THE care given by prison staff to a Warrington inmate jailed for a ‘rampage’ on the roads ‘fell short’, a review has found.

It follows an independent investigation into the death of Appleton man Ryan Brennan at HMP Buckley Hall, near Rochdale, on August 23, 2022.

This was carried out by the Prisons and Probation Ombudsman, which aims to ‘make a significant contribution to safer, fairer custody and community supervision’, with a report recently published.

Brennan was remanded to HMP Altcourse on August 24, 2021, after being charged with threatening behaviour and driving offences.

He had been in prison twice before, but this was his first time in 12 years, and he revealed to prison staff his history of substance misuse and mental health issues.

On November 22, he was sentenced to five years imprisonment and moved to HMP Buckley Hall three days later.

His sentencing hearing heard how he held a pensioner and NHS worker at knife point in a ‘rampage’ of offences.

He crashed into the back of a car driven by an ‘elderly man’ on Capesthorne Road in Orford and became verbally abusive to him.

A couple who stopped to assist backed away when they saw him draw a pen knife and pin the elderly man to his car.

An NHS worker also stopped to try and calm Brennan down, but he held a knife to her throat, then dragged a passing delivery driver from his bike.

The defendant then pulled another woman out of her car and drove off in it, before he was finally tasered by police, whom he also threatened with the knife.

In his defence, it was said that he was struggling with his mental health on the day and was under the influence of alcohol and drugs.

He was said to be appalled at his behaviour, had shown genuine remorse and had drafted a letter to apologise to the victims.

Warrington Guardian: He was sentenced at Liverpool Crown CourtHe was sentenced at Liverpool Crown Court (Image: Newsquest)

The report into his death tells of Brennan’s issues with his mental health inside the prison and discussions with prison staff during reviews.

Staff monitored him using suicide and self-harm procedures (called ACCT) on two occasions between January and March, 2022, after he self-harmed due to concerns about sharing a cell.

After the last period of monitoring, he appeared to settle and was able to share a cell with another prisoner.

On August 19, Brennan began making threats towards other prisoners. Staff noticed he ‘appeared intoxicated’ and had a facial cut and grazes, and they moved him to the segregation unit at around 5.40pm.

Shortly after 8pm, he broke the glass observation panel in his cell door by hitting it repeatedly and continuously demanded specific socks be brought to him, but staff told him they were unable to do this.

At approximately 2am on August 20, Brennan used the glass from the broken observation panel to cut himself, and staff started ACCT monitoring.

Staff later removed the glass from his cell to prevent further injury.

He became abusive when staff told him he would be held in segregation over the weekend and said: “I might as well kill myself.”

He was checked by staff multiple times, but at 1.52pm, an officer found him unresponsive in his cell and called for help.

A nurse already on the segregation unit started CPR and ambulance staff arrived by 2.05pm and were able to resuscitate him before he was taken to hospital.

However, Brennan never regained consciousness and died in hospital on August 23. This was the first self-inflicted death at Buckley Hall since 2017.

The report states that it was clear from calls he made before his death that he was ‘involved in some level of drug supply within the prison, and that the socks he was demanding, which were never recovered, most likely contained drugs’.

The pathologist concluded that Brennan died as a result of a hypoxic-ischaemic brain injury, with samples taken from his body showing the presence of ‘various types of illicit medication’.

Warrington Guardian: HM Prison Buckley HallHM Prison Buckley Hall (Image: Google Maps)

His inquest, held from January 15 to 26 this year, concluded that he took his own life, but it was unclear whether his intention was to end his life.

A jury concluded that the failure in the awareness and removal of the broken observation panel more than minimally contributed to his death.

A section of the report entitled ‘findings’ states: “When Brennan self-harmed in the segregation unit in the early hours of August 20, staff correctly started ACCT monitoring.

“When he broke his observation panel, staff did not temporarily repair the damage or record that they had considered moving him to another cell.

“Brennan was able to use the broken observation panel to self-harm on four occasions, the last time proving fatal.

“CCTV shows that he was last checked at 1.34pm, not 1.45pm as recorded in the ACCT paperwork. The officer responsible for the check has left the Prison Service. Police interviewed her under caution but took no further action.

“Staff working in the segregation unit told us that they did not feel adequately trained or supported to carry out their duties competently, safely and effectively.

“The clinical reviewer found that aspects of Brennan’s care were not equivalent to that which he could have expected to receive in the community.

“She found that the service provided by the mental health team was a matter of concern. She made several recommendations as set out in her clinical review report.”

Recommendations are that the governor should ensure that staff use all the available evidence to assess whether the location of prisoners on ACCT, and the items in their possession, increase the risk of harm.

They should also take necessary steps to reduce the identified risk, as set out in the ACCT guidance.

Moreover, the governor should review the staffing structure and training provided to staff working in the segregation unit to ensure that all staff are confident and competent to safely deal with challenges often experienced in this setting.