Gartree prison inmate died after failings in mental health care, supervision rules

Mental health failings have been identified at two prisons after a Leicestershire inmate took his own life. Shane Tester was transferred to Gartree Prison in Harborough Borough from HMP Lewes in East Sussex in November 2022.

A little over a month later, he was found unresponsive in his cell. Prison staff ended suicide and self-harm prevention support for Mr Tester, 34, just days before his death.

Now a report published this week by watchdog the Prisons and Probation Ombudsman has highlighted a number of failings in how Mr Tester’s mental health needs were met by the two prisons.

READ MORE: The police officer carried out “extensive” searches of “sensitive” data.

Mr Tester “was a complex man who had regular thoughts of suicide and self-harm”, the Ombudsman said. He was diagnosed with “dissocial personality disorder with schizoid and paranoid features” and also experienced “periods of high anxiety and recurrent depression.”

Mr. Tester has been in and out of prison since he was 17, the report added. In January 2022, he was arrested for making death threats, possessing offensive weapons and assaulting police officers, the Ombudsman said.

He was remanded in custody at HMP Lewes and later sentenced to 27 months in prison. While there, he tried to kill himself, but later told medical staff there it was “a moment of madness” and he was “scared” that he almost died.

Mr Tester was transferred to Gartree Prison on Friday September 23 because HMP Lewes did not “feel equipped to deal with Mr Tester’s needs”. Prison staff explained in their transfer application that Mr Tester was either in the medical unit or in isolation during his time there because he “refused to take his prescribed anti-psychotic medication, which meant his behavior was unpredictable and his tendency towards violence it was a risk that could not be managed in a standard wing.”

However, HMP Lewes did not complete a handover form for Gartree Prison regarding Mr Tester’s mental health needs, the Ombudsman said. This was a failure, it added, with the watchdog saying the prison should further ensure “a formal clinical handover is arranged for all prisoners with complex mental health prior to transfer to a new prison”.

When he arrived at HMP Gartree, Mr Tester was seen by a nurse who told him he had no “thoughts of self-harm” at the time. The review team at Gartree determined that they should have three “observations” per hour. These were gradually reduced over the following weeks by the prison’s mental health team before being stopped on Tuesday 11 October.

In meetings, Mr Tester said he was “fine”, “never really suicidal” and “didn’t want to die”. However, he repeatedly said he would prefer to be in a smaller facility than Gartree and did not understand why he was being moved, according to the ombudsman’s report.

The sightings briefly resumed when Mr Tester reported he was “worried he might kill himself”. However, Mr Tester had not been reviewed at the time of his death, with his mental health leader saying he had “no concerns for Mr Tester’s safety”.

The prison’s psychology team also contacted the institution’s mental health unit in September to ask if it would be “helpful” for them to see Mr Tester. The ombudsman said the psychological team had not received a response. However, the team booked him anyway to see a psychiatrist, towards the end of October, regarding the multiple diagnoses.

It was later rescheduled for Wednesday, November 16. Mr. Tester died before it could take place.

The ombudsman said it “would have been prudent” for the prison to continue monitoring Mr Tester until after the psychiatric appointment, when staff would have had “more information about Mr Tester’s complex mental health and personality disorders”. The prison should learn from this, the watchdog added.

On the night of his death, Mr Tester’s mother called the prison’s “in danger” helpline. The message was retrieved around four hours later at 1:35 am on Tuesday, November 1. She called the helpline because her phone wasn’t working, but then it was fixed, and she wanted her son to call her because he “hadn’t heard. from him for a while.”

The night inspector asked a security guard to check on Mr. Tester to see if he was awake and deliver the message. The guard found him on the floor of his cell and radioed an emergency code.

An ambulance was called and a nurse intervened in the cell. Mr. Tester was not breathing and unresponsive to CPR. When paramedics arrived, they confirmed his death.

A clinical assessor who reviewed the case with the ombudsman also found flaws. She said the prison should have created a “safety plan” for Mr Tester that would have “provided a more structured and evidence-based intervention”. Gartree was told he should ensure such plans were written “for all prisoners who have self-harmed”.

The ombudsman added that Mr Tester’s care plan was lost by HMP Gartree after his death, meaning it was not possible to “assess the adequacy of the plans developed to identify and address Mr Tester’s most urgent needs, nor to assess whether all care plan actions had been completed when (assessments) were stopped’.