Former soldier took own life in HMP Leeds after being placed on suicide watch four times

Mr Richard Franks, aged 39, was found face down on the floor of his cell at HMP Leeds on 12 April 2019.

A post-mortem examination later confirmed that he had died of hanging.

Prisons and Probation Ombudsman, Sue McAllister, noted that Mr Franks had a history of self-harm and suicidal thoughts, and was dealing with personal issues such as PTSD and his son's cancer diagnosis.

In a report published on November 3 2021, Ms McAllister said that prison staff had not fully addressed Mr Frank's risk to himself and had missed an opportunity to safeguard him.

Ms McAllister said: "Staff monitored Mr Franks under suicide and self-harm prevention procedures (known as ACCT) four times at Leeds.

"Although there was some good practice, I am concerned that staff did not fully address his risks.

"It is not the first time that I have identified deficiencies in Leeds’ suicide and self-harm prevention procedures. This issue needs to be addressed urgently by the Prison Group Director for Yorkshire."

She added: "I am concerned that staff did not assess Mr Franks’ risk of suicide and self-harm when he returned to Leeds from court on April 11 and missed a potential opportunity to put preventative measures in place.

"There was a delay in the emergency response. While it did not affect the outcome for Mr Franks, the Governor will need to address this."

Mr Franks was remanded into HMP Leeds on December 29, 2018 after being charged with causing actual bodily harm to his partner.

In the report, an officer stated that Mr Franks was "tearful" as his son had been diagnosed with cancer and a nurse stated that he said he had posttraumatic stress disorder (PTSD) due to serving six years in the British Army.

He also told her that he had taken an overdose within the last twelve months.

On December 30, an officer noted cuts on Mr Franks arms, and at an suicide and self-harm prevention review he was found to be displaying signs of mild depression and anxiety.

A caremap with three 'action steps' was created as Mr Franks was assessed at a risk of self-arm.

The three actions steps included; for his mother’s phone number to be submitted for approval, for him to be referred to the chaplaincy for personal support and to an officer the Veterans in Custody (VIC) co-ordinator.

Two days later, the prison stopped monitoring Mr Franks for suicide and self-harm despite noting that Mr Franks had cut himself the previous day, the report states.

On January 14, Mr Franks’ cellmate pressed their emergency cell bell and told an officer that Mr Franks had taken 50 paracetamol tablets

A nurse arrived and found Mr Franks unresponsive on the top bunk and called a medical emergency code blue. After around 10 minutes, he regained consciousness.

Paramedics took Mr Franks by ambulance to hospital where he treated for a paracetamol overdose.

The report stated that he was placed under suicide and self-harm monitoring again on January 16, though Mr Franks did tell staff that he "did not plan to end his life and had acted impulsively after an argument with his partner."

It added that a mental health nurse completed a mental health assessment and noted that Mr Franks did not show signs of an acute mental illness.

The suicide and self-harm monitoring was ended on January 23 after Mr Franks said he felt more "settled".

Days later, on January 25, Mr Franks approached an officer and showed him several superficial cuts that he had made to his left wrist.

The officer searched Mr Franks’ cell and found a ligature under his mattress.

Self-harm and suicide monitoring was restarted again.

At 12.05am on February 3, an officer looked through Mr Franks’ cell observation panel to conduct an suicide and self-harm prevention check and noticed that he had a ligature around his neck.

Officers entered Mr Franks’ cell, cut the ligature and placed him in the recovery position. He was then placed under constant watch.

The report states that Mr Franks raised concerns about feeling anxious and depressed the following day, and said that he had not had a response regarding a GP appointment.

Mr Franks pressed his emergency cell bell and showed an officer several superficial cuts that he had made to his left wrist on February 8.

On February 14, Mr Franks’ risk of suicide and self-harm was assessed as low by prison staff, as he had a GP appointment booked and "presented in high spirits".

There was another recorded incident of self-harm and Mr Franks began taking antidepressants. He was removed from suicide and self-harm monitoring on March 11.

A prison GP told the Ombudsman that Mr Franks had stated that he had began self-harming on March 20 but suicide and self-harm monitoring procedures were not restarted.

Mr Franks went to court on April 11 where his case was adjourned.

When he returned he told a prison listener, a prisoner who has been trained by the Samaritans to support other prisoners, that he had been sentenced to five years in prison.

In the report, the prisoner stated that he asked officers to restart suicide and self-harm monitoring procedures but was advised to speak to another officer.

A prisoner in one of the cells near Mr Franks told the Ombudsman that Mr Franks did not suggest he would harm himself, but that he "thought it was a little strange that Mr Franks was giving away his belongings."

At 6am on April 12, an officer found Mr Franks lying face down on the floor.

Red marks were found around his neck and a piece of loose fabric was attached to the cell window.

A nurse did not start CPR as it was clear he was dead, the report states. A paramedic pronounced him dead at 6.24am.

A post-mortem examination found that Mr Franks died of hanging.

The investigation concluded that staff stopped suicide and self-harm prevention monitoring prematurely on one occasion and that staff should have done more to identify any increased risk after he returned to prison.

Investigators also stated that they not all the caremap actions set for Mr Franks were sufficient.

The Ombudsman has made recommendations to the Head of Healthcare at HMP Leeds. These include restarting ACCT procedures if a prison is at risk. consider all relevant factors when assessing risk and consider whether cell sharing is appropriate.

Mr Franks was the seventeenth prisoner to die at HMP Leeds since April 2017. Of the previous deaths, seven were from natural causes, six were self-inflicted, two were drug-related and one was a homicide.

The Samaritans can be contacted for free on 116 123 or on email at [email protected].

Visit www.samaritans.org to find your nearest branch.