SAFEGUARDING measures to prevent suicide at HMP Chelmsford – described as one the country's "most violent local prisons" – have been slated after an inmate killed himself less than a week after he arrived.

Paul Joseph, who had been remanded in custody on February 24, 2021, charged with attempted murder and kidnap, had already told court staff he would kill himself if he was sent to prison that day.

Court staff emailed and spoke to a nurse at Chelmsford Prison to warn them about what Mr Joseph had said but staff stopped the suicide and self-harm monitoring protocol (known as ACCT) the day after his arrival on February 25.

Mr Joseph was not being monitored when he was found hanging in his cell on March 2. He died in Broomfield Hospital later that day aged 46.

Elizabeth Moody, Deputy Prisons and Probation Ombudsman said she was concerned that staff stopped ACCT monitoring after less than 24 hours in a report published November 30.

She added staff ignored warnings from court staff that Mr Joseph had said he would kill himself if he was sent to prison and placed too much emphasis on Mr Joseph's presentation and not enough on his risk factors.

She added that the prison also failed to wait for Mr Joseph's mental health to be assessed before they stopped ACCT monitoring.

The criticism comes two years after previous reports highlighted failings around ACCT at Chelmsford Prison. HM Inspectorate of Prisons said in 2021 said that despite serious concerns raised in 2018 and the subsequent intervention of the Prisons and Probation Ombudsman, outcomes had deteriorated in those three years.

It had recommended work to prevent suicide or self-harm "should be improved significantly" with the use of listeners, ACCT case management and other preventative measures delivered "proactively and robustly".

In her latest report into the death of Mr Joseph Ms Moody said she was concerned the same issues arising in February 2021 have been found again.

In her report, she said: "I consider that staff showed poor judgement and stopped ACCT monitoring too soon. This is not the first time I have raised concerns about ACCT management at Chelmsford.

"The reception nurse made a mental health referral when Mr Joseph arrived at Chelmsford. A mental health assessment should have been completed within 72 hours but Mr Joseph had not had one by the time he died."

The report finds that the prison officer who assessed Mr Joseph in reception did not know about the phone calls made by court staff. However, the report has found he was aware of the self-harm warnings for Mr Joseph.

The ombudsman report added: "We are concerned that he did not properly record and assess Mr Joseph's risk factors for suicide and self-harm.

"We are concerned that the ACCT was closed after less than 24 hours. The staff at the ACCT review were aware of what Mr Joseph had told court staff but did not address this with him.

"We saw no evidence that staff had done anything to mitigate Mr Joseph's risk. They also failed to wait for Mr Joseph's mental health to be assessed before closing the ACCT.

"We have previously identified failures in the management of ACCT procedures at Chelmsford. In response to previous recommendations on this issue, we were told that new guidance had been issued to staff in August 2020.

"We are concerned that we have found the same issues arising in February 2021.

"Mr Joseph should have had a mental health assessment within 72 hours of the referral. He had not had one in the six days he was at Chelmsford."

She has now set out a set of recommendations to the governor and head of healthcare.

This means that reception staff should consider all documentation that arrives with a prisoner so that they properly assess their risk of suicide and self-harm, share important information about a prisoner's risk of suicide and self-harm and record the information considered and their reasoning when they decide not to start ACCT procedures.

She has said the governor should ensure that staff manage prisoners at risk of suicide or self-harm in line with national guidelines, in particular, that they consider all risk factors when assessing a prisoner's level of risk and do not just rely on what the prisoner says or how he appears.

They also need to ensure that the ACCT is not closed until measures have been put in place to mitigate the prisoner's risk and that risk has sufficiently reduced.

The head of Healthcare should also ensure that prisoners referred for a standard mental health assessment are seen within 72 hours.

The ombudsman noted that the most recent full inspection of Chelmsford from His Majesty's Inspectorate of Prisons (HMIP) was in May and June 2018 and that inspectors were concerned at how the prison managed prisoners at risk of self-harm and suicide.

That report noted there had been 16 self-inflicted deaths over the previous eight years, and four since the last inspection, but too many recommendations from the ombudsman had not been implemented.

Inspectors found that levels of self-harm were very high and that the care was often not good enough. They also found that many staff had become very risk averse, which meant that ACCT procedures were often overused, which in turn risked masking the needs of particularly vulnerable men. They were concerned about the almost complete lack of a broad strategic response to these issues.

In April 2019, HMIP reviewed Chelmsford's progress against the main recommendations made following their inspection in June 2018.

Inspectors found then that the levels of self-harm remained high and the number of self-inflicted deaths remained worrying, but there had been reasonable progress in improving the quality of care for prisoners in crisis or at risk of self-harm.

They found that the quality of ACCT paperwork had improved. However, the prison needed to keep recommendations from the ombudsman under constant review to ensure that progress was sustained.

HMIP carried out a further inspection in August 2021. The inspection report has not yet been published, but on 27 August, HM Chief Inspector of Prisons issued an Urgent Notification (UN) requiring immediate action from the Secretary of State for Justice to address violence, safety and poor conditions at Chelmsford.

The concerns set out in the UN included that HMIP found Chelmsford to be one of the country's most violent local prisons. There had also been eight self-inflicted deaths since 2018 and a further four non-natural deaths in three years. In addition, self-harm had continued to rise for the fourth successive inspection.

HMIP found that although some staff were committed and constructive, many others described very low morale, disillusionment and disengagement. Many staff, for example, failed to respond to even basic requests from prisoners and too many were dismissive in their dealings with prisoners or evidenced only limited empathy. Almost half of the prisoners said that they had been victimised by staff, particularly those prisoners with disabilities and mental health problems.

HMIP found that a lack of accountability and management oversight enabled poor performance and behaviour to go unchallenged. Many staff had witnessed poor behaviour among their peers and too few took responsibility for the duties to which they had been deployed. Emergency cell bells were often only answered after long delays.

HMIP found that many prisoners were locked in their cell for almost 23 hours a day. This reflected Covid-19 restrictions but even in 2018 many prisoners had been locked in their cell for 22 hours a day. Plans to reintroduce a meaningful regime were limited and being implemented far too slowly.

Ms Moody said: "We have raised concerns about the operation of ACCT at Chelmsford in previous investigations into self-inflicted deaths at the prison. In response to a previous recommendation about poor assessment of risk and ACCT management, we were told that new guidance had been produced and circulated in August 2020, and that since then three newsletters had been issued to remind staff about important aspects of ACCT management. We are, therefore, very concerned to have identified similar failings in this investigation."

An inquest, which concluded on November 3 2023, the jury recorded a narrative conclusion. They found that the ACCT should have been left open on 25 February and that Mr Joseph should have been provided with continued support using ACCT procedures. They concluded that Mr Joseph did not receive adequate care or support from prison or healthcare staff at Chelmsford and there were numerous serious failures in deploying the care and support that Mr Joseph was entitled to.