Man recalled to prison died at HMP Holme House, Stockton

Both HMP Durham and HMP Holme House in Stockton have been ordered to improve after the death of 35-year-old Christopher Parker, who was sentenced to nearly five years in prison for robbery in 2017.

Parker was said to have been "at the risk of death" when he was recalled to HMP Durham in June 2020 after he overdosed and breached his release conditions.

But just a few months later, he was found dead in his cell at HMP Holme House, on November 12, 2020.

Now, a probe by the Prisons and Probation Ombudsman (PPO) has found suicide and self-harm procedures were "poor" and breached prison service policy.

The report details that Parker arrived at HMP Durham on recall on June 13, where it was noted by an officer that he "did not have any thoughts of suicide or self-harm".

By the end of the month, Parker had been transferred to HMP Holme House where he underwent "regular welfare checks" - but did not see the mental health team until he self referred on September 7.

That same month, he told nurses he was "feeling very anxious and was not sleeping", had a history of self harm and was fearful for his safety due to another prisoner.

The report continues to outline, however, how Parker's mental health continued to deteriorate and self harmed on October 22, confessing to an officer who found alcohol in his room that his mental health was "through the roof".

It was only at this point that staff s referred him to the mental health team.

The next day, he confessed he had self harmed, but was still deemed to be at "low risk of suicide and self-harm".

A nurse then concluded that Parker "was not mentally unwell", and he "did not meet the criteria to be on the secondary mental health team’s caseload".

But on the day he died Parker asked to be moved to a new houseblock as he was "concerned for his safety", but this did not happen.

Investigators found an officer said he "could not remember" Parker asking for this transfer, leaving him "upset and distressed" the last time he was seen alive. Later that day, Parker was found dead in his cell.

Ombudsman Sue McAllister has now ordered HMP Durham to begin ACCT (Assessment, Care in Custody, and Teamwork) procedures "irrespective of (a prisoners) demeanour".

She wrote: "The recall paperwork said that it was not known if the overdose was intentional or accidental.

"There is no evidence that prison staff assessed Mr Parker’s risk of suicide or self-harm when he arrived at Durham on June 13.

"We consider that given Mr Parker’s recent self-harm, Durham should have started ACCT monitoring."

Addressing HMP Holme House, the ombudsman added "overall management of the ACCT was poor" and that Parker's behaviour on the day he died should have raised alarm.

She wrote: "His behaviour was a cause for concern and suggested an increased risk of suicide and self-harm.

"We consider that the custodial manager should have arranged an urgent case review to assess Mr Parker’s risk and whether the ACCT needed to be re-opened.

"We consider that Holme House need to take steps to improve the ACCT process."

A Home Office spokesperson added: “Our thoughts remain with the friends and family of Christopher Parker.

“We have accepted and actioned the Prison and Probation Ombudsman’s recommendation.

“This includes updating suicide and self-harm prevention procedures to ensure we can better identify prisoners at risk.”

If you are in need of support you can contact the following:

- Samaritans is available, day or night, 365 days of the year. You can call them for free on 116 123, email them at jo@samaritans.org, or visit www.samaritans.org to find your nearest branch.

- If U Care Share on 0191 387 5661 or text IUCS to 85258

- SANE on 07984 967 708, Calm on 0800 58 58 58