Luke Mikael PEARCE · Prevention of Future Deaths report

On 12 April 2023 I commenced an investigation into the death of Luke Mikael PEARCE aged 21. The investigation concluded at the end of the inquest on 16 May 2024. The conclusion of the inquest was that: suicide.

Mr Luke Pearce was found hanging in his cell on 6 April 2023, at HMP/YOI Swinfen Hall. He was 21 years old. Mr Pearce had given no indication to staff that he was at risk of suicide or self harm in the months leading up to his death.

Shortly after 5.30am on 6 April 2023, during a routine check, ████████
████████ response. He looked through the crack of the door and saw Mr Pearce with a ligature around his neck. The officer radioed for urgent assistance but did not use the appropriate coded wording of “Code Blue”.

An Operation Support Grade attended and briefly entered Mr Pearce’s cell before coming out again. When another officer attended, the first officer and OSG told her that she should not enter the cell as it was a crime scene. She contacted a custodial manager for permission to go in and then cut the ligature and lowered Mr Pearce to the floor. The officer and OSG waited outside and did not assist.

At 5.40am, more staff arrived and the control room staff called an ambulance. Staff started CPR at 05.42am. Ambulance paramedics arrived at 5.59am and took over CPR. At 6.30am, they pronounced that Mr Pearce had died.

There was a delay in staff entering the cell, removing the ligature and starting CPR. This did not contribute towards Mr Pearce’s death.

That relevant training and guidance to equip staff to understand when and how to enter a cell in a medical emergency, and the appropriate use of Code Blue and Code Red communications in a medical emergency, is not being delivered in a timely manner to appropriate staff.