Johnpaul Digweed · Prevention of Future Deaths report

On 25 April 2024, I commenced an investigation into the death of Johnpaul Digweed, aged 35 years...

The medical cause of death was
1a Hanging

How, when and where
see Conclusion

Conclusion
Mr DIGWEED died between 17:06 on 12 April 2024 and 11:31 on 13 April 2024 at HMP Garth, Leyland. The cause of death was suicide by hanging. Mr DIGWEED was found hanging in his cell. He took deliberate steps to end his life and intended to do so. ████████ Numerous opportunities were missed in the months prior to Mr DIGWEED's death to assess his mental state and provide appropriate support. Routine prison procedures to monitor welfare were not carried out as per prison policy and mandatory governor's orders. The gaps in care possibly contributed to Mr DIGWEED's death. The observations on 12-13 April 2024 were also not carried out as per prison policy and mandatory governor's orders. A prisoner discovered Mr DIGWEED's body. Staff attempted resuscitation but rigor mortis had set in and attempts were futile

See box 7

1. Evidence was heard that despite several staff being aware of incidents of self-harm involving a prisoner at HMP Garth an Assessment, Care in Custody Teamwork process (ACCT) was not opened. Whilst evidence was provided that staff are trained as part of their induction program and that training materials is available to staff, no assurance could be given that there was any ongoing mandatory refresher training or any system in place to monitor understanding that every member of staff is responsible for opening an ACCT where required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths

2. Evidence was heard that there is a regular practice of prisoner's covering their observation panels in their cell doors at HMP Garth. Despite Governor's Orders and staff instructions being in place requiring staff to take steps to ensure any inundation is removed, this was not being adhered to. Evidence was heard that some staff were not aware of the instructions which were issued by email. As a result, the orders and notices have been updated and reissued by email clarifying expectations in relation to welfare checks and steps requires if observations panels are obscured. However, no assurance could be given that staff had read and understood the instructions or that there was any system outside the email system to ensure important information is cascaded and seen by affected staff. In addition, whilst the amended instructions confirm a verbal response is mandatory for welfare checks, they do not explicitly state a visual check of the prisoner is also required. Given your responsibility for HMP Garth, I consider you are responsible for taking the action that is required to prevent future deaths