Risley Prison offered recommendations after probe into inmate death

Paul Degg died aged 46 while a serving prisoner at HM Prison Risley on September 29, 2018.

He was the eighth prisoner to die at the Warrington Road facility since August 2015, of which two were self-inflicted, two were drugs related and three were from natural causes.

There have been four deaths since Degg’s – three from natural causes, one homicide and one awaiting classification.

An inquest into his death concluded last month that the prisoner died as a result of a self-applied instrument, but that his intention at the time cannot be determined.

A report has now been published following an independent probe by the Prisons and Probation Ombudsman, which aims to make a significant contribution to safer and fairer custody.

On 19 June, 2017, Degg was sentenced to 32 months in prison for wounding and grievous bodily harm with intent. He had been in prison before.

Having told staff at HMP Manchester that he had a history of self-harm and substance misuse, as well as a diagnosis of dissocial personality disorder and schizophrenia, he was moved to HMP Risley.

Arriving on June 30, he was said to be happy there as it was closer to home and his nephew was also there. Degg said he had no thoughts of suicide or self-harm.

On July 18, the inmate made superficial cuts to his arm and an officer started suicide and self-harm prevention monitoring (ACCT).

Degg said that he had self-harmed as a coping mechanism but he did not want to die. He said he was unhappy that his methadone was withheld the previous evening.

The report states that he was found under the influence of psychoactive substances on several occasions at Risley.

The death occurred at HMP Risley

Staff warned him of the dangers of using them and the effects they could have on his mental health and attempted to engage him in work to address his use, but he did not want to.

On September 29, at around 6.40pm, an officer carrying out an ACCT check found him in his cell, called for assistance, and started CPR.

Paramedics arrived at 6.58pm but were unable to resuscitate him, and he was declared dead at 7.15pm.

Toxicology tests found that Degg had psychoactive substances in his system when he died.

A section of the report entitled findings states: “Degg had complex needs which resulted in him regularly self-harming, including three serious attempts to take his life.

“Overall, we found that he was well-supported by prison and healthcare staff and that his risk was appropriately managed.

“However, we found that some of his ACCT reviews were not multidisciplinary as they should have been, in that some lacked input from the mental health team.

“Given Degg’s complex needs, we are concerned that at the ACCT review four days before his death, his risk was reassessed as low, and the frequency of his observations was reduced without input from the mental health team.”

Making recommendations, the ombudsman says that the governor and head of healthcare should ensure that prison staff manage prisoners at risk of suicide and self-harm in line with guidance.

The governor should ensure that staff adhere to the requirements of the prison’s psychoactive substance policy when prisoners are suspected of using them.

The report adds that a manager should hold a hot debrief promptly after a death in custody, and that the governed should undertake a review of post-incident processes to ensure that staff are offered support following an unexpected death.