Tyrone Richards

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Tyrone Richards,
a prisoner at HMP Manchester,
on 25 October 2022
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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 HMPPS in ensuring the standard of care received by those
within service remit is appropriate then our recommendations should be focused,
evidenced and viable. This is especially the case if there is evidence of systemic failure.
Mr Tyrone Richards was found hanged in his cell at HMP Manchester, on 25 October
2022. He was 32 years old. I offer my condolences to Mr Richards’ family and friends.
Mr Richards spent almost all of his adult life in prison. Staff had managed him under
suicide and self-harm prevention procedures (known as ACCT) on several occasions,
although not for three years before he died. While he had additional risk factors for suicide
and self-harm, there was little to indicate that he was at heightened risk in the time
immediately before his death.
Mr Richards was one of a record number of prisoners serving Imprisonment for Public
Protection (IPP) to take their lives in 2022. It is important that the Governor, and other
senior leaders in HMPPS, learn from his death and others that I highlighted in my recent
Learning Lessons Bulletin about the self-inflicted deaths of IPP prisoners.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman June 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. In July 2009, Mr Tyrone Richards was charged with wounding with intent to do
grievous bodily harm. He was given an Imprisonment for Public Protection (IPP)
sentence in February 2010, with a minimum tariff of two years and 163 days.
2. In 2016 and 2018, Mr Richards was released from prison on licence after being
granted parole but was recalled both times due to poor behaviour.
3. Mr Richards had a long history of using illicit substances but refused to engage with
substance misuse services in prison. He had a history of self-harm and attempted
suicide by ligature in 2019, while in prison.
4. On 8 July 2022, Mr Richards transferred to HMP Manchester from HMP Lindholme.
Healthcare staff screened Mr Richards and found there was no indication of
significant mental health issues. However, they referred him to ‘OUTSPOKEN’, a
counselling service based in the prison. He died before he could receive his first
session.
5. On 23 September, Mr Richards was assaulted by another prisoner, who was
charged with an offence against prison discipline. Staff suspected that the assault
might have been related to debt.
6. At around 8.15am on 25 October, a prison officer attended Mr Richards’ wing to
unlock prisoners for their education classes. Mr Richards said he did not want to
attend because he had a headache.
7. At around 11.50am, two prisoners shouted to another prison officer on the landing
that they could see, through a small gap in Mr Richards’ cell door, that he had
hanged himself. Officers quickly entered the cell, called a medical emergency ‘code
blue’ and began cardiopulmonary resuscitation (CPR). Healthcare staff arrived
shortly afterwards.
8. Paramedics arrived at the cell shortly after 12.00pm and took over CPR. At
12.38pm, they confirmed that Mr Richards had died.
Findings
9. Mr Richards had a history of self-harm and attempted suicide and had been
managed under suicide and self-harm prevention procedures (known as ACCT)
several times previously. While he also had other risk factors for suicide and self-
harm, we are satisfied that there was little to indicate that he was at heightened risk
in the time before his death.
10. Mr Richards was not prioritised for key work while at Manchester and did not
therefore receive any meaningful key work sessions. Prisoners serving IPP
sentences have since been added to the priority group.
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The Investigation Process
11. We were notified of Mr Richards’ death on 25 October 2022. The investigator
issued notices to staff and prisoners at HMP Manchester informing them of the
investigation and asking anyone with relevant information to contact him. No one
responded.
12. The investigator obtained copies of relevant extracts from Mr Richards’ prison and
medical records.
13. The investigator interviewed 16 members of staff at HMP Manchester on 4 and 6
January 2023.
14. NHS England commissioned a clinical reviewer to review Mr Richards’ clinical care
at the prison. All interviews were conducted jointly with the clinical reviewer.
