A man who took his own life in his prison cell rang his mum to say his "head’s going" shortly before his death.
Ashley Dougan, 32, was found in his cell on the Valentine's Green Wing of HMP Altcourse at around 8.20am on September 2, 2021. He was taken to Aintree University Hospital, where he died at 8.40pm the following day, having suffered a severe brain injury and cardiac arrest.
The Prisons & Probation Ombudsman has now published the findings of its investigation into Mr Dougan's death.
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The report outlines that Mr Dougan was arrested on June 22, 2021 following a police chase on the M62. He was stopped in Cheshire between Junction 10 (Croft Interchange) and Junction 11 (Birchwood) at around 9pm, and was searched by officers, who discovered a firearm.
He was taken into police custody and later charged with possession of a firearm with intent to endanger life, possession of a firearm without a certificate, possession of ammunition, receiving stolen goods, driving without insurance and driving without a licence.
Mr Dougan was remanded in custody to HMP Altcourse on June 23, 2021. According to the report, his first two months in prison "were uneventful and he was promoted to the highest level of Altcourse’s Incentives and Earned Privileges (IEP) scheme to encourage and reward responsible behaviour".
He pleaded guilty to his charges on July 21, 2021. On August 24, 2021, Mr Dougan called his mum to say that he was struggling to cope with prison life and was worried about his sentencing, scheduled for September 15, 2021.
In line with prison policy, this call was not monitored by staff at the time. The call was not listened to until after his death.
During the call, Mr Dougan said: "[My] f*****g head’s going, I don’t know what’s going on … Trying to battle through this but it’s hard … Gonna be stuck in here, can’t cope with it. It’s horrible … Not sleeping, feel like s**t, drained, head feels like it’s gonna explode … Gonna end up doing something stupid … Worrying about what sentence I’m gonna get.”
Mr Dougan received two negative entries in his record on August 26, having made comments to female officers.
He rang his mum again the following day and discussed his sentence. He said his solicitor had the “intent to endanger life” charge dropped, which meant he was therefore looking at a sentence of around six years rather than eight years he had expected.
In a key work session on August 30, Mr Dougan said “head is up his a*** due to going guilty on his charges and is thinking about it all the time” but declined an opportunity to speak to the mental health team.
The officer described Mr Dougan as a “bouncy and bubbly” man, who had lots of friends on the wing and didn't cause trouble. He said, however, that Mr Dougan was a bit down about his potential sentence when they spoke. This was said to not be unusual for prisoners facing an imminent court date.
On the evening of August 1, Mr Dougan's cellmate saw a mark around his neck and said he shared his concern with an officer.
At around 8.20am on September 2, Mr Dougan was found on his bed with a "self-applied ligature" around his neck. Officers arrived to treat him.
The report states: "The first officer returned to the cell, cut the ligature and placed Mr Dougan on the floor. The other officer arrived at the cell and pressed a ‘first response’ button on his radio, which indicates an emergency that requires other staff to attend immediately. Both officers began cardiopulmonary resuscitation. The control room operator recorded the ‘first response’ at 8.20am.
"A nurse was working on the unit at the time and went to Mr Dougan’s cell. On arrival, she asked the second officer to radio a code blue medical emergency, indicating a life-threatening situation. The control room operator recorded the call at 8.22am and telephoned for an ambulance.
"The nurse left the cell to fetch an emergency medical bag, returning after a minute. She applied a defibrillator, which advised no shock and to continue chest compressions. At 8.30am, paramedics arrived and took charge of the resuscitation."
He was taken to Aintree Hospital at around 9.12am. He died at around 8.20pm on September 3.
His week-long inquest found he died as a result of a "self-applied ligature", with a jury handing down a narrative conclusion.
The ombudsmen's findings were: "Mr Dougan had few risk factors for suicide and self-harm. While he evidently struggled with the thought of his upcoming sentencing, we are satisfied that it was reasonable for staff at the time not to start suicide and self-harm prevention procedures.
"When staff were first alerted to the incident on 2 September, they initially summoned assistance using an inappropriate method. There was only a short delay before the correct emergency radio message was used and we cannot say that this delay would have affected the outcome."
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