'Missed opportunities' found during investigation into death of prisoner at Leyland's HMP Garth
A prison officer falsified records relating to cell checks.
A probe into the death of an inmate at Leyland’s Garth Prison has revealed ‘missed opportunities’ and falsified records by staff.
Aaron Taylor, 32, was found hanged in his cell on August 28, 2023, aged 32. He had been recalled to prison seven months before he died for breaching his licence conditions relating to a 10-year sentence for wounding with intent, and had a history of self-harm.
A Prison and Probation Ombudsman (PPO) investigation into the circumstances of his death has now concluded and a report has been issued this week.
It states that Mr Taylor struggled with being in prison and the potential length of his sentence. He was supported by the probation service suicide and self-harm monitoring procedures on three occasions while at HMP Garth, but Ombudsman Adrian Usher said: “My investigation found there was a missed opportunity for further suicide and self-harm monitoring following a self-harm incident three weeks prior to Mr Taylor’s death.”
Falsified records
His report also found that the prison officer on night duty did not complete the morning routine check and falsified records to say that he had, and the officer who was unlocking prisoners for work the morning Mr Taylor died did not take appropriate action when he found that Mr Taylor had covered his observation panel, and he did not attempt to gain a response from him.
However, the report states that Mr Taylor did not present as in crisis in the days before his death and says: “We do not think there was sufficient evidence for staff to consider him a high suicide risk.” A clinical reviewer concluded that Mr Taylor’s clinical care was equivalent to what he could have expected to receive in the community.
Recommendation
The PPO recommended that The Head of Healthcare at HMP Garth should ensure that all healthcare staff are aware of their responsibilities regarding ACCT ( Assessment, Care in Custody and Teamwork) procedures, including communicating with wing staff if there are concerns around suicide and self-harm. An action plan shows work has been done. It states: “All concerns around self-harm and suicide are communicated with wing staff and healthcare staff have been informed this is to be written in the wing observation book. All healthcare staff have been provided with ACCT training including refreshers and under responsibilities.”
Prevention of Future Deaths Report
The coroner dealing with Mr Taylor’s death issued a Prevention of Future Deaths report earlier this year, raising issues around a lack of pyschologist resources at HMP Garth, unless prisoners have been victims of sexual assault, and even then, there are reports of lengthy waiting lists.
PPG Healthcare who are now responsible for healthcare at HMP Garth, responded in February, stating that work was being done to recruit psychologists, but there was a lack of candidates in the employment market.
They said that anyone who is now referred for psychological services is allocated a health and well-being practitioner, who can undertake a lot of low level work that can be done in meantime, in preparation for psychological input. Patients requiring urgent psychological interventions are discussed at a multi professional complex case conference (MPCCC) at a local level and referred to the Regional MPCCC for review and care planning.
HMP Garth is also having discussions with the neighbouring prison, HMP Wymott, as to whether they can share their psychological resources while they await posts being filled.
A spokesman for PPG said: “We are committed to providing a high-quality healthcare service at HMP Garth and are doing everything we can to ensure those detained there are as safe as possible and receive the best quality care. We are deeply sorry that Aaron Taylor died while receiving care from our service and we will ensure that the lessons learnt are not just implemented at HMP Garth but across Practice Plus Group’s services.”
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