15. We informed HM Coroner for Manchester City of the investigation. The Coroner
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 Richards’ mother to explain
the investigation and to ask if she had any matters she wanted us to consider. Mr
Richards’ mother said that she had received two different accounts of what
happened; one was that staff had found Mr Richards and the other that prisoners
had found him. She wanted to know which account was correct. Mr Richards’
mother explained that her son had tried to hang himself on two previous occasions
and that he had a history of depression. Consequently, she asked whether staff
were checking on him regularly and, if not, whether they should have. We have
addressed Mr Richards’ mother’s questions in our report and in the clinical review.
17. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
18. Mr Richards’ mother received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Manchester
19. HMP Manchester is a high security prison designed for long-term prisoners. The
prison holds up to 744 prisoners in nine residential units, a segregation unit,
specialist intervention unit and a healthcare unit. During Mr Richards’ time at
Manchester, Greater Manchester Mental Health NHS Foundation Trust provided
24-hour nursing care.
HM Inspectorate of Prisons
20. The most recent full inspection of HMP Manchester was in September 2021.
Inspectors reported that 25% of prisoners said they felt unsafe at the time of the
inspection and those with mental health problems or other disabilities were
significantly more negative than other prisoners. Although levels of violence were
lower than at their previous inspection, the rate of serious assaults had increased.
21. Inspectors reported that the mental health team was responsive to demand,
promptly assessing patients and prioritising support. They noted that a dual
diagnosis pathway for patients with both mental health and substance misuse
needs was being used effectively.
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 28 February 2022, the IMB
reported that the prison had a steady decrease of self-harm in the early part of
2021, which mirrored trends shown across the prison estate throughout the COVID-
19 pandemic.
23. The IMB reported that levels of self-harm rose sharply in September 2021, when
COVID-19 restrictions were lifted, and has remained high ever since. To reduce this
risk of self-harm, the Head of Residence aimed to ensure that all prisoners being
monitored under suicide and self-harm prevention measures (ACCT) were allocated
a key worker to provide them with that stability of support on top of the usual ACCT
processes.
Previous deaths at HMP Manchester
24. Mr Richards was the 19th prisoner to die at Manchester since October 2019. Ten of
the previous deaths were from natural causes, two were drug-related, four were
self-inflicted and two were unclassified. Since Mr Richards’ death, two further
prisoners have taken their own lives at Manchester.
25. Our report into the death of a prisoner in May 2022 identified that the man did not
receive key work in line with expectations, despite being a priority prisoner.
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Imprisonment for Public Protection (IPP)
19. IPP sentences are indeterminate, which means that when the minimum tariff has
expired, individuals are required to demonstrate to the Parole Board that their risk
has reduced enough to be managed in the community. IPP sentences were
introduced in 2005 and abolished in 2012, but the abolition did not apply
retrospectively to those who had already received the sentence.
Assessment, Care in Custody and Teamwork (ACCT)
20. 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
carried out at irregular intervals to prevent the prisoner anticipating when they will
occur. Regular multidisciplinary review meetings involving the prisoner should be
held.
21. As part of the process, a support 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 support
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,
Management of prisons at risk of harm to self, to others and from others (Safer
Custody).
Key worker scheme
22. The key worker scheme aims to improve safer custody by engaging with prisoners,
building better relationships between staff and prisoners and helping prisoners
settle into life in prison. It provides that all adult male prisoners will be allocated a
key worker who will spend an average of 45 minutes a week on key worker
activities, including having meaningful conversations which each of their allocated
prisoners.
23. The key worker scheme was suspended across the estate on 24 March 2020 due to
the COVID-19 pandemic. To ensure that meaningful interaction continued for
priority prisoners, the Prison Service used an Exceptional Delivery Model until May
2022. This involved weekly conversations with prisoners identified as vulnerable.
24. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan, which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
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Key Events
Background
25. In July 2009, Mr Tyrone Richards was charged with wounding with intent to do
grievous bodily harm. He was given an Imprisonment for Public Protection (IPP)
sentence in February 2010, with a minimum tariff of two years and 163 days. Mr
Richards had spent most of his teenage years and adult life in prison, from the age
of 15. He was 32 years old when he died.
