‘Missed opportunities’ for staff to assess prisoner’s risk of suicide two weeks before he hanged himself at Bassetlaw jail

A report by the Prisons and Probation Ombudsman (PPO) has been published into the death of Shaun Davies, aged 51, who was found hanged in his cell at HMP Ranby on December 28 2021.

The report states: “We are concerned that in the two weeks before Mr Davies’s death, there were missed opportunities to properly assess his risk of suicide and self-harm and put supportive measures in place.”

The report stated although a welfare check had been carried out on Mr Davies on December 15, after his solicitor phoned the prison concerned about his client’s mental health, the mental health team were not informed.

The report also stated no one had started Assessment, Care in Custody and Teamwork (ACCT) monitoring on December 22 when Mr Davies told staff that he was having suicidal thoughts.

In the months before his death, Mr Davies became very agitated and harmed himself by cutting his chest on November 8 after doctors reduced his pregabalin, a prescribed pain relief medication.

The report stated: “My investigation found that, while staff at Ranby provided a good level of support for Mr Davies’s complex needs, there were some failings in staff assessing and managing his risk of suicide and self-harm.

“I am also concerned that when Mr Davies harmed himself by cutting his chest on November 8, the officer who responded did not tell healthcare staff so there was a delay of around four hours before a nurse saw him.”

Mr Davies had been jailed in 2008 for arson and served more than nine years in prison before he was released in August 2017. He was subsequently recalled to prison three times, the last time in August 2020.

Mr Davies who had a long history of mental health and substance misuse issues was sent to Ranby on October 28 2021, after failing a drugs test while he was in open conditions at HMP Sudbury.

A number of recommendations were made in the report including ensuring that staff manage prisoners at risk of suicide or self-harm in line with national instructions, ensuring that staff are fully aware of when it is appropriate to start ACCT monitoring and ensuring that staff alert healthcare immediately if a

prisoner has harmed himself and requires medical assistance.

A Prison Service spokesperson said: “Our thoughts remain with Mr Davies’ family and friends. “Since this incident, HMP Ranby has improved its safety procedures to better spot and support those at risk of self-harm and suicide, receiving the highest grading for safety from its inspection in 2022. We will take on board the recommendations of the independent investigation to ensure improvements continue to be made.”

Mr Davies was the fifth prisoner to die at Ranby since December 2019. Of the four previous deaths, two were self-inflicted and two were from natural causes.