STAFF at a prison have been criticised after an inmate with a history of self-harm died after he cut himself on the arm following an altercation with another prisoner.

Alan Johnston, 32, from St Helens, who was at HMP Liverpool, died due to blood loss on the evening of November 27, 2019, after he made a significant cut to his left forearm.

A Prisons and Probation Ombudsman report found staff had “underestimated” his risk after he had been involved in an altercation with a prisoner earlier that day.

Prison officers also did not unlock Mr Johnston’s cell on the evening he died until nearly 40 minutes after it was first noticed his observation panel was blocked.

An inquest hearing into the death of Mr Johnston was held on September 5, which confirmed that the medical cause of his death was “an incised wound to his left forearm”, reaching the conclusion that Mr Johnston died by misadventure.

Prisoner had history of 'prolific self-harm'

The ombudsman report noted “Mr Johnston had a history of mental ill health and significant and prolific self-harm” and “had last harmed himself a month before his death and had regularly been monitored under suicide and self-harm monitoring procedures, known as ACCT”.

Also, there was “a clear and well-documented pattern to Mr Johnston’s self-harm which regularly occurred after confrontations with staff and prisoners”.

Mr Johnston had told staff he “was bullied during his time at Liverpool”.

He had been remanded to HMP Liverpool in January 2019 after he was charged with possession of indecent images, and it was not his first time in prison.

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On June 20 that year he was convicted and sentenced to 21 months in prison, and due for release on December 13, 16 days after his death.

On November 22, a psychologist noted Mr Johnston’s “generally positive progress” but that he “remained concerned about his return to St Helens”. Mr Johnston had “felt his safety would be at risk”.

At 4.11pm on the day he died, Mr Johnston was involved in an altercation with a prisoner in which was “a verbal and then physical confrontation which ended with the prisoner falling downstairs”.

Following this he has “presented as agitated to prisoners and staff”.

It was said a prisoner, who spoke to Mr Johnston, “told police that he was worried that Mr Johnston would cut himself and advised him not to do so”.

The ombudsman was noted that “between 4.52pm and 7.12pm, no checks were carried out on Mr Johnston”.

At around 7.10pm, a night patrol officer arrived and was told Mr Johnston had been involved in a fight with another prisoner but that “the officer did not give him any information which would have caused him to have had concerns about either of the prisoners”.

At 7.13pm it was noticed the cell observation panel was blocked on Mr Johnston’s cell.

Despite attempts to get a response from Mr Johnston and officers kicking the cell door, the cell was not unlocked until 7.51pm and they saw Mr Johnston lying on the cell floor, and that the cell was “covered in blood”.

Mr Johnston was later confirmed dead and a blood-stained note was found in which Mr Johnston wrote: “I tried not to cut. I did get the bell it took over 45 minutes for someone to answer.

“Then an officer answered and refused to get me someone to talk to. I then said I was going to cut myself, he laughed and said, ‘go on’ so I have.”

The ombudsman noted “we do not know when Mr Johnston wrote this note” and “the officer told police that he did not have such a conversation with Mr Johnston”.

Ombudsman's findings

In their findings, the ombudsman noted: “There is no evidence that staff considered the impact that the altercation with another prisoner might have had on Mr Johnston, despite well documented evidence that he would ham himself after such incidents.

“We consider that staff who worked on the wing should have been aware of his previous consistent and repeated patterns of behaviour and considered starting ACCT procedures”.

It was added: “Despite Mr Johnston not responding to any of the night patrol officer’s attempts to communicate with him, and several staff having been informed of the blocked panel, it was nearly 40 minutes until the cell was opened.

"This is too long, particularly given the events of the afternoon.

“Our view is that he should have contacted colleagues for support immediately, remained at the cell, and opened it at the first opportunity.

“We consider that staff should have acted with more urgency. We recognise that it can be difficult for staff to make instant decisions in difficult and unknown circumstances. However, when there is a potentially life-threatening situation, it is essential that staff act quickly and exercise good judgement.”

A Prison Service spokesperson said: “Our thoughts remain with Alan Johnston’s friends and family.

“Since his death, we have taken action to improve procedures for supporting vulnerable prisoners.

“All staff at HMP Liverpool have received additional training in suicide and self-harm prevention, and we have improved our response to incidents of bullying.”