Prisons and Probation Ombudsman finds staff at HMP Doncaster failed in their duty after death of 18-year-old inmate

On 1 March 2023, Mr Kevin Smith, who was 18 years old, was remanded to HMP Doncaster charged with various offences including burglary and theft of a motor vehicle. Mr Smith had been released on licence from HMYOI Wetherby a little over a week earlier and had failed to arrive at an approved premises where he was required to live for a period of time.

Mr Smith was very briefly supported through prison suicide and self-harm monitoring procedures (known as ACCT) on three occasions in April 2023. On the first two occasions, Mr Smith cut himself and said he did so because he was under threat and was also having difficulties with his partner.

On the third occasion, Mr Smith said that he had showed an officer his existing cuts and had just been wasting staff time as he was bored.

At 8.50am on 22 April, an officer found Mr Smith hanging in his cell. The officer radioed a medical emergency code and went into the cell, followed immediately by another officer.

The officers cut the ligature and started cardiopulmonary resuscitation (CPR). Nurses arrived two to three minutes later. They noted that Mr Smith had signs of rigor mortis but continued to give CPR.

Ambulance paramedics arrived at 9.03am and after checking Mr Smith, they instructed that efforts to try to resuscitate him should stop as he was dead.

Staff found a letter in Mr Smith’s cell which made clear his intent to die.

The report findings stated: “ACCT support for Mr Smith ended with insufficient exploration of his concerns or consistent attendance of healthcare staff at reviews.

“Mr Smith did not have a consistent key-work officer. He ran out of phone credit twice in the days before his death, meaning he could not make calls to family or friends as and when he wanted or needed to.

“Officers did not make a routine check of prisoners at 6.15am on 22 April as required.”

The report recommends the following:

• The Director and Head of Healthcare should ensure that there is a robust quality assurance process to ensure that healthcare staff attend ACCT reviews in line with policy to facilitate an informed and considered approach to risk management.

• The Director should ensure that intelligence regarding a prisoner feeling at risk is properly investigated, the prisoner is appropriately supported and that there is a quality assurance process in place to ensure that this is being routinely done.