Andrew Douglas Frere · Prevention of Future Deaths report

On 13/02/2014 I commenced an investigation into the death of Andrew Douglas Frere, 34 . The investigation concluded at the end of the inquest on 08 September 2015. The conclusion of the inquest was that he took his own life whilst the balance of his mind was disturbed.

On 19 January 2014 Andrew Frere self harmed whilst a prisoner at HMP Moorland, Doncaster. He was placed on an ACCT, which remained open and which was subject to 11 reviews under the ACCT procedure until 10 February 2014, when he died as a result of suspending himself by a ligature formed from a bedsheet in his cell.

He was initially placed on continuous observation and for this purpose was moved from the houseblock where he was located to a gated cell in the Induction Wing. He was diagnosed as suffering from depression with some psychotic features, and appeared in particular to have concerns about returning to reside on the houseblock and about which would happen following his forthcoming release from prison. As regards the former concern, although he clearly felt more comfortable on the Induction Wing, it was recognised that long-term residence on that wing was not practicable, and that he would have to be reintegrated to the houseblock at some point. It was also recognised that it was undesirable for him to remain under constant observation for any longer than was necessary.

Andrew Frere appears to have made good progress under the ACCT, but the improvement was not without setbacks during which he felt low in mood and expressed suicidal ideation. Those were appropriately recorded in the ACCT ongoing record.

At the ninth review, held on 31 January 2014 , the level of observation was reduced to one per hour. At the tenth review, on 4 February 2014, it was decided to move him back to his cell in the houseblock. At the eleventh review, on 7 February 2014, this level of observation was further reduced to 6 per 24 hours. He hanged himself in his cell during a short period when prisoners were locked up for lunch, between 12.30 pm and 1.30 pm.

(1) Prison Service Instruction 64/2011 requires that prisoners under continuous observation should be seen by a doctor very 24 hours. The evidence given at the inquest indicated that this was not practicable, and the rule was widely recognised as not being so practicable.

My concern is less or to the apparent impracticability of the PSI, but more that, this impracticability having been recognised, the rule appears to have been ignored, rather than any attempt having been made at least to comply as closely as possible. Since Andrew Frere’s death this is now done at HMP Moorland by having nursing staff see the prisoner when a doctor is not available, but the problem with the impracticability of the PSI appears to be national, rather than a local one, and ought to be the subject of some sort of guidance at national level.

(2) The PSI does not appear to include any specific instruction that the case manager, or others attending ACCT review, should ensure that they read the ongoing observations, at least as far back as the previous review, in order to ensure that they are aware of recent events when they carry out such a review.

My concern is that potentially important information, which might affect decisions taken at the review, may be missed if the recent observations are not read.