26. Mr Richards had a long history of using illicit substances in prison, including
psychoactive substances (PS). Staff found him under the influence of drugs several
times. They referred him to substance misuse services on several occasions,
however he generally refused to engage with them.
27. Mr Richards also had a history of anxiety and depression, for which he was
prescribed antidepressant medication. He had a history of self-harm and had
previously attempted suicide by ligature. He received EMDR (eye movement
desensitisation and reprocessing therapy) during 2017-18 at HMP Lancaster Farms
to treat Post-Traumatic Stress Disorder (PTSD).
28. Prison staff put a challenge, support and intervention plan (CSIP) in place for Mr
Richards on several occasions to manage the risk of violence he posed to other
prisoners.
29. On 24 June 2016, Mr Richards was released from prison on licence after being
granted parole. He was recalled to prison on 2 August 2017, due to poor behaviour.
30. On 7 November 2018, Mr Richards was released from prison on licence for the
second time. He was recalled again on 15 August 2019, for poor behaviour. When
he arrived in prison, Mr Richards threatened to harm himself, so staff began
monitoring him under ACCT procedures. Staff closed the ACCT procedures on 6
September.
31. From 19 October to 1 November, staff monitored Mr Richards under ACCT
procedures after he attempted suicide by ligature.
32. Between February and July 2022, Mr Richards was segregated at HMP Lindholme
on four occasions for poor behaviour, including after he produced an improvised
weapon during an adjudication hearing and attacked another prisoner with a
sharpened toilet brush.
HMP Manchester
33. On 8 July 2022, due to his poor behaviour, Mr Richards was transferred to HMP
Manchester (a Category B prison). The reception nurse completed Mr Richards’
initial health screen. She recorded that there was no indication that Mr Richards
was low in mood or thinking of self-harm. Mr Richards said that he had PTSD and
knew he should see the mental health team but said that he did not usually engage
with them. She did not record any information about Mr Richards’ self-harm history.
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34. After the reception health screening, a mental health nurse completed a mental
health triage. She recorded that Mr Richards had overdosed on drugs in the past
and had attempted suicide in 2019. She concluded that there were no signs Mr
Richards was feeling in low mood or had thoughts or plans of self-harm, so did not
make a referral to the mental health team. She referred him to ‘OUTSPOKEN’, a
counselling service based in the prison.
35. The next day, a substance misuse worker visited Mr Richards in his cell to offer
substance misuse advice and support. Mr Richards told him that he had no issues
with drugs or alcohol and did not require any support. Mr Richards received no
further input from substance misuse services.
36. On 14 July, a nurse completed Mr Richards’ second health screening. She
assessed Mr Richards’ mental health and found there was no indication of
significant issues.
37. On 25 July, a senior trauma counsellor from OUTSPOKEN completed Mr Richards’
initial trauma assessment. At interview, she told us that Mr Richards engaged quite
well and demonstrated future thinking. Mr Richards said that he had no thoughts of
self-harm. She told him that the counselling service was heavily subscribed and that
unless someone was deemed high risk, the wait was likely to be eight to nine
months. Based on her initial assessment, she did not deem Mr Richards to be high
risk. Mr Richards remained on the waiting list and received no further input from
mental health services before his death.
38. On 1 September, Mr Richards received a letter confirming that his paper-based
parole review had been unsuccessful, and that he would remain in prison until his
next review in at least two years’ time.
39. On 23 September, prison staff saw Mr Richards being punched by another prisoner
on his wing. When they spoke to Mr Richards and the other prisoner, staff could not
establish the reason for the assault, but suspected it may have been debt related.
Mr Richards said he did not want to press charges and was happy for the incident
to be dealt with via the adjudication process. (The prisoner who assaulted Mr
Richards was later found guilty of an offence against prison discipline.) The Head of
Safety told us that staff interviewed Mr Richards afterwards and that he said he was
content to remain on the same wing as the other prisoner.
