforts to work with Mr Devereux to reduce his risk and
that healthcare involvement in the process was frequent. Both prison and
healthcare staff demonstrated compassion and understanding and tried to support
Mr Devereux by referring him to various programmes.
74. When Mr Devereux presented as emotionally stable, prison staff stopped ACCT
procedures. However, they took the unusual step of monitoring him weekly by
extending the post-closure period because Mr Devereux was struggling with the
very restricted regime during the COVID-19 pandemic. Mr Devereux’s ACCT had
been in post-closure for around nine weeks when he died and there was no
evidence to suggest that he was at an increased risk of suicide. A supervising
officer told the investigator that he did not notice anything unusual about Mr
Devereux in the days following his post-closure review on 19 May and that staff did
not report any concerns. We are satisfied that staff acted appropriately and could
not reasonably have predicted Mr Devereux’s actions.
75. However, we note that, like other prisoners, Mr Devereux was spending up to 23
hours a day in his cell – a single cell in his case – at the time, without access to his
normal activities and that this may have been particularly difficult for a prisoner who
was subject to mood disorders. Although an officer checked Mr Devereux on behalf
of the prison’s safer custody department two days before his death, his contact with
wing staff would have been much reduced and it would therefore have been more
difficult for staff to pick up on signs that his mood might be deteriorating.
76. Although the prison received intelligence after Mr Devereux had died indicating that
he may have been bullied over PS debt, there is no record that he reported any
concerns about debt in the weeks leading to his death. A supervising officer told us
that staff regularly spoke to Mr Devereux about debt and helped him to spread his
vape capsules across the week so that he would be less tempted to borrow from
prisoners. However, he also said that Mr Devereux did not view debt as an issue
and was not keen to engage in a debt management programme. We note that Mr
Devereux did not mention debt in his suicide note. We are satisfied that prison staff
offered appropriate support to Mr Devereux.
77. However, despite the positive work, we are concerned that not all caremap actions
set for Mr Devereux were sufficient. PSI 64/2011 on safer custody states that
completing a caremap is an integral part of the ACCT process and that it must
reflect the prisoner’s needs, level of risk and the triggers of their distress. The PSI
also notes that a caremap should be tailored to the individual needs of the prisoner
and be time-bound.
78. Prison staff did not add any actions to the caremap between 16 October 2019 and
11 February 2020. Although staff identified several actions and arranged for these
to take place, such as meeting with the family support worker and offering Mr
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Devereux support with debt management, they did not include these in the caremap
despite indicating that it had been updated. A supervising officer told us that he did
not always add to the caremap and may have recorded that he had updated it in
error. He also said that he did not add debt management to the caremap as it was
an ongoing issue and would have prevented staff from closing the ACCT document.
We consider that staff should have at least set a time-bound action to discuss debt
management with Mr Devereux and ensured the caremap was updated.
79. Channings Wood have previously accepted our recommendations intended to
address the quality of ACCT procedures but we are concerned that we have again
identified deficiencies in this report. In response to a previous investigation, the
prison told us in November 2019 that they had appointed a full-time custodial
manager to Safer Custody and that part of their role was to ensure ACCT
compliance. They also said that ACCT documents were scrutinised at monthly
Safer Custody meetings to provide assurances that staff used them correctly.
80. While we recognise that Channings Wood has made positive steps to improve
ACCT management, we are concerned that six months after having implemented
these changes, our investigation of Mr Devereux’s death shows that caremaps
continue to be inadequate and that the prison’s response to our previous
recommendation does not appear to have been entirely effective. We therefore
consider that urgent action is now required to ensure that ACCT procedures
improve. We make the following recommendations:
The Governor should ensure that staff manage prisoners at risk of suicide
and self-harm in line with national guidelines, including that staff set effective
caremap actions that are specific and meaningful, aimed at reducing risk, and
update them at each review.
