HMP Leeds: Prison told to take 'urgent action' over monitoring suicide risks after prisoner's death

The prisons ombudsman has said that “urgent action” needs to be taken at HMP Leeds following the death of a prisoner by hanging within weeks of entering.
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Christopher Riley died aged 35 in hospital on March 10 last year two days after he was found hanging in his cell. A report into his death by the Prisons and Probation Ombudsman was published last month and stated that staff “failed to identify several risk factors for suicide and self-harm” upon his arrival.

The writer of the report, acting deputy prisons and probation ombudsman Caroline Mills, said that there had been previous cases of this happening at Leeds and that it was “disappointing” to find it had happened again.

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She also said that two administrative errors meant that healthcare staff failed to promptly refer Mr Riley to the mental health team

The ombudsman said that it was 'disappointing' to find that there had been problems identifying a prisoner's risk of suicide upon their entry as this had happened before.The ombudsman said that it was 'disappointing' to find that there had been problems identifying a prisoner's risk of suicide upon their entry as this had happened before.
The ombudsman said that it was 'disappointing' to find that there had been problems identifying a prisoner's risk of suicide upon their entry as this had happened before.

Mr Riley was remanded at HMP Leeds in Armley on February 12 charged with attempted robbery. An officer interviewed Mr Riley, who had a history of mental health issues, but “did not identify significant information about his risk of suicide and self-harm”.

A nurse then conducted an initial health screen with Mr Riley, but despite noting his mental health history, the report states there is “no record that she considered starting suicide and self-harm prevention procedures”.

On February 14 an intelligence report was received in which Mr Riley’s family stated that they were worried he may try to take his own life in prison. The next day a risk of suicide identification form was carried out and two supervising officers were asked to see Mr Riley for a welfare check but this never took place. A healthcare assistant made a separate mental health referral but this was not received as she mistakenly sent it to herself.

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On February 22 another mental health referral was made but Mr Riley was not seen before his death.

In the findings, the ombudsman writes that reception staff “gave too much weight to Mr Riley’s presentation rather than his range of risk factors” and that the care he received was “not equivalent to that which he could have expected to receive in the community”.

The ombudsman said that while improvements have been made at HMP Leeds, “failures to identify and manage the risk of suicide adequately in reception and during (sic) early days in custody have continued”. It requested that the prison’s director set out “meaningful improvements” to tackle this.

A Prison Service spokesperson said: “Our thoughts remain with Mr Riley’s friends and family.

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“Since this report, HMP Leeds has introduced new processes to better spot and support those at risk of self-harm and suicide, strengthened staff training, and fully reviewed its support for those who have just arrived at the prison from the courts.”

A spokesperson for Practice Plus Group, which provides healthcare at the prison, said: “We were deeply saddened by Mr Riley’s death from suicide and our heartfelt sympathies go to his family and friends. Our aim is to provide healthcare which is equivalent to that which patients would expect in the community. We have accepted and acted upon the recommendations in the Prison and Probation Ombudsman report and continue to support our mental health and substance misuse teams in striving to deliver high standards of patient care.”