A prison has been slammed after an inmate died only two days after he was taken off suicide watch in November 2022.

Adam Thompson, 33, died in HMP Northumberland only three weeks into his seven-month sentence. He was serving time for assault and breaking a suspended sentence when he was found hanging in his cell.

In the run-up to his death, prison staff had noted that Thompson was exhibiting signs of high anxiety and mental health decline, as well as psychosis as a result of previous substance misuse. He was put on suicide and self-harm procedures (known as ACCT)

Five days before he was found deceased in his cell, he had severely cut himself, and was placed in the segregation unit, following his concerns about his own safety, as he felt “under threat from other prisoners”.

But only three days after this incident, staff stopped ACCT procedures, and after another two days, Thompson took his own life. Adrian Usher, from the Prison and Probations Ombudsman, said he was left “concerned” by the staff’s decision to stop ACCT procedures “prematurely”.

As a result, the clinical reviewer found that Thompson received appropriate care for his mental health up to October 24 but that after this, the care was inadequate due to the poor input to the ACCT case reviews.

She concluded that the care Thompson received at Northumberland for his mental health was “not equivalent” to that which he could have expected to receive in the community.

HMP Northumberland, run by Sodexo Justice Services, is a category C prison which holds around 1,350 male prisoners. Spectrum Community Health CIC provides healthcare services. Healthcare staff are on duty from 7.30 am to 7.30 pm, Monday to Friday. Tees, Esk, and Wear Valley Mental Health NHS Foundation Trust are contracted to provide mental health services.

Thompson was the 14th prisoner to die at Northumberland since November 2020. Of the previous deaths, four were self-inflicted, one was drug-related and eight were from natural causes.

In a previous investigation, the PPO found that ACCTs were closed prematurely, and not reopened when there was concern about a prisoner’s presentation.

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The Ombudsman recommended that the Director and Head of Healthcare should ensure that staff manage prisoners being monitored using ACCT in line with prison policy, in particular;

  •  that they invite all relevant staff involved in supporting the prisoner to case reviews;
  •  discuss and record how identified sources of support should be involved in the ACCT process;
  • record care plan actions and ensure they are followed up;
  • refer cases to the Safety Intervention Meeting when prisoners are segregated;
  • and are alert to any changes in the prisoner’s behaviour during the post-closure period that may indicate increased risk and consider whether the ACCT should be reopened.