The Prison Group Director for Devon and North Dorset should assure herself
that meaningful action is being taken to ensure that ACCT procedures at
Channings Wood improve.
Roll check
81. The purpose of a roll check is to ensure that all prisoners are accounted for and to
check that they are alive and well. When a POELT officer carried out a roll check at
8.27pm, he noticed that Mr Devereux was kneeling on the floor beside his bed and
moved to the next cell. He told the investigator that he suddenly thought that
something was not quite right, so he returned to Mr Devereux’s cell to check on him
again. He said that it was at this point that he saw a ligature around his neck.
While this caused a delay of around 20 seconds, we are satisfied that he acted
appropriately in the circumstances.
Emergency response
82. PSI 03/2013 on medical response codes requires prisons to have a two-code
medical emergency response system. Channings Wood’s local policy instructs staff
to use a medical code blue to indicate an emergency when a prisoner is
unconscious, or has breathing difficulties. Calling an emergency medical code
should automatically trigger the control room to call an ambulance, and for staff to
attend with the appropriate equipment.
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83. The POELT officer responded swiftly when he saw that Mr Devereux had tied a
ligature around his neck. He broke the security seal on his key pouch, entered the
cell after risk assessing the situation and cut the ligature. While we are satisfied
that this action was appropriate, we are concerned that the requested assistance
instead of calling an emergency medical code. This meant that staff did not call an
ambulance or collect a defibrillator until the custodial manger asked them to. This
caused a delay of around four minutes. The POELT officer told the investigator that
he was aware of the local emergency response policy and that, in hindsight,
recognised that he should have radioed a code blue.
84. We are also concerned that the POELT officer gave an incorrect location over the
radio. This meant that responding staff went to the wrong cell, adding to the time it
took for them to reach Mr Devereux and to request an ambulance. The POELT
officer told us that he mistakenly provided the wrong location in the heat of the
moment. While we appreciate that finding a prisoner in these circumstances is
distressing, it is essential that staff provide correct information.
85. Although calling an ambulance sooner is unlikely to have changed the outcome for
Mr Devereux, in other cases, it could be critical. We therefore make the following
recommendation:
The Governor should ensure that all prison staff are made aware of and
understand their responsibilities during medical emergencies, including that
staff promptly use an emergency code to communicate the nature of the
emergency and provide their correct location.
Clinical care
86. The clinical reviewer concluded that the healthcare that Mr Devereux received at
HMP Channings Wood was equivalent to that which he could have expected to
review in the community. Mental health staff reviewed him frequently, attended
ACCT reviews, completed comprehensive mental health assessments and spoke to
him on several occasions about the negative effect of his substance misuse on his
mental health. There was, however, one aspect of Mr Devereux’s care that the
clinical reviewer considered required improvement, namely that healthcare staff did
not complete a secondary health screen.
87. Prison Service Order (PSO) 3050 on the continuity of healthcare for prisoners
requires that newly arrived prisoners should be offered a general health
assessment in their first week. This did not happen. While we recognise that a
mental health nurse and a recovery worker reviewed Mr Devereux within his first
week, it was particularly important for healthcare staff to have conducted a
secondary health screen to ensure that he received prompt and appropriate
support.
88. We are satisfied that, overall, the clinical care that Mr Devereux received at
Channings Wood was of a satisfactory standard. However, we make the following
recommendation:
The Head of Healthcare should ensure that healthcare staff offer all prisoners
a full general health assessment within a week of their arrival, in line with
PSO 3050.
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Learning Lessons
89. We have identified a number of concerns in this report. We consider it is important
that staff learn from our findings. We recommend the following:
The Governor should ensure that a copy of this report is shared with the
POELT officer and a supervising officer and that a senior manager discusses
the Ombudsman’s findings with them.
Inquest
90. At the inquest, which took place on 6 May 2025, the Coroner concluded that Mr
Devereux died as a consequence of suspension by ligature.
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