25 October
40. At around 8.15am, an officer attended Mr Richards’ wing to unlock prisoners for
their education classes. When he arrived at Mr Richards’ cell, he found him lying in
bed. Mr Richards said he did not want to attend his education class because he had
a headache. In interview, the officer told us that he did not see any reason to
challenge Mr Richards, so left him in his cell and continued his duties.
Emergency response
41. At around 11.50am, two prisoners shouted to an officer on the landing that, through
a small gap in the cell door, they could see Mr Richards hanging. In interview, she
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told us that Mr Richards had covered his cell observation panel with tissue. We do
not know when Mr Richards first covered the observation panel.
42. The officer ran towards Mr Richards’ cell, opened the door and saw that he had a
ligature around his neck that was attached to the ceiling light. She climbed on to the
top bunk bed and cut the ligature.
43. Another officer and a Supervising Officer (SO) entered the cell immediately after the
first officer. At 11.51am, the SO radioed a medical emergency code blue
(requesting assistance from staff and triggering a call to the ambulance service). An
officer began cardiopulmonary resuscitation (CPR) with assistance from colleagues.
44. Around three minutes later, two nurses arrived at the cell in response to the code
blue and set up the defibrillator. One nurse told us in interview that the defibrillator
advised ‘no shock to be given’.
45. Paramedics arrived at the cell shortly after 12.00pm and took over CPR. At
12.38pm, they confirmed that Mr Richards had died.
Contact with Mr Richards’ family
46. Shortly after 5.00pm on 25 October, the prison family liaison officer (FLO) and an
operational manager travelled to the home of Mr Richards’ next of kin and broke the
news of his death.
47. Manchester contributed to the costs of Mr Richards’ funeral in line with Prison
Service instructions.
Support for prisoners and staff
48. After Mr Richards’ death, the duty operational manager debriefed the staff involved
in the emergency response to ensure they had the opportunity to discuss any
issues arising, and to offer support. The staff care team also offered support.
49. The prison posted notices informing other prisoners of Mr Richards’ 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 Richards’ death.
50. The Head of Safety told us that there is no record of support offered to the two
prisoners who found Mr Richards hanging. She said that usual procedures are for
wing staff to support them immediately following the incident and to offer them the
opportunity to speak to peers and Listeners (prisoners who have been trained by
the Samaritans to offer support to those who request it).
Post-mortem report
51. The post-mortem report concluded that Mr Richards’ cause of death was hanging.
52. Toxicology tests found that cannabis metabolites (substances produced by the body
when processing cannabis) were present in Mr Richards’ system.
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Findings
Identifying the risk of suicide and self-harm
53. Prison Service Instruction (PSI) 64/2011 ‘Managing prisoner Safety in Custody’
requires that staff who have contact with prisoners are aware of the risk factors and
triggers that might increase the risk of suicide and self-harm, so that they can take
relevant action. Any prisoner identified as at risk of suicide or self-harm must be
managed under ACCT procedures. We have considered whether staff at
Manchester should have identified Mr Richards as at risk and begun ACCT
procedures to support him.
54. Mr Richards had some risk factors for suicide and self-harm. He was serving an IPP
sentence and had spent most of his life in detention settings. He had recently had a
parole application rejected. He had a documented history of poor mental health,
suicide attempts and self-harm. Mr Richards had most recently attempted suicide
by ligature in 2019 and prison staff had managed him under ACCT procedures
several times, most recently in 2019. Around a month before he died, staff
witnessed Mr Richards being assaulted by another prisoner, which they thought
might have been related to debt.
55. While Mr Richards had these risk factors, we are satisfied that there was little to
indicate to staff that he was at immediate risk of suicide at the time of his death. Mr
Richards had not made a telephone call for around three weeks before he died and
there was no indication that he had received bad news from family or friends.
