Alan Joseph Whelan · Prevention of Future Deaths report

On 08/01/2025, I commenced an investigation into the death of Alan Joseph Whelan, aged 41 years...

The medical cause of death was 1a) Hypoxic Encephalopathy; b) Hanging

The deceased died on 30/12/2024 in Leeds General Infirmary, where he had been brought on 25/12/2024 from HMP Leeds, where he had been found hanging in his single-occupancy cell on the Segregation Unit.

Conclusion (Jury’s narrative conclusion)

Alan Joseph Whelan was found ligatured in his cell on 25th Dec 2024 and subsequently died on 30th December 2024 at Leeds General Infirmary.

It is possible that loss of work was a trigger to Alan’s mental state and thought process.

Following previous incidents, we feel that observations should have been made more regularly, and any ACCT reviews should have considered previous incidents.

It cannot be established that Alan not being more frequently observed probably contributed to his death, but it is possible that it did so.

Admission by MoJ

The prison officer conducting ACCT observations on Alan on the night of 25th Dec did not comply with the requirement to conduct one check at irregular intervals every 60 minutes. By the time he conducted the check which led to Alan’s discovery it had been 1 hour and 11 minutes since the last check. It cannot be established that this finding probably contributed to the death, but (it) may have done so.

Alan Whelan, a serving prisoner in HMP Leeds who was on an open ACCT document, was moved to the Segregation Unit in the prison after starting a fire in his cell shortly before 1500 hrs on 24/12/2024. Pursuant to PS 1700 he should have had a mental health assessment within 24 hours of his arrival in the Segregation Unit. No such assessment took place. An ACCT review attended by a mental health practitioner was held on the morning of 25/12/2024, but that practitioner gave evidence that an ACCT review was not an appropriate substitute for a 1:1 mental health assessment. The evidence at inquest did not establish whether the failure to conduct a mental health assessment as required by PS 1700 was an oversight or a deliberate decision, to which the resources available in the prison on Christmas Day may have contributed. Shortly before 2330 hrs on 25/12/2024, Alan was found hanging in his cell on the Segregation Unit and transferred to hospital, where he died on 30/12/2024.

A mandatory requirement that a prisoner on an open ACCT document should have a mental health assessment within 24 hours of being transferred to the Segregation Unit was not complied with. Alan took steps that caused his death after that 24-hour window had closed. There was scant acknowledgement of this breach of a standing instruction from the witnesses who gave evidence to the inquest. The possibility that not carrying out such an assessment made no difference to the outcome is obvious. But that possibility neither explains nor excuses the failure to comply with the instruction, especially where it is unclear whether that failure was inadvertent or deliberate, and if deliberate, with what justification.