A coroner has raised concerns over the death of a suicidal prisoner who wasn’t checked on properly.
Michael Pugh, 29, took his own life in his prison cell on June 29 last year.
An inquest into his death found that despite officers needing to check on him hourly, this wasn’t done, and an ongoing record which logged how often he was checked on was filled out after he died.
Pugh was an inmate at HMP Swaleside in Eastchurch on the Isle of Sheppey.
He was the subject of an Assessment, Care in Custody and Teamwork (ACCT), which is a process used in prisons to support people at risk of self-harm and suicide.
An inquest headed by coroner Patricia Harding in Maidstone, which concluded on Monday, July 21, found these observations were being recorded incorrectly.
Additionally, the hearing heard no observations were carried out for more than 90 minutes, between 7.22am and 9.57am, when Pugh was discovered dead.
I didn’t understand the importance of observing a prisoner at unpredictable times…
However, the ongoing record was completed retrospectively to show that they had been carried out.
Ms Harding has now written a Prevention of Future Death report, which will be sent to His Majesty’s Prison and Probation Service.
She said: “During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion, there is a risk that future deaths could occur unless action is taken. In the circumstances, it is my statutory duty to report to you.”
The coroner’s concerns related to new recruits who had just months of Prison Officer Entry Level Training (POELT).
One officer had three months of experience, while the second had just one month.
The report added: “Both officers gave evidence that following their POELT training, their understanding of the ACCT process was incomplete.”
One employee said observations were explained to them, but they “didn’t have a fair idea what to do or how to undergo the process.”
The second said: “I didn’t understand the importance of observing a prisoner at unpredictable times.
“Even though I was told the observations should be hourly, it was not explained to me how to stagger timing. I misunderstood what was required of me in recording the details when I recorded them as having happened at 1pm, 2pm, 3pm and 4pm.”
The prison service has until September 19 to respond to Ms Harding’s concerns.
The Ministry of Justice has been approached for comment.
