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Jury finds failings in ACCT process possibly contributed to Lee Robinson’s death

A five-day inquest into the death of Lee David Robinson concluded on 18 October 2024. Mr Robinson died in his cell in HMP Leeds on 11 December 2022, his thirty-ninth birthday. The jury concluded that Mr Robinson died by suicide, and found that failures in the ACCT process possibly contributed to his death. 

Mr Robinson’s family said at his inquest: ‘Lee was a wonderful son and a dedicated father to his children. He was quite a character; he loved to laugh, play pranks, and was one of the most genuine souls anyone could meet. He was very much a lad’s lad, and his passion was always cars and bikes. He also played rugby and loved to watch football. He cared for everyone around him and took the time to help others. He had many friends and was loved by so many in our community’.

Over the course of the inquest, the jury heard evidence that:

  • Mr Robinson had intervened in an argument between a man and a woman on a night out with friends, striking the man with a single punch which knocked him to the ground. Mr Robinson learned whilst in police custody that the victim, Jack Kirmond, had died from his injuries. Mr Robinson was ‘absolutely devastated’ and ‘couldn’t live with himself’ as a result of Mr Kirmond’s sad death.

  • Mr Robinson was charged with murder and was remanded into custody at HMP Leeds on 10 August 2022. Throughout his stay in custody, he awaited news about whether his charge would be dropped from one of murder to one of manslaughter. The uncertainty around his charge, and guilt about Mr Kirmond’s death, caused Mr Robinson anxiety and was a key driver of his risk of suicide.

  • Mr Robinson had made a number of previous suicide attempts and made a further attempt on his own life on the journey from court to HMP Leeds. Mr Robinson was identified as being at a high risk of suicide upon entry to HMP Leeds and was placed on an Assessment, Care in Custody and Teamwork (‘ACCT’) plan (a care plan for prisoners who are at risk of self-harm or suicide) from the outset, which remained in place until his death – an unusually long time for an ACCT to be in place. 

  • Mr Robinson was placed on constant observation for two periods whilst at HMP Leeds, and made a further attempt on his own life shortly after one such period of constant observation was relaxed. His ACCT observations were reduced over the following months, and at the time of his death, Mr Robinson’s ACCT plan stipulated six observations at irregular intervals overnight and three meaningful conversations per day, in the morning, afternoon and evening.

  • In the days before his death, Mr Robinson had been unwell and had reported during a telephone conversation that he couldn’t stop crying and was crying ‘every time I stand up’. CCTV showed that Mr Robinson left his cell at 11:48 on 10 December 2022, but did not leave his cell again before being found just after 14:00 the following day.

  • The Prison Service Instruction applicable to the ACCT process states of the requirement to carry out meaningful conversations that: ‘In addition to the conversation itself being meaningful, the written summaries of these also need to be meaningful and sufficiently detailed to effectively convey the key details of what was discussed’. It further states: ‘The Ongoing Record must be completed daily, with observations and conversations carried out in line with levels set by case review teams and documented on the first page of the ACCT document. It is important that the Ongoing Record is filled out immediately following observations and conversations taking place’.

  • ACCT User Guidance states that: ‘All entries in the conversation and summary sections of the ongoing record must be meaningful. Recording 'no change' or 'appears okay' etc. is not acceptable’.

  • Staff support was a protective factor for Mr Robinson and day-to-day interactions were an important aspect of managing his risk.

  • In the week prior to Mr Robinson’s death, a number of boxes on the ACCT ongoing record were left blank, including where prison staff ought to have recorded meaningful conversations, summaries of Mr Robinson’s demeanour and interactions, and supervisory reviews of the ongoing record. Alex Littlewood, Head of Safety, Equalities and Segregation at the prison, said of one of the blank entries: ‘I cannot give an explanation as to why that has been missed’. 

  • There were also a number of entries which were brief and lacking in detail, such as an afternoon summary on 6 December 2022 which stated, ‘Came out for medication’. Alex Littlewood, Head of Safety and Equalities at the prison, accepted that the entry on 6 December 2022 was ‘poor’.

  • A prison officer observed that in the week prior to his death, Mr Robinson was unwell and suffered a ‘noticeable dip in his mood’ and ‘withdrew a little bit’. That officer spoke to Mr Robinson in his cell on Sunday 10 December 2022, the evening prior to his death, but Mr Robinson ‘was not in a good mood and had been a bit snappy’ and refused his medication. However, this was not recorded on the ongoing record and the space on the ongoing record where officers should have recorded the evening meaningful conversation and evening summary were left blank. The officer accepted that he did not make such records and ought to have done. Of the missing entry, Paul Ysart, now the Head of Equalities at HMP Leeds, stated: ‘Yes but that was Lee’s demeanour, it was frequently mentioned he had up and down moods. Maybe we didn’t pay enough attention on that’.

  • Mr Ysart confirmed in evidence that: ‘HMP Leeds has undertaken a significant amount of work in the last 12 months to improve safety outcomes for both staff and prisoners’, which had included training on the ACCT process and identification of risks, triggers and changes in circumstance.

In respect of the ACCT process, the jury concluded that: ‘There is not the appropriate documentation to support that all the meaningful interactions and conversations took place, as required by the ACCT guidelines. Lee’s illness prior to death may have contributed to this. Some meaningful conversations and interactions that took place were recorded, but not appropriately recorded in the ACCT documentation, which all officers and staff had access to and a responsibility to complete, and some interactions were not documented at all’. The jury found that these failings possibly contributed to Mr Robinson’s death.

The jury found, in terms of how, when, where and in what circumstances Mr Robinson came by his death: ‘Lee David Robinson, aged 39 was held at HM Prison, Leeds from 10th August 2022 onwards after being remanded in custody by Leeds Crown Court. As he was identified as being at high risk of self-harm and had a long history of undiagnosed mental health conditions, an ACCT was opened and remained in place throughout the time he was in the prison, including extended periods when he was on constant watch. Throughout this time Lee was remorseful of his actions and the impact on those affected. Lee was also facing uncertainty and delays over the pending charges against him. Lee was well liked by staff and fellow inmates and supported by his family. On 11th December 2022 (his birthday) he was seen in his single occupancy cell during the morning. Around 14:00 hours he was discovered in an unresponsive condition in his locked cell […] Emergency treatment was initiated promptly and continued by paramedics and doctors at hospital, but he could not be revived. He was pronounced dead at 15:11 hours on Sunday 11th December 2022 at Leeds General Infirmary’.

The jury further concluded that ‘Lee’s life-long struggles with mental health, lack of diagnosis of a mental health condition and uncertainty about his charge were possible contributing factors’.

The family was represented by Ruby Peacock, instructed by Iftikhar Manzoor of Hudgell Solicitors.

The inquest has been reported here: BBC News.