Missed opportunities by prison and probation in the case of North East offender, 34, found dead in his flat

HMP Durham
HMP Durham -Credit:Newcastle Chronicle

The prison and probation service missed opportunities when dealing with an offender who was later found hanged in his flat.

Christopher MacGillivray was handed an 18 month suspended prison sentence after being convicted of motoring offences in January 2021. The 34-year-old was allocated a Community Offender Manager (COM) at North Tyneside Probation to manage his sentence.

Two months later, MacGillivray received an additional 16-and-a-half month suspended prison sentence after being convicted of violence offences. The sentence ran alongside the one he was already serving.

MacGillivray's COM reviewed his risk assessment report on April 7. The assessment noted a previous suicide attempt but did not assess MacGillivray posed a risk to himself.

On April 16, 2021, CCTV operators alerted police after they saw MacGillivray standing on a bridge. He told police he was having difficulties with alcohol, drugs and his relationship but he was not suicidal.

Police passed this information to probation and MacGillivray’s COM logged it on his probation record on April 19. There is no record that his COM discussed the incident with him or that he updated his risk assessment.

On 19 May, a new COM took over MacGillivray’s case. The two COMs said there was a handover, which consisted of an informal conversation about MacGillivray’s risk factors and current concerns. However this was not recorded on probation records.

The new COM said she read through MacGillivray’s record but despite this, she said she was not aware of the events of April 16.

On September 17, 2021, police arrested MacGillivray for theft from a motor vehicle. He was given bail and a condition of this was a curfew which was monitored electronically.

The following month, on October 9, a member of the public reported to police that they were concerned about someone they saw on a bridge. Police attended and found MacGillivray.

Remanded in custody

He was found to have breached his curfew, so was arrested for breach of bail conditions. He was remanded in custody and transferred to HMP Durham the following day.

Police records state that officers had no concerns about MacGillivray. However, when he arrived at Durham, he had documentation with him stating he had been under constant watch in police custody.

On 10 October, 2021, MacGillivray told a member of the drug and alcohol recovery team (DART) that he might harm himself. Prison staff started suicide and self-harm prevention procedures (known as ACCT) and he was put on hourly observations.

The same day, a prison nurse completed a mental health assessment with MacGillivray. She assessed that he did not need to be under the care of the mental health team but that he should continue to work with DART. She noted that he appeared under the influence and did not engage fully with the assessment.

At an ACCT review the next day, MacGillivray said that he did not expect to be in prison for long as he was expecting to get bail. On October 12, the court granted MacGillivray bail

Prison staff held an ACCT review with MacGillivray who said he was pleased to be getting out. They closed the ACCT and did not pass any information about it to the probation service.

Two days later, MacGillivray’s ex-partner found him hanged in his flat. Paramedics attended and at 2.30pm on October 14 and pronounced him dead.

MacGillivray’s previous COM said he found out about MacGillivray’s death from a police officer that worked with probation and he was not offered any support.

MacGillivray's most recent COM said she thought a Senior Probation Officer (SPO) had told her of MacGillivray's death. She said she was not offered any support but she felt confident that she knew who to approach if she was struggling.

An inquest into MacGillivray's death, held on April 8 this year, concluded that he hanged himself whilst under the influence of a combination of cocaine and alcohol. A post-mortem concluded that he died from pressure to his neck from hanging.

Missed opportunities

An independent investigation was carried out by the Prisons & Probation Ombudsman (PPO) following MacGillivray's death.

They recorded that he was managed under Prison Service suicide and self-harm procedures (known as ACCT) from October 10 up to his release from the category B prison.

They were "very concerned" that the prison did not tell probation staff about this or provide any details about why he had been assessed as at risk of suicide and self-harm.

The PPO also found that the Community Offender Manager (COM) missed an opportunity to explore this bridge incident in April 2021 with MacGillivray.

They said there was a "missed opportunity" to explore the incident, which may have led to completing work around suicide and safety planning, or how MacGillivray could manage low moods.

They said: "Mr MacGillivray had made previous suicide attempts and this should have been explored further."

  • The PPO recommended that the Regional Probation Director North East should ensure that incidents of concern are explored and relevant intervention work is completed if required.

The PPO found that there was a further missed opportunity for the new COM to explore the same incident when his case was transferred to them on May 19, 2021.

They said both COMs told the investigator that a handover took place, which was an informal conversation highlighting risk factors and current concerns. However, this was not logged on probation systems.

The new COM told the investigator that, when given a new case, they were required to review the records. They said that following her review of MacGillivray’s records, she had no concerns around suicide or self-harm.

She also said she wasn't aware of the incident on April 16 - despite it being recorded in the probation records.

The PPO found that the case handover between that COM and the subsequent COM was not thorough.

  • They recommended that the Regional Probation Director North East should ensure that officers complete detailed handovers when a case is transferred and record details in the probation record; undertake a thorough review of records when given a new case.

They also noted that COMs should be made aware of support services available to them, such as counselling, after a death and told they can use these services at a later date if required.

They found that the process was not followed and the COMs who worked closely with MacGillivray were not offered support following his death.

  • The PPO recommended that the Regional Probation Director North East should ensure COMs are offered support following the death of a service user on their caseload.

A Prison Service spokesperson said: "Our thoughts remain with Mr MacGillivray's family and friends.

"We have accepted all of the Ombudsman’s recommendations and measures have been put in place to ensure frontline staff share all vital information with the local probation team when an individual who has been supported with their safety and wellbeing leaves prison."