The Prisons and Probation Ombudsman (PPO) has criticised HMP Garth over its failures after a prisoner took his own life.
Simon Dunn, 55, died in custody at Garth in September 2024. He had been in prison since September 2019 and was serving a 16-year sentence. He left a note indicating that he intended to take his life.
An inquest into Mr Dunn’s death concluded on 22 May and recorded a verdict of suicide.
Adrian Usher, the PPO, led the investigation. He found that the prison took too long to tell Mr Dunn’s next of kin. “Garth informed Mr Dunn’s next of kin of his death five days after he died,” his report said. The prison initially struggled to obtain the right address. Even once it had an updated address, the report found, the prison took too long to visit and break the news.
Mr Usher called the delay “unacceptable”.
Risk factors and triggers
According to the PPO, Mr Dunn had several physical and mental health diagnoses and took prescribed medication. His history of self-harm and attempted suicide was extensive.
He spent his first period on remand at HMP Durham before moving to Garth in November 2019. Staff at Garth monitored him under suicide and self-harm prevention procedures on nine occasions, most recently in January 2024.
In August 2024, Mr Dunn pleaded guilty to further charges, and his case went to the crown court for sentencing. He took part in a court video hearing on 17 September, and the hearing then moved to 2 October. When he spoke to his support worker on 19 September, he said he was not OK but had no suicidal thoughts.
Another prisoner said that on 24 September, with an officer present, Mr Dunn described problems on the wing. He said four people were out to get him. According to this prisoner, Mr Dunn said he could not cope and that the situation was affecting his health.
Staff found Mr Dunn unresponsive on the morning of 26 September. A doctor pronounced him dead at 12.10pm. His note indicated that he faced bullying.
Findings
The PPO found that Mr Dunn had several risk factors for suicide and self-harm. Two potential triggers emerged before his death: his impending sentencing for further offences, and concerns that others were bullying him.
Mr Usher said staff did not explore these risks and triggers as well as they might have. Staff had also not checked on his welfare after court appearances. Some officers did not know how to apply local violence reduction procedures, and failed to record low-level bullying.
The clinical reviewer found Mr Dunn’s physical and mental healthcare partially equivalent to care in the wider community. The reviewer said a multi-disciplinary team should have discussed a decision about his medication. This was because of his personality disorder and his history.
The Ombudsman made several recommendations. “HMP Garth has accepted all the Ombudsman’s recommendations and made changes to better support prisoners at risk of self-harm and suicide,” a Prison Service spokesperson said. The spokesperson said the changes include better staff training and more robust welfare checks.
HMP Garth is a category B prison for men. Its last full inspection, in November 2024, rated purposeful activity as poor. Safety and respect were not sufficiently good, and preparation for release was reasonably good.
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