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Independent investigation into the life-threatening self-harm of AC at HMP Brixton on 4 June 2010 and Her Majesty’s Prison and Probation Service and NHS England response published

The independent investigation conducted by Rob Allen into the life-threatening attempted suicide of AC at HMP Brixton on 4 June 2010 is published. Also published are the responses to the investigation from NHS England and Her Majesty’s Prison and Probation Service (HMPPS).


AC was received at HMP Brixton on 6 March 2010. On 4 June he was seen by staff to have placed a noose around his neck, and he stood upon and jumped off a pipe in his cell. He had barricaded his door using his bed and staff were not able to enter the cell for some time. The door was removed and staff entered AC’s cell and CPR was started by an officer, before healthcare staff took over. An ambulance was called and then paramedics called for an air ambulance which took AC to hospital. AC sustained a serious and long-term brain injury and resides in a hospital setting.


A Prison Service investigation of the circumstances surrounding the incident was carried out in 2010, which made a number of findings and recommendations. Investigations were also undertaken by the South London and Maudsley NHS Foundation Trust, Care UK and the Lambeth Primary Care Trust to consider the healthcare provided to AC whilst at HMP Brixton.


In order to meet the State’s investigative obligation under Article 2 of the European Convention on Human Rights, the National Offender Management Service[1] commissioned Rob Allen, former Director of the International Centre for Prison Studies, to conduct an independent investigation to examine the circumstances surrounding AC’s life-threatening attempted suicide on 4 June 2010 and to see whether there are lessons to be learned that might contribute to the care of prisoners at risk of suicide and self-harm.


The investigation report completed by Rob Allen is published, along with the responses to Rob Allen’s investigation from NHS England and HMPPS.



[1] On 1 April 2017 Her Majesty’s Prison and Probation Service (HMPPS) replaced the National Offender Management Service as the Executive Agency responsible for delivering prison and probation services across England and Wales.


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