Urgent steps needed after prison death - report

Urgent action is needed over a prison's self harm and suicide prevention measures following a man's death, the prisons ombudsman has said.

Keith Williams, 46, died in 2021 at HMP Dovegate, which is run by Serco.

He had “bizarre and distressing beliefs” about an infection in his body, although there was no evidence of a physical health problem, and harmed himself to stop the pain, a report said.

Serco said it was studying the report to see if there were lessons to be learned, Healthcare provider Practice Plus Group said it had taken steps to improve care.

The Prisons & Probation Ombudsman, Sue McAllister, said: “Although elements of Mr Williams’ clinical care at Dovegate were satisfactory, his mental health care was not equivalent to that which he could have expected in the community.”

She raised concerns the prison near Uttoxeter, Staffordshire, did not inform Mr Williams’s family of his death promptly.

Investigators found mental health staff focused too heavily on his physical health and apparent substance misuse but missed opportunities to arrange a psychiatric assessment, she said.

Ms McAllister said staff monitored Mr Williams six times under suicide and self-harm prevention measures, known as ACCT.

But she said healthcare staff did not hold a complex case review, or inform Mr Williams of a scan result, and did not always complete paperwork.

She said: “While there was some good practice, I am concerned that staff did not fully address his risks or consider the possibility of accidental death.”

She added: "We have raised concerns about ACCT management at Dovegate before and urgent action is now required.”

Mr Williams had been sentenced to eight years for robbery in 2017 and a further four years for the same offence in 2019.

An inquest found he died from misadventure and the ombudsman said: “We cannot say if Mr Williams intended to kill himself.”

A Serco spokesman said: "The death of Keith Williams was a tragedy and our thoughts are with his family and friends. We will study the findings of the Ombudsman report to see if there are any lessons to be learned.”

At Practice Plus Group, a spokeswoman said: "We have taken a number of actions to improve the treatment and care provided to patients with complex needs."

She said this included training staff on an improved version of the ACCT process, implementing weekly meetings to discuss patients with complex needs and weekly safety intervention meetings for high risk patients, and improving communication between healthcare teams and mental health partners.

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