Brian Burrows (also known as Brian Smith) · Prevention of Future Deaths report

On 18ᵗʰ June 2024, an investigation was commenced into the death of Brian Burrows (also known as Brian Smith), born on 23 June 1980 and died on 15 May 2024.

The investigation concluded at the end of the Inquest which held before a jury between 1 and 8 September 2025.

The medical cause of death was:
1a Hypoxic Ischaemic Encephalopathy
1b Hanging

The conclusion of the inquest was suicide.

Brian Burrows was admitted to HMP Leeds on 28 March 2024. He experienced a number of self-harm incidents between 22 April 2024 and 9 May 2024 before the incident on 10 May 2024 which led to his death on 15 May 2024. Mr Burrows died as a result of using a ligature.

Mr Burrows was on an ACCT and was assessed as requiring 3 observations per hour. The inquest heard evidence that the wing where Mr Burrows resided was extremely busy on 10 May 2024 with one officer stating that it was the busiest day of his career so far. There was one officer who was alone responsible for conducting ACCT checks on 3 prisoners on one landing including Mr Burrows.

Mr Burrows was not checked between 13:50 and 14:43 despite him being assessed as requiring 3 ACCT checks per hour. Between 14:00 and 14:43, 22 emergency cell bells were activated on the landing where Mr Burrows resided. The inquest heard evidence that prison officers are instructed in training to treat a cell bell as an emergency and not walk past a cell bell when activated for any reason. Prison officers were also aware of the need to perform ACCT checks as required as a priority task.

The inquest heard evidence that there was no guidance given to prison officers by senior officers or management about how to prioritise these tasks in such circumstances. Evidence was also heard that during the daily briefings there was no guidance given to prison officers about how to manage such tasks. Additionally, evidence was heard that no training is given to prison officers about making decisions in such circumstances and how to critically assess which task to prioritise.

(1) The inquest was told that no training is given to prison officers about decision making in dynamic situations where competing priority tasks needs to be completed namely what to do when faced by a number of emergency cell bells and a number of ACCT checks.

(2) The inquest was told that briefings delivered by senior staff on the wing do not assist prison officers by providing guidance on how to complete tasks of competing priority.