56. In September 2023, we issued a Learning Lessons Bulletin that was prompted by
the increase in self-inflicted deaths of IPP prisoners in 2022, which saw the highest
number since the sentence was introduced. We highlighted that a prisoner’s IPP
status and parole hearings should be considered as potential risk factors for suicide
and self-harm. We highlight later in this report that Mr Richards was not given the
opportunity, through the key worker scheme, to discuss these risk factors.
Assault on 23 September
57. Manchester has a local violence reduction policy which states that they will identify
and support those who are victims of violence. The policy states that all incidents
should be reported correctly, with investigations and actions undertaken.
58. Prison staff interviewed Mr Richards after he was assaulted by another prisoner,
who was charged with, and found guilty of, an offence against prison discipline
through the adjudication process.
59. The Head of Safety told us that the Safety Team has since reviewed their post-
violence procedures. Safer custody staff now complete welfare interviews after the
initial interview by wing staff, to give prisoners a second opportunity to report
concerns to a member of staff with whom they might feel more comfortable. We are
satisfied that suitable action was taken against the perpetrator of violence against
Mr Richards and that appropriate steps have since been taken to provide additional
support for victims of violence.
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Substance misuse
60. Post-mortem toxicology tests suggest that Mr Richards may have used cannabis in
the lead up to his death, which may have affected his judgement and perception.
61. While Mr Richards had a history of using illicit drugs in prison, there is no record
that he was ever suspected of using drugs at Manchester. We note that the
substance misuse service tried several times to work with Mr Richards, however he
consistently refused to engage with them. Substance misuse workers advised Mr
Richards’ of the risks of using illicit drugs and how to contact the team. The clinical
reviewer did not identify any concerns regarding substance misuse services at
Manchester.
Governor to note
Key work
62. One of the main aims of the Key Worker Scheme is to improve prisoner safety
through meaningful contact with a consistent member of staff. The scheme usually
requires 45 minutes of key work per prisoner per week, delivered by a named
officer. During his time at Manchester, Mr Richards did not receive a full key work
session and told a member of staff that he did not know who his key worker was.
Our Learning Lessons Bulletin regarding IPP prisoners highlighted that they should
be prioritised for key work and that the outcome of parole hearings and sentence
progression should be considered and covered during key work sessions.
63. The Head of Safety told us that key work delivery has fluctuated since the pandemic
but has never been above 30 per cent. She identified various reasons for this,
including staff sickness, priority escorts for Category A prisoners and provision of
staff on detached duty. She identified that Manchester has reviewed prisoner
groups who are priorities for key work and that this now includes IPP prisoners. She
told us that Manchester now allocates staff on restricted duties (such as those with
health conditions that might prevent them from completing some wider duties) to
key work to achieve better completion.
64. We appreciate that Mr Richards was not, at the time, a priority prisoner for key work
and are pleased that Manchester has broadened its definition to include IPP
prisoners. Key work is an important aspect of prison life, particularly for those who
might be vulnerable but are not supported by other means such as ACCT
procedures or through the mental health team. It is important that Manchester
continues to strive to meet its obligations in the matter.
Head of Healthcare to note
65. Shortly after his arrival at Manchester, Mr Richards was assessed by OUTSPOKEN
and added to their waiting list for counselling services, which was around eight to
nine months. The clinical reviewer identified that the commissioning of this service
at Manchester is a helpful addition to the services offered by the mental health
team, and that waiting times are broadly equivalent to those in the community.
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66. In the community those on the waiting list have access to additional sources of
support (such as drop-in meetings) while they await counselling. Mr Richards
received no additional support. The clinical reviewer found that interim mental
health input while he was waiting for counselling could have been offered to Mr
Richards, to assess his mood and potential risk.
Inquest
67. An Inquest into Mr Richards’ death was opened on 27 October 2022 and concluded
on 20 January 2025 found that Mr Richards’ cause of death was hanging.
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