Staff at HMP Haverigg had enough evidence to consider suicide and self-harm monitoring for a man who took his own life on the day of his planned release, an investigation has found.
Adrian Usher, the Prisons and Probation Ombudsman (PPO), investigated the death of Nigel Keenan, 62. His report criticised staff for missing chances to assess Mr Keenan’s risk of suicide.
The PPO concluded that there was enough evidence for staff to consider ACCT in the weeks before Mr Keenan died. ACCT, short for Assessment, Care in Custody and Teamwork, is the name for the monitoring procedures.
Mr Keenan died in the early hours of 13 March 2025 at the open prison, on what should have been his release date. He was pronounced dead at 4.20am.
Warning signs
According to the report, Mr Keenan had no significant recorded history of self-harm. But pressures on him grew in the weeks before his death. A relationship had broken down and his housing after release was uncertain. He also had concerns about his safety in the community.
In February 2025, healthcare staff learned that Mr Keenan had been having suicidal thoughts. He had recently started a prescription for nerve pain.
Staff put the thoughts down to a side-effect of the drug. They took reassurance from his statement that he had no intention of acting on them. Nobody referred him to the mental health team, and ACCT procedures did not begin.
Investigators also found that prison staff received reports in the following weeks suggesting his risk might have risen. However, the PPO said staff focused more on their view of him as manipulative than on the possible warning signs.
“Mr Keenan had risk factors for suicide including a history of anxiety, recent relationship breakdown, and fears about risks to his safety on release. I consider there was sufficient reason to think that ACCT procedures were appropriate,” Mr Usher said.
Recommendations accepted
The PPO made two recommendations. The first asks the Governor and healthcare leaders to make sure staff understand their duty to identify and assess risk information. Staff should also know when to open ACCT procedures.
The second says healthcare staff should consider a referral to mental health services whenever a prisoner reports suicidal thoughts. Staff should also record the reasons for their decision.
HMP Haverigg and its healthcare provider, Spectrum Community Health CIC, accepted both recommendations. Their response includes extra staff training and wider promotion of ACCT procedures. Staff will also routinely review prisoners who are nearing their release dates.
Healthcare staff will receive mental health awareness training. Prison safety meetings will gain a new agenda item to review prisoners due for release. The aim is to spot any concerns and arrange support where needed.
According to the PPO, Mr Keenan was the second person at Haverigg to take his own life since March 2022.
HMP Haverigg is a category D open prison for men in the North West. Its most recent full inspection before this report took place in July 2025. Inspectors rated safety, respect, purposeful activity and preparation for release as good.
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