Man charged over bomb hoax took his own life in Preston Prison - investigation launched
A man charged over a bomb hoax took his own life less than a month after being remanded at Preston Prison, a report has revealed.
Paul Roberts, 37, died in hospital from hypoxic brain injury (lack of oxygen to the brain) on November 14, 2023, two days after he was found hanging in his cell at HMP Preston.
His death was the second self-inflicted death at Preston in three years. The Prison and Probation Ombudsman (PPO) launched an investigation into his death, and has made recommendations over “systemic issues” highlighted.
What happened?
On October 28, 2023, Paul Roberts was remanded in prison charged with carrying out a bomb hoax. He had been on 15-minute checks in police custody as he said he wanted to kill himself.
When he arrived at Preston, the reception nurse started suicide and self-harm monitoring, known as ACCT, and the ACCT assessor set observations at two an hour. At an ACCT review on November 6, Mr Roberts said that he had been struggling with being in prison and that he had considered suicide, and observations were increased to three an hour.
At an ACCT review four days later, Mr Roberts said that things had improved since his last review and the ACCT case manager recorded that he appeared to be more positive and future focused. The case review team agreed that Mr Roberts should continue to be supported by the ACCT process, but they reduced observations to one an hour.
Code Blue
At around 11.10am on November 12, an officer was returning Mr Roberts’ cellmate to his cell after exercise. When she could not open the door, she looked through the observation panel and saw that a cupboard was obstructing the door. The officer did not have a radio so shouted for staff assistance, and then shouted code blue - a medical emergency code.
An officer responded and the two officers, together with two prisoners, kicked the door open. They saw Mr Roberts hanging. He was lowered to the floor and around a minute later, a custodial manager arrived and started CPR. An ambulance was called and at 11.29am, paramedics arrived and took over the management of Mr Roberts’ resuscitation. The paramedics managed to regain a pulse and took Mr Roberts to hospital where he was put on a life support machine.
On November 14, a decision was made to end life support and he died shortly after. The post-mortem report concluded that Mr Roberts died from hypoxic brain injury caused by hanging.
Findings
The PPO report into the death said: “Some aspects of the ACCT were managed well and others less so.” They praised consistency by the mental health team, but said that an Immediate Action Plan was not completed because there was no supervising officer on duty on the day Mr Roberts arrived, the ACCT document lacked records of meaningful conversations and several ACCT observations were missed.
They also noted that the officer that found Mr Roberts hanging shouted a code blue, but because she did not have a radio, she could not call a code blue over the radio network. This caused a short delay in the control room calling an ambulance.
The report continues: “The clinical reviewer concluded that the care Mr Roberts received for his mental health was of a very good standard and was equivalent to that which he could have expected to receive in the community.”
Recommendations
Recommendations are that the prison governor should undertake a review of the ACCT quality assurance process to satisfy himself that systemic issues are identified, and suitable remedial actions taken in response
Prison inspection
The most recent inspection of Preston was in March 2023. Inspectors were positive about the quality of ACCT documents and said that the quality assurance by leaders meant that the standard was consistently good, although there was scope for improvements in the quality of some support plans.
The inspectors reported that the Head of Healthcare was doing an “outstanding” job and standards had improved markedly since the last inspection. Inspectors said that healthcare had a strong and proactive staff team working to improve outcomes for a population that had many difficulties with mental health and substance misuse.