DP: Inappropriate response by prison officers and inadequate ACCT procedure after prisoner self-harmed
DP was a much-loved brother and father. He was incarcerated in HMP Erlestoke at the time of his death, but was due to be released just a few months later.
Whilst DP had struggled with substance abuse and depression for many years, he had worked hard to get clean in the weeks before his death. Just a few days before he died, he had come off the prison ‘basic’ regime and officers commented on how well he was doing.
However, around a week before his death, he had been prescribed antibiotics for a suspected urinary tract infection and was worried that he was having an allergic reaction to this.
On 5th August 2019 – the day he died - DP had repeatedly asked to have an antihistamine. At around 14:30, he attended healthcare but was refused access due to not having a ‘movement slip’. At 15:30 he asked his prison key worker and two members of healthcare staff who said they would sort it out for him. Shortly after, he asked a member of the wing staff who called healthcare. A plan was put in place for him to be brought to healthcare and be given an antihistamine. However, for unknown reasons, this did not happen. At 17:30, he asked another prison officer, who tried to call healthcare but could not get through. At 18:10 he asked another officer, who said he did not know anything about it but would try to call.
At this point, around 18:15, DP took some peppers – which he was allergic to – and ate them in front of the officer. The officer agreed this was an “extreme” and “desperate” act, because he wanted to go to healthcare.
The officers interpreted this as an act of self-harm, and started a procedure – known as ‘Assessment, Care in Custody and Teamwork’ (ACCT) – to keep DP safe. When informed about this, DP became very upset and distressed. He called his older sister and told her that he was going to take his own life. Officers were in the vicinity at the time. Multiple former prisoners said that DP stated he was going to kill himself, and that officers were made aware of this. At this point, DP refused to go to healthcare.
Whilst still very upset and distressed, and without being seen by healthcare, DP was put into his cell for the night lock up. He complained that he was going to get a reaction to the peppers, and said he would barricade his cell. The officer escalated this to the Oscar 2, who came to the cell but found DP was unwilling to engage and had started to barricade his cell. The officers turned around and left. Some of the former prisoners reported that they were laughing at him and joking that the door ‘swings both ways’.
DP was kept on 15-minute observations. At 19:30 he was seen to be ‘very agitated’ and barricading his cell door. At 19:45, he was seen to be packing / sorting his belongings.
Whilst the ACCT procedure was supposed to have been started at the time of the self-harm – i.e., 18:15 – it was not in fact opened until an hour later, at 19:15. There was therefore a delay of one hour and no ‘Immediate Action Plan’ (IAP) – a requirement of the ACCT procedure - was put in place at the time of DP’s death. The jury heard extensive evidence about different options that were available under the ACCT process, including constant observations, and movement to the ‘Care and Separation Unit’, the prisoner ‘Listener’ scheme, and contact with family. However, none of these measures were put in place.
At 20:00, DP was found to have covered his cell observation panel. At 20:19, officers entered his cell and found that he had taken his own life. DP had written on his cell wall complaining about how he had been treated by staff.
The jury concluded that officers did not deal with DP appropriately on the day he died, and the ACCT procedure was not appropriate or adequate, and that these failures probably contributed to DP’s death. They added that the specific failure of the delay in opening the ACCT and initiating the IAP and subsequent procedures, as well as ineffective communication, possibly contributed to his death.
Matthew Turner represented DP’s family at the inquest, instructed by Ruth Mellor and Emma Gregg and of Deighton Pierce Glynn (DPG).
The Coroner was HM Senior Coroner for Wiltshire and Swindon, Mr David Ridley. The other Interested Persons were the Ministry of Justice / HMP Erlestoke and Avon and Wiltshire NHS Mental Health Partnership NHS Trust.
Matthew is a specialist in deaths in custody. He has secured 10 neglect verdicts in different inquests since December 2021.
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