Aaron Lee Taylor · Prevention of Future Deaths report

On 7 September 2023 I commenced an investigation into the death of Aaron Lee Taylor, 32 years old. The investigation concluded at the end of the inquest on 29 October 2025. The conclusion of the inquest was:

With the evidence provided by the pathologist, CCTV footage from 27 August and the 28 August, combined with witness statements from the prison officer who found Mr Aaron Lee Taylor at 08:05am on the 28 August 2023, Mr Aaron Lee Taylor died between 7.30pm on the 27 August 2023 and 6am on the 28 August 2023, in a cell on the ████████
premises of HMP Garth, 1 Moss Lane, Ulnes Walton, Leyland. ████████

Taking into account the three letters that Mr Taylor wrote, the preplanning and method in which Mr Taylor did, leads us to conclude Mr Taylor did take steps intending to take his own life.

There were multiple failures in the measures taken to prevent self-harm and suicide. From the evidence that has been presented in court, multiple opportunities were missed by multiple professionals (nurse, GP, prison officers, mental health nurse, Prison Officer Manager, Governor, Senior prison officer) to support or offer suitable/appropriate care and resources for Mr Taylor. Inadequate preventative steps and assessments, lack of documentation, inability to adhere to policies and procedures and a 'lack of professional curiosity' as stated by an Operations Manager from GMMH who undertook an external investigation. All contributed to Mr Taylor's death.

Witness testimony from a prison officer demonstrated that the relevant observations had not been carried out on the 28 August 2023. With the evidence and testimony of the pathologist, and the uncertainty surrounding time of death, we cannot say that these observations or lack of, contributed to Mr Taylor's death.

As highlighted by the external investigation carried out by GMMH, there were multiple serious failures to provide minimal/adequate mental health interventions for Mr Taylor. These serious failures and inadequacies possibly contributed to Mr Taylor's death..

Mr Taylor was discovered in his cell on 28 August 2023 by a prison officer. ████████
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(1) Evidence was heard that despite several prison officers being aware of a serious incident of self-harm involving a prisoner with a history of self-harm, an Assessment, Care in Custody Teamwork process (ACCT) was not opened. No evidence was provided confirming all prison officers were ACCT trained and/or were all aware of their responsibilities in relation to ACCT

(2) Evidence was also heard that keyworker sessions were not being carried out as they should have been with a prisoner who had been identified as in need of support through the keyworker scheme. A prison officer with keyworker responsibilities gave evidence that they did not know how frequently keyworker sessions should take place

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