Care given to prisoner found dead in cell ‘unacceptable’
APRISONER found dead in his HMP Bristol cell had not been spoken to for more than five and a half hours, according to a report.
The Prisons and Probations Ombdusman carried out an investigation into the death of Shaun Dewey after he was found hanged in his cell at HMP Bristol on April 13, 2018.
The report says no member of staff spoke to the 30-year-old or noticed he was not collecting his meals for more than five and a half hours and describes this as “unacceptable”.
A prison service spokesperson said, since Mr Dewey’s death, they have enhanced support for vulnerable prisoners and given staff extra training.
Mr Dewey – an electrician from Redditch – had been charged with murder and grievous bodily harm in September 2017 and was transferred to HMP Bristol in January 2018 for his own safety, the report explains.
Prisons and Probation Ombudsman Sue McAllister writes in the report: “It was his first time in prison.
“In November 2017, he self-harmed after being assaulted by another prisoner, and in January 2018, he was moved to Bristol where it was thought he would be safer. He remained extremely anxious that he and his family were at risk of harm as a result of his offence.
“Although he was appropriately monitored under suicide and selfharm prevention procedures (known as ACCT) when he first arrived at Bristol, I am concerned that the ACCT was closed prematurely and that staff gave too much weight to Mr Dewey’s assurances that he had no suicidal intentions and insufficient weight to his risk factors and extreme anxiety which remained unchanged.
“I am also concerned that staff did not notice that Mr Dewey had not collected his meals or medication and that no one had spoken to him for at least five and a half hours before he was discovered hanged in his cell. This was unacceptable.”
Mr Dewey was moved to the Vulnerable Prisoners’ Unit on February 1, 2018, but was reluctant to leave his cell, not collecting his antidepressants or meals on several occasions. Prison staff appropriately monitored Mr Dewey under ACCT procedures from January 4 to February 12, the report says.
But on February 12, staff stopped ACCT monitoring as they considered Mr Dewey appeared positive and he assured them that he felt more settled – a decision which has been described as “premature” by the ombudsman.
The clinical reviewer concluded the mental health care offered to Mr Dewey did not match the provision that could be expected in the community for someone with enduring depression after a serious and deliberate attempt of self-harm, the report states.
The report says Mr Dewey was found hanged in his cell when staff doing a lunchtime check just before midday on April 13, having last been seen alive between 5am and 6am.
The report said: “An officer should have spoken to him when unlocking his cell for the first time after the night shift; when he did not collect breakfast or his medication; when cells were locked after breakfast; when cells were unlocked for an association period and collection of lunch; and when he did not collect his lunch. “We are concerned that no member of staff spoke to Mr Dewey or noticed that he was not collecting his meals for more than five and a half hours. This was particularly unacceptable given the concerns that should have existed about Mr Dewey’s social isolation.”
The report makes several recommendations, all actioned according to the prison service, including producing clear guidance about procedures for identifying prisoners at risk of suicide and self-harm and for managing and supporting them.
The Ombudsman has also recommended that out of character or unusual behaviour is recorded by staff and discussed at shift handover, together with staff satisfying themselves of a prisoner’s safety and welfare when a cell door is unlocked.
A Prison Service spokesperson said: “Our thoughts remain with the family of Mr Dewey.
“Since his death in 2018, we have enhanced support for vulnerable prisoners and given staff extra training.”
In November 2019, an inquest into Mr Dewey’s death found he was failed by HMP Bristol.
Last year, inspectors found the jail still had worryingly high levels of suicide and self-harm among prisoners.
The ombudsman report states there have been 13 deaths at Bristol since 2016, seven self-inflicted, and recommendations have previously been made about the management of the ACCT process after three prisoners died within 48 hours of arrival.
❝ No member of staff spoke to Mr Dewey or noticed he was not collecting his meals for more than five and a half hours Official report