A prison guard failed to check on a suicidal prisoner who later took her own life at HMP Styal, an investigation into her death has found.
And when Susan Knowles was found hanged in her cell, the guard couldn't enter because he'd left the key in his jacket on the floor below. Following Ms Knowles' death, it emerged the guard had falsified the record to claim he had carried out the required checks, the investigation by the Prison and Probations Ombudsman found.
He was later investigated by police and dismissed following a disciplinary probe. Ms Knowles, 48, was suffering from heroin withdrawal, depression and anxiety and was considered to be a suicide risk when she arrived at Styal on May 8, 2019, having been jailed for eight weeks for theft and breaching a community order.
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She requested methadone, but because her heart rate was too low it was 'withheld'. The next day Ms Knowles said she would kill herself if she didn't get methadone. Instead she was prescribed a combination of drugs, including painkillers and anti-sickness medication, and put on suicide and self-harm watch, also known as ACCT monitoring.
That should have meant she was observed twice an hour. But in the three hours and 45 minutes between her being seen by a nurse and her death, she was checked on just three times.
Despite that entries were made in the record claiming checks had been carried out. One read 'x2 checks in the hour lay on her left side knocked on the door to get a response Susan stuck her 2 fingers up at the door no concerns raised'.
Just after midnight on May 10, Ms Knowles was found hanged in her cell in a part of the prison known as the first night centre. But the night officer couldn't get into the room as he had left the key in his jacket pocket on the floor below. He also failed to radio in a medical emergency - which would have triggered an immediate call for an ambulance.
Instead a nurse responded to a radio call for 'immediate healthcare assistance' and attempted to resuscitate Ms Knowles. An ambulance was called at 12.18am, eight minutes after she was first discovered. By the time paramedics arrived 15 minutes later Ms Knowles had died.
The night officer, who was not named in the report, was suspended from duty on May 11, 2019. Cheshire Police conducted a criminal investigation, but the decision was made in August 2020 not to charge him. On January 21, 2021, the officer was dismissed following a disciplinary investigation.
A report by Prison and Probations Ombudsman Sue McAllister found that although it was not known what time Ms Knowles died 'it is possible that she would have been found sooner had observations been carried out at the required frequency'. The delay in calling an ambulance 'made no difference' in Ms Knowles' case, but the prison was rebuked for not following the correct emergency procedures.
Help and support
Samaritans (116 123) samaritans.org operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org, write to Freepost SAMARITANS LETTERS (no more information needed) and visit www.samaritans.org/branches to find your nearest branch.
For support for people feeling suicidal, if you are concerned about someone or if you are bereaved by suicide see http://shiningalightonsuicide.org.uk
CALM (0800 58 58 58) thecalmzone.net has a helpline is for men who are down or have hit a wall for any reason, who need to talk or find information and support. They're open 5pm to midnight, 365 days a year.
Greater Manchester Bereavement Service Greater Manchester Bereavement Service can help to find support for anyone in Greater Manchester that has been bereaved or affected by a death. No one needs to feel alone as they deal with their grief. www.greater-manchester-bereavement-service.org.uk
Childline (0800 1111 ) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.
PAPYRUS (0800 068 41 41) is a voluntary organisation supporting teenagers and young adults who are feeling suicidal.
Beat Eating Disorders: Beat provides helplines for adults and young people offering support and information about eating disorders. These helplines are free to call from all phones. Adult Helpline: 0808 801 0677, Studentline: 0808 801 0811, Youthline: 0808 801 0711. www.beateatingdisorders.org.uk
Anorexia & Bulimia Care: ABC provide on-going care, emotional support and practical guidance for anyone affected by eating disorders, those struggling personally and parents, families and friends. Helpline: 03000 11 12 13. www.anorexiabulimiacare.org.uk/
Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts. Bullying UK is a website for both children and adults affected by bullying studentsagainstdepression.org
For information and links to charities and organisations that can help with substance abuse, visit https://www.supportline.org.uk/problems/drugs/
"We know that in a medical emergency a delay of a few minutes may be critical," the ombudsman wrote.
Ms McAllister added: "I am not satisfied that Ms Knowles' withdrawal from drugs was appropriately managed. While it was appropriate for staff to withhold methadone, there was an unnecessary delay in prescribing symptomatic relief.
"Ms Knowles arrived at Styal with several risk factors for suicide and self-harm, and I am concerned that staff did not start ACCT monitoring earlier. In addition, although staff did start ACCT monitoring 12 hours before Ms Knowles died, they did not carry out all the required observations on the night she died.
"The officer who discovered Ms Knowles was not carrying a room key which resulted in a delay in entering her room. I am also concerned the officer did not call a medical emergency code when he discovered Ms Knowles, resulting in a delay in calling the ambulance. Failure to call a medical emergency code is something I have raised previously with Styal."
Ms Knowles was the fourth woman to have died in the first night centre at Styal since 2018. The ombudsman wrote that in response to previous criticism the prison has been significant changes to its induction processes, including better monitoring of inmates withdrawing from drugs.
What the MOJ has to say
A Ministry of Justice spokesperson said: "Self-harm in prisons is too high and deaths like Susan Knowles’ are why the new Government will form a Women’s Justice Board to reduce the number of women going to prison in the first place.
"Since 2019, HMP Styal has implemented changes to provide more consistent healthcare support for female prisoners in the early days of custody and we will respond to the full report in due course."
