Michael Pugh · Prevention of Future Deaths report

On 3rd July 2024 I commenced an investigation into the death of Michael Pugh, 29 years. The investigation concluded at the end of the inquest on 21st July2025. The conclusion of the inquest was suicide; Mr Pugh having suspended himself in his cell at HMP Swaleside ████████

Michael Pugh was found in his cell on 29th June 2024 having died. He was subject of an ACCT at the time of his death. It was determined at the last ACCT review before his death that he should be subject to hourly observations. Observations were carried out on the afternoon of 28th June 2024 but recorded incorrectly. No observations were carried out on 29th June 2024 between 07.22 and 09.57 when Mr. Pugh was discovered having died, but the ongoing record was completed retrospectively to show that they had been carried out

(1) The prison officers who gave evidence in relation to observations on 28th and 29th June 2024 were relatively new recruits, one having 3 months experience following POEL training and the other 1 month experience. Both officers gave evidence that following their POEL training their understanding of the ACCT process was incomplete; one stating “observations were explained but I didn’t have a fair idea what to do or how to undergo the process”, another stating “I didn’t understand the importance of observing a prisoner at unpredictable times. Even though I was told the observations should be hourly it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 13.00, 14.00, 15.00 and 16.00.