Ombudsman Report Urges Immediate Action on Prison Self-Harm Prevention After Inmate’s Death

The prisons ombudsman has stated that a man’s death necessitates urgent action regarding a prison’s self-harm and suicide prevention protocols. Keith Williams, aged 46, passed away in 2021 at HMP Dovegate, an institution managed by Serco. According to a report, Mr. Williams held “bizarre and distressing beliefs” concerning an infection within his body, despite the absence of any physical health issue, and engaged in self-harm to alleviate perceived pain. Serco indicated it is reviewing the report to identify potential lessons, while healthcare provider Practice Plus Group affirmed it has implemented measures to enhance care. Sue McAllister, the Prisons & Probation Ombudsman, commented: “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.” Ms. McAllister also expressed concerns that the facility, located near Uttoxeter, Staffordshire, failed to promptly notify Mr. Williams’s family of his demise. She stated that investigators determined mental health personnel concentrated excessively on his physical health and apparent substance misuse, thereby overlooking chances to arrange a psychiatric assessment. Ms. McAllister noted that staff monitored Mr. Williams on six occasions using suicide and self-harm prevention protocols, referred to as ACCT. However, she added that healthcare staff did not conduct a complex case review, neglected to inform Mr. Williams of a scan result, and did not consistently complete necessary paperwork. She further stated: “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 concluded by saying: “We have raised concerns about ACCT management at Dovegate before and urgent action is now required.” Mr. Williams had received an eight-year sentence for robbery in 2017, followed by an additional four years for the same offense in 2019. An inquest determined his death was due to misadventure, and the ombudsman remarked: “We cannot say if Mr Williams intended to kill himself.” A spokesperson for Serco commented: “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.” A spokeswoman for Practice Plus Group stated: “We have taken a number of actions to improve the treatment and care provided to patients with complex needs.” She specified that these actions encompass training staff on an enhanced version of the ACCT process, establishing weekly meetings to address patients with complex needs, conducting weekly safety intervention meetings for high-risk patients, and fostering better communication between healthcare teams and mental health partners.