Six similar deaths among prisoners held at HMP Leeds have led the Prisons and Probation Ombudsman to identify "failings in the way staff assess the risk of suicide".
Sue McAllister, the ombudsman for England and Wales prisons, told the YEP that prisoners were not monitored and supported appropriately due to failings in the way prison staff assess risks of suicide and self-harm.
She made the remarks after the publication of her report into the death of Mohammed Irfann Afzal, who died from malnutrition and other factors after losing three stone in 48 days while in custody at the prison in 2019.
Two teenagers in hospital after crashed motorbike sets on fire on Leeds street
Leeds Olympian Nicola Adams and girlfriend Ella Baig reveal baby boy's name as they talk about parenthood
Caught on camera Leeds: West Yorkshire Police need to speak to these people urgently
Met Office storm warning for Leeds - when the stormy weather is due to hit and how long it will last
17 pictures you'll only understand if you're from Leeds
Ms McAllister said she was very concerned that he "never received a full mental health assessment and that HMP Leeds missed the opportunity to identify how physically unwell he had become".
The report references a five similar deaths at HMP Leeds since 2019, all of which she has investigated.
Speaking to the YEP, Ms McAllister said HMP Leeds must now ensure that mental health assessments are completed, any concerns about prisoners are logged in their prison record and all prisoners have a key worker who engages, motivates and supports them.
"They should action referrals for learning and disability assessments and manage all prisoners appropriately, in line with national guidelines", she added.
"In this case and other deaths at HMP Leeds in recent years, I am concerned about staff underestimating prisoner’s risk to themselves and we have made many recommendations around this."
In a statement in response to Ms McAllister's findings, a Ministry of Justice spokesperson said HMP Leeds had improved staff training on suicide and are now assigned a key worker upon arrival in prison.
They said: “Our thoughts remain with the families who have lost a loved one and we have put stringent measures in place to avoid this happening again.
“HMP Leeds has improved staff training on suicide and self-harm and all prisoners are now assigned a key worker upon arrival to the prison, as part of our commitment to improving mental health at the institution.”
The six deaths referred to by Ms McAllister are:
Richard Franks - died April 12, 2019Richard Franks was found dead in his cell at HMP Leeds. He was 39 years old and had been charged with actual bodily harm.
Staff monitored Mr Franks under suicide and self-harm prevention procedures (known as ACCT) four times at Leeds.
In her report, Ms McAllister said: "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.
"I am concerned that staff did not assess Mr Franks’ risk of suicide and self-harm when he returned to Leeds from court on 11 April 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.
"There were also failings in the keyworker process and the procedure for storing CCTV evidence securely."
David Harness - died April 26, 2019David Harness was found dead in his cell at HMP Leeds. He was 38 years old.
Mr Harness had been sentenced to 58 months in prison on May 1, 2014 for robbery. He was released on licence on October 20, 2017 but recalled on April 11, 2018 after committing a further offence.
When Mr Harness was moved to Leeds from HMP Lindholme on August 13, 2018, he was being monitored under suicide and self-harm procedures (known as ACCT).
Staff at Leeds stopped ACCT monitoring the next day and he was not monitored under ACCT again.
Mr Harness had a history of substance misuse and completed a drug detoxification programme at Leeds. However, he told staff that he continued to use illicit substances as a means of coping.
In January and March 2019, Mr Harness told staff that he had concerns about his mental health and he asked to speak to someone from the mental health team. The mental health team gave him self-help materials but did not assess him.
A report into his death found the care he was given was "not equivalent to that which he could have expected to receive in the community".
Ms McAllister's report said: "We have identified inadequacies in mental health assessments in previous investigations into deaths at Leeds and this issue must now be addressed.
"The investigation also found that Mr Harness’ continued drug use, including a drug test failure, was not communicated to healthcare staff."
Mohammed Irfann Afzal - died August 4, 2019Mohammed Irfaan Afzal died in hospital from bronchopneumonia after being found unresponsive in his cell at HMP Leeds earlier that day.
He had been remanded in prison custody charged with assault and breach of a community order.
Mr Afzal was a healthy weight when he arrived at Leeds, but over the next 48 days, he lost three stone - almost one third of his body weight - and became very underweight.The pathologist noted that Mr Afzal was emaciated and that his poor nutritional state would have increased the risk of him developing a chest infection.
Prison staff suspected that he may have a learning disability or mental health issues.
Although there were signs that Mr Afzal was not eating or drinking, neither prison or healthcare staff appeared to pay much attention until a few days before his death, by which time his weight had dropped alarmingly.
The clinical reviewer found that the mental health care which Mr Afzal received at HMP Leeds was not equivalent to the care that he could have expected to receive in the community.
"This is the sixth death at Leeds in two years, where my investigations have reached that conclusion", Ms McAllister said in her report.
"This is extremely concerning and needs to be addressed urgently."
Karar Ali Karar - died September 5, 2019Karar Ali Karar died in hospital after being found dead in his cell in the segregation unit at HMP Leeds. He was 29 years old and was charged with murder.
Staff under-estimated Mr Karar’s risk to himself, according to the report.
Mr Karar had a number of significant risk factors for suicide and self-harm. He was facing a long sentence (a life sentence with a 25-year tariff); he spent 120 days in the prison’s segregation unit, over two periods; he had mental health problems and he spoke only limited English.
Staff did not create a mental health care plan within 30 days; did not hold an initial case review when there were healthcare reasons not to segregate him and did not complete certain Initial Segregation Health Screens accurately.
Mistakes were also made when the Prison Group Director authorised Mr Karar’s segregation beyond 42 and 84 days.
Staff should have used an interpreter during complex discussions with him, according to the ombudsman report.
Darren Pallas - died January 31, 2020Darren Pallas was found dead in his cell at HMP Leeds. He was 40 years old and charged with robbery.
Mr Pallas had a history of anxiety, depression and poor sleep, and these risk factors remained during his time at Leeds.
He was also concerned about his relationship with his partner according to the report.
Mr Pallas was monitored under suicide and self-harm prevention procedures (known as ACCT) on three occasions during his stay at Leeds.
Staff did not operate some basic aspects of these procedures appropriately, the report found.
Mr Pallas was not being monitored under ACCT procedures at the time of his death.
However, Ms McAllister said: "I am satisfied that Mr Pallas received appropriate physical and mental health care at Leeds and did not give any indication that he was at imminent risk of suicide or self-harm before his death."
Terence Papworth - died November 22, 2020 Terence Papworth was found dead in his cell at HMP Leeds. He was 45 years old and charged with murder.Mr Papworth was monitored under suicide and self-harm prevention procedures (known as ACCT) on two occasions during his time at Leeds but was not being monitored when he died.
His last period of ACCT monitoring ended in August 2020.
Mr Papworth was on remand, charged with murder. He attended court on November 17, 18 and 20 and his trial was due to start on November 30. He had expressed anxiety about appearing in court.
Ms McAllister said: "My investigation found that staff potentially missed an opportunity to put ACCT monitoring in place in the lead up to Mr Papworth’s trial.
"Information about Mr Papworth’s potential risk of suicide and self-harm was not shared among relevant staff.
"The investigation also found that Mr Papworth was not screened to assess his risk of suicide and self-harm when he returned from court as he should have been.
"I also found that there was a lack of meaningful contact and engagement with Mr Papworth by both his key worker and prisoner offender manager in the months before he died, which meant opportunities to support him in the lead up to his trial were missed."