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Independent investigation into the incident of life-threatening self-harm involving ‘CR’

Independent investigation into an incident of life-threatening self-harm involving ‘CR’1 at HMP Swansea on 3 December 2015

The report of the independent investigation conducted by Barbara Stow into the incident of life-threatening self-harm involving ‘CR’ at HMP Swansea on 3 December 2015 is published here.  Also published are the responses to the investigation from His Majesty’s Prison and Probation Service (HMPPS) and the Swansea Bay University Health Board.

‘CR’ was discovered hanging in his cell  at HMP Swansea on 3 December 2015.  Staff administered first aid, including CPR, before paramedics arrived and ‘CR’ was taken to hospital.  ‘CR’ sustained a serious and long-term brain injury and sadly died before the independent investigation concluded.

In order to meet the State’s investigative obligation under Article 2 of the European Convention on Human Rights, Barbara Stow, a former Assistant Prisons Ombudsman, was commissioned to conduct an independent investigation to examine the circumstances surrounding the incident of life-threatening self-harm involving ‘CR’ and to see what lessons can be learned. 

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

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


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