Jason O’Rourke · Prevention of Future Deaths report

Jason O’Rourke died on 2nd April 2019 at HMP Belmarsh, aged 34 years. An investigation into his death was commenced. The investigation concluded at the end of the inquest on 21st January 2021. The jury found that the medical cause of Mr O’Rourke’s death was hanging. Their conclusion was that he died by suicide, to which a series of factors possibly contributed, as explained further under section 4 below.

Jason O’Rourke died in his single occupancy cell on House Block 3 in HMP Belmarsh at some point between 7.28 pm on the 1st April 2019 and when he was found at 9.33 am on 2nd April 2019, hanging from the window bars in his cell using a ligature made from a bedsheet. He had clearly been dead for some time.

No one had entered Mr O’Rourke’s cell overnight. The roll checks scheduled to take place at 9.00 pm on the night of 1st April 2019 and 6.00 am on the morning of 2nd April 2019 had not been carried out, although it cannot be said that had those checks been done, the outcome would have been any different.

Prior to his death Mr O’Rourke had chosen to self-isolate in his cell. The jury found that Mr O’Rourke’s suicide was possibly contributed to be the following factors:

(i) The serious failure to take further steps with respect to Mr O’Rourke’s mental health after the Primary Care Mental Health Nurse’s attempt to triage him on 8th March 2019;

(ii) The fact that healthcare staff did not provide sufficient information about Mr O’Rourke’s mental health to prison staff during the month that he was resident on House Block 3;

(iii) The fact that prison staff on the wing did not have sufficient understanding of Mr O’Rourke’s mental health history and history of self-harm (a) information received from healthcare; (b) the information on the Cell Sharing Risk Assessment and (c) information on the OASys record; and

(iv) The fact that the Safety Intervention Meetings in March 2019 were an inadequate way of addressing the issue of self-isolation and risk in relation to Mr O’Rourke.

(1) The ‘immediate needs’ form completed for prisoners on arrival at HMP Belmarsh does not facilitate a clear assessment of any risk of self-harm or suicide and the actions to be taken if such a risk is identified.

The form poses a question: “Is there any specific concerns re self-harm or suicide?” and then gives the guidance “if yes, amend care plan”. However, this guidance is only effective for those prisoners who already have a care plan, meaning those who are already on an Open Assessment, Care in Custody and Teamwork (‘ACCT’) plan. The action to be taken for those prisoners where specific concerns regarding self-harm or suicide are identified, but who do not already have a care plan, is unclear from the form.

It is also unclear how the above question interacts with further questions below it which address any past ACCTs/F2052SHs, the level of support available to the prisoner and the answer the prisoner gives to the question “Do you feel suicidal now?”

Accordingly, this form does not sufficiently highlight prisoners who are in fact suicidal, or where there are concerns about their risk of self-harm or suicidal, to those on the wing.

(2) The nightly roll checks at HMP Belmarsh are due to be carried out by a single member of Operational Support Grade (OSG) staff at 9.00 pm and 6.00 am. Their stated purpose is to check for escape or death among the prisoners. On handing over to the morning staff, the OSG signs paperwork indicating that the roll checks have been completed. There is no robust system by which the prison management audit this process. This means that the prison management can be under the impression that the checks have been carried out, when they have not been, as occurred here.