Failings at two prisons found after inmate's death

The Prisons and Probation Ombudsman said Shaine Tester did not receive "an appropriate level of care" at HMP Gartree

Mental healthcare failings have been identified at two prisons following the death of an inmate who took his own life.

Staff at HMP Gartree, near Market Harborough in Leicestershire, found Shaine Tester unresponsive in his cell on 1 November 2022.

A report by the Prison and Probation Ombudsman said the 34-year-old was getting suicide and self-harm prevention support, but it ceased just days before he died.

Failings were found at the prison and at HMP Lewes in Sussex, where Mr Tester had been transferred from.

Mr Tester "did not receive an appropriate level of mental health care during his time at HMP Gartree", having transferred there in September 2022, the report said.

The Prison Service told the BBC it had already taken action to address the concerns raised.

Ombusdman Adrian Usher said Mr Tester was serving a 27-month sentence after he was charged with making threats to kill, possession of offensive weapons and assaulting police.

Mr Usher's report said the prisoner was a "complex man who had regular thoughts of suicide and self-harm".

The Local Democracy Reporting Service (LDRS) said Mr Tester was moved to HMP Gartree because he had attempted to kill himself at HMP Lewes, where staff did not feel equipped to deal with his needs.

However, the ombudsman said HMP Lewes did not complete a handover form regarding Mr Tester's mental health needs.

This was a failing, the ombudsman added, with the watchdog saying the prison should ensure that "a formal clinical handover is arranged for all complex mental health prisoners before transfer to a new prison".

Mr Tester had attempted to kill himself at HMP Lewes before he was moved to HMP Gartree

At HMP Gartree, it was decided Mr Tester should have three observations an hour but these were gradually reduced over time, and then stopped on 11 October, the report said.

The observations briefly restarted when Mr Tester reported he was "worried that he might kill himself", but then ceased again on 27 October.

The ombudsman said "it would have been prudent" for the prison to have kept Mr Tester's monitoring in place until after a psychiatry appointment, scheduled for 16 November, when staff would have had "more information about his mental health".

The watchdog's report said Mr Tester's mother had rung the prison's "at risk" helpline on the night he died, as "she had not heard from him for a while".

Her message was picked up about four hours later.

After this, the night orderly officer asked staff to check on Mr Tester, who was then found unresponsive. He was confirmed dead a short time later.

Care plan lost

A clinical reviewer who considered the case alongside the ombudsman said the prison should have created a "safety plan" for Mr Tester, which would have "provided a more structured and evidence-based intervention".

Gartree has been told it should ensure such plans are written "for all prisoners who have self-harmed".

The ombudsman added that "disappointingly", Mr Tester's care plan had been lost by HMP Gartree following his death, which meant it was not possible to "assess the adequacy of the plans drawn up to identify and address his most urgent needs, nor assess whether all of the care plan actions had been completed when [reviews] were stopped".

A Prison Service spokesperson said: "Our sympathies remain with Mr Tester’s family.

"We have already taken action in line with the ombudsman's recommendations including improving procedures to better spot and support those at risk of suicide and self-harm."

The spokesperson added HMP Gartree had adopted new suicide and self-harm procedures in June 2023 and implemented training for all staff.

They also said HMP Lewes had implemented a new prison transfer process to reinforce plans for moving inmates with complex mental heath needs.

If you have been affected by any of the issues raised in this story, you can visit the BBC Action Line.

Follow BBC Leicester on Facebook, on X, or on Instagram. Send your story ideas to [e-mail] or via WhatsApp on 0808 100 2210.