Concerns over reduced welfare checks after Leeds prisoner found hanged during Covid pandemic

A report has suggested that staff at HMP Leeds had little clue that a prisoner who hanged himself was suffering from depression, possibly due to the strict regime during Covid lockdown.

Gary Davies, who was on remand for suspected drug dealing, died five years ago.

The document published this month by the independent Prisons & Probation Ombudsman (PPO) found that a reduced welfare structure may have led to red flags being missed.

Mr Davies, who was 63, was found hanged in his cell at the Armley prison on June 10, 2021.

He had been on remand for four months at the time of his death. The report suggests he was “devastated” at finding himself back in prison for the first time in 30 years.

Staff assessed that he was not at risk of suicide or self-harm but he was offered support for his own substance misuse.

He was housed on the drug-free wing weeks after being remanded.

At approximately 8am on June 10, an officer found Mr Davies hanging in his cell.

The officer called for help and staff responded quickly, trying to resuscitate Mr Davies until paramedics arrived and took over. They were unable to save him.

A suicide letter was found in his cell. He had written that he was “sorry”, he loved his family but that he could not handle the “pressure” he was getting in prison and that he had “no fight left in him and could not take anymore”.

A clinical reviewer concluded that the care Mr Davies received at Leeds was of a good standard, although there were concerns that the officer who found him hanging did not provide immediate medical assistance. This led to a delay of one-and-a-half minutes while they waited for colleagues to assist.

However, the PPO found that earlier intervention “might not have changed the outcome”.

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In conclusion, the report reads: “Although we think that staff should have considered opening suicide and self-harm procedures when Mr Davies first arrived at Leeds, we are satisfied that they could not reasonably have been expected to foresee that Mr Davies was at risk of suicide at the time of his death.

“However, the restricted pandemic regime and the limited nature of the welfare checks made on Mr Davies meant that staff were not well placed to identify any deterioration in his mood or other problems.”

Recommendations by the PPO included prison staff being given clear guidance on welfare checks, and to understand their immediate responsibilities during medical emergencies.