Jury find failings in ACCT process contributed to Jason McQuoid’s death

The inquest into the death of Jason Lee McQuoid concluded on 15 October 2024 with the jury highlighting several failures with Jason’s care – some of which contributed to his death. Jason died from hypoxic-ischaemic brain injury after he was found to have ligatured in his cell at HMP Risley on 2 March 2021. He was 37 years old.

Jason’s family were represented by Cian Murphy, instructed by Alice Wood and David Corrigan of Farleys Solicitors and also supported by Jodie Anderson of INQUEST.

In January 2021, Jason arrived at HMP Risley. As part of his reception screening, he requested mental health intervention. The jury found that a failure to refer Jason for mental health intervention at this point possibly contributed to his death. The jury heard evidence that if this had been done, he would have been considered by the mental health team within a week.

A few weeks later, Jason’s mental health deteriorated. Over the space of five days, he displayed paranoid and ‘bizarre’ behaviour, set a fire in his cell, was restrained and segregated in the Care and Separation Unit, and was monitored under suicide and self-harm prevention procedures known as ACCT (Assessment, Care in Custody and Teamwork). There were multiple missed opportunities to consider Jason’s risk. Jason’s treatment plan was to be discussed at a dual diagnosis meeting scheduled for 26 February, but the meeting was moved to 3 March, the day after Jason’s death.

The ACCT process is designed to support someone in prison who is at risk of self-harm or suicide. The jury found that the ACCT process was used as a method of gaining trained mental health input, as the mental health referral system was over-subscribed and may not have been commenced in this case.

The mental health practitioner at the initial ACCT review did not know Jason’s history, did not consider his records and was not aware of his recent presentation. The initial ACCT was closed within hours of being opened.

The next day, the ACCT was re-opened, when Jason set a fire in his cell. Jason also said, more than once, that he was going to hang himself. He made a further request to see the mental health team. 

The jury recorded inadequate communication between prison officers and the mental health team. Because of the use of agency staff, who did not have access to the prison NOMIS records, Jason’s comments about suicide were not recorded electronically. The jury found that this information was not included in the notes of the second ACCT review. The jury recorded: “This inadequate communication continued through a number of opportunities…”.

The jury also found that due to a lack of communication between reception, prison officers and the mental health team, Jason’s mental state was not fully assessed. Further, the frequency of the weekly assessment meetings did not allow for the mental health team to pick up on the rapid deterioration of Jason’s mental state. 

During the ACCT review on 28 February, information was not shared which may have led to different safeguards being taken by the mental health team. 

The jury heard evidence that, on the night of 1-2 March, Jason was on hourly observations under the ACCT process. However, the jury concluded that “a lack of a robust handover procedure and the observations not carried out irregularly to the stated frequency on the balance of probability did contribute more than minimally to Jason’s death”.