HMP The Mount prison officers failed to call emergency code after inmates death
A watchdog's report's found that it's the third time this kind of incident happened in as many months
Prison officers at HMP The Mount in Hertfordshire failed to call the required emergency code when they discovered a prisoner had died, the Prisons Ombudsman has found.
It is the third death report released in the last three months to find that officers at the prison failed to call the correct emergency code.
Dale Samm, 28, was found dead in his cell on September 25, 2022, less than a month after he entered the prison, in Bovingdon near Hemel Hempstead. He had been sentenced to two months and 23 days in jail for property damage and carrying a knife.
An officer saw that Mr Samm was “slumped” between his bed and cell window during a routine check, and called for assistance from another officer.
She then noticed that Mr Samm was not breathing – but failed to call a radio emergency code until the second officer arrived.
Officers entered Mr Samm’s cell when further back-up arrived, and found that he was dead. An inquest concluded that Mr Samm had taken his own life.
While Mr Samm had a history of depression and substance misuse, he told officers he was “fine” and did not need mental health support. He had been prescribed methadone, a heroin substitute, at the time of his death.
A report from the Prisons & Probation Ombudsman said “staff could not have foreseen his death”, but found there were “delays” with the emergency response.
They said a medical emergency code should have been called as soon as the first officer on the scene realised Mr Samm was not breathing, and that officers should have entered the cell when two of them were present, rather than waiting for further backup.
It is the third report in three months to note problems with officers calling an emergency code at HMP The Mount.
In July, a report found officers had not called the correct code for emergency support when they found James Bailey dead in his cell. And, in August, the Ombudsman said it was “concerned” that staff failed to call a medical emergency code when Godfrey Muzhuzha – who later died – reported breathing difficulties.
In Mr Samm’s case, the Ombudsman also found that he had not yet been allocated a key worker, four weeks after being moved to HMP The Mount. The report said: “Key work sessions might have identified that Mr Samm was struggling.”
The Ombudsman recommended the prison’s governor should ensure staff “understand their responsibilities” during medical emergencies, and ensure the key worker scheme “provides meaningful and ongoing support” to all prisoners.
A Prisons Service spokesperson said: “Our thoughts remain with the family and friends of Dale Samm.
“We have accepted all the report’s recommendations and have reminded staff at HMP The Mount of their responsibilities during a medical emergency.”