Prisoner under observation dies after staff failings

Prisoner Michael Pugh died at HMP Swaleside last year despite being subject to hourly observations

A prisoner in Kent who should have been checked every hour was found dead in his cell after staff failed to monitor him, a report has found.

Michael Pugh, 29, who was in HMP Swaleside on the Isle of Sheppey for wounding with intent, was left unattended between 07:22 BST and 09:57 on 29 June last year.

The findings form part of a prevention of future deaths report, which is issued when a coroner believes action is required in order to protect lives.

HM Prison & Probation Service said it would carefully consider the findings of the report, published on Monday, and respond to them in due course.

In the report, senior coroner in Kent and Medway Patricia Harding said the last Assessment, Care in Custody and Teamwork (ACCT) review to take place before Pugh's death determined he should be subject to hourly observations.

The ACCT is the care planning process for prisoners identified as being at risk of suicide or self-harm.

"Observations were carried out on the afternoon of 28 June, but recorded incorrectly," Ms Harding said.

"No observations were carried out on 29 June between 07:22 and 09:57, when Mr Pugh was discovered having died, but the ongoing record was completed retrospectively to show that they had been carried out."

Inexperienced prison officers

The two prison officers who gave evidence in relation to the observations on 28 and 29 June were "relatively new recruits", Ms Harding added.

She said that one officer had three months experience following basic training – known as Prison Officer Entry Level Training – while the other had one month of experience.

Both officers gave evidence stating their understanding of the ACCT process was "incomplete".

One said: "Observations were explained, but I didn't have a fair idea what to do or how to undergo the process."

The other 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."

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