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Independent investigation into an incident of life-threatening self-harm involving ‘TA’

The report of the independent investigation conducted by Barbara Stow into the  incident of life-threatening self-harm involving ‘TA’1 at HMP Chelmsford on 1 July 2013 is published here.

Also published are the responses to the investigation from those responsible for commissioning and providing custodial and healthcare services at the prison.

‘TA’ was discovered hanging in his cell at HMP Chelmsford on 1 July 2013.  Staff administered first aid, including CPR, before paramedics arrived and ‘TA’ was taken to hospital.  ‘TA’ sustained a serious and long-term brain injury and resides in a care setting. 

HMP Chelmsford conducted a fact-finding investigation into the incident, which made a number of findings and recommendations.    

In order to meet the State’s investigative obligation under Article 2 of the European Convention on Human Rights, an independent investigation was commissioned to examine the circumstances surrounding the incident of life-threatening self-harm involving ‘TA’ and to see what lessons can be learned.  The investigator initially commissioned to conduct the investigation was regrettably unable to complete it, and was replaced by Barbara Stow, a former Assistant Prisons Ombudsman, who did so.

The investigation report completed by Barbara Stow is published, along with the responses to the  investigation from those responsible for commissioning and providing custodial and healthcare services at the prison.


  1. A pseudonym is used to protect the identity of the individual concerned. ↩︎