Ombudsman critical of HMP Durham over the death of a South Tyneside prisoner
The Prisons & Probation Ombudsman has highlighted “missed opportunities” following the death of a South Tyneside prisoner.
Mark Mason died on December 8, 2022, after he was found in his cell at HMP Durham - with an inquest into his death concluding that he “died of a ligature which was self-inflicted but his probable intent cannot be determined”.
In the Prisons & Probation Ombudsman’s report, it was outlined that during a mental health assessment on December 6, 2022, the 45-year-old told a nurse that he had lived with thoughts of self-harm for years, but had resisted because of his love for and from his family and partner.
He also flagged to medical staff that he was scared to leave his cell as he believed that other prisoners were going to attack him.
The report notes that Mr Mason had no known issues with other prisoners on the wing at HMP Durham and that he had told staff that he “did not know why he was under threat or from whom”.
The nurse who carried out the mental health assessment discussed Mr Mason’s safety fears with a wing officer, who agreed to look into a wing move but she did not mention his thoughts of self-harm.
It was also reported that the nurse did not think that Mr Mason needed to be monitored under suicide and self-harm prevention procedures, as well as discharging him from the mental health team.
The Prisons and Probation Ombudsman report highlights that Mr Mason’s medical records had not been properly reviewed due to the fact that him having a history of suicide attempts was not identified.
The Ombudsman noted: “This information would have added to the overall picture of Mr Mason’s risk to himself and was again a missed opportunity, as was the failure to pass on relevant information to wing staff.”
During the investigation into Mr Mason’s death, the clinical reviewer concluded that the mental care that he received at HMP Durham “was not equivalent to that which he could have expected to receive in the community”.
In his report, Adrian Usher, Prisons and Probation Ombudsman, concluded: “My investigation found that there were missed opportunities to provide support to Mr Mason for his mental health and to manage the risk he posed to himself.
“The clinical reviewer concluded that the mental health care Mr Mason received at Durham was not equivalent to that which he could have expected to receive in the community.”
The full report into Mr Mason’s death can be found at: https://ppo.gov.uk/fatal_incident/mark-mason/.