Vulnerable man's death shows continued failures at Essex prison

Chelmsford Prison
-Credit: (Image: Chris Rushton/Essex Chronicle)


A vulnerable man with a history of mental issues took his own life just nine days after arriving at Chelmsford Prison after being remanded into custody. Mohammed Eumda died in his cell at HMP Chelmsford on January 30, 2023, after he had been charged by police with arson.

Mr Eumda is the eighth prisoner to die at Chelmsford Prison since January 2020. The prison has been heavily criticised for its failure to monitor prisoners in the prevention of suicide and self-harm. Mr Eumda’s remand to Chelmsford on a charge of arson was his first time in prison.

When he arrived at Chelmsford on January 21, 2023, the 28-year-old was monitored for the initial four days. However, that monitoring was stopped after it was believed he was not at risk. However, an investigation from the Prison and Probation Ombudsman (PPO) has found that the decision to end suicide monitoring was premature, and staff placed too much emphasis on what Mr Eumda told them rather than his known risk factors and recent behaviour.

Read more: Essex school's warning to parents over 'explicit' WhatsApp group

Read more: Essex school's warning to parents over 'explicit' WhatsApp group

The PPO has said the prison also recorded inaccurate information about Mr Eumda’s interactions with staff and, as a result, “made a poor assessment of his risk level”. It adds that “postclosure monitoring was not carried out as it should have been, which might have flagged concerns in the days leading up to Mr Eumda’s death.”

The death comes after HM Inspectorate of Prisons identified multiple weaknesses in suicide and self-harm monitoring processes at Chelmsford Prison during their 2021 inspection. However, they reported improvements during their follow-up inspection in 2022.

A statement from the Prisons and Probation Ombudsman said: “While I am aware that Chelmsford has taken steps to improve the quality of the Assessment, Care in Custody and Teamwork (ACCT) process, this case demonstrates that poor decision making and failure to follow basic procedures persists. Senior managers need to review whether the measures introduced are leading to sustained improvements.”

Of the previous deaths at HMP Chelmsford, five were self-inflicted, one was from natural causes, and one was drug-related. In a previous investigation into a death at Chelmsford in March 2021, it was found that staff stopped ACCT procedures prematurely. The Prison Ombudsman was told that training had been delivered, and ACCT champions were introduced in September 2021 to improve its quality.

Another recent investigation found that ACCT post-closure monitoring was not completed properly. However, the ombudsman said that the staff had prematurely stopped ACCT monitoring for Mr Eumda. On arrival, Mr Eumda said he had no issues and had been sleeping a lot. He said he was confused when he first arrived because he was not sure how long he was going to be in prison.

The PPO report states that he became frustrated when he was told his next court appearance was not until February 20. His solicitor told him he would be in prison for only 24 hours. Mr Eumda said that he had been in a mental health hospital and had been discharged because they thought he was well enough, but he had set a fire within 24 hours, which is what brought him into custody.

In the PPO report, Mr Eumda told the officer and nurse that he had no thoughts of suicide or self-harm - it was recorded that Mr Eumda had not self-harmed in the four days he had been at Chelmsford, that he would be monitored for seven days during the ACCT post-closure period and that the nurse would see if the mental health team could offer more support.

The SO and nurse both agreed that the ACCT should be closed. However, as that section of the ACCT document is blank, there is no evidence that post-closure monitoring was carried out. On January 29, a nurse saw Mr Eumda for a mental health review. He recorded that Mr Eumda said things were going well, and he had no issues with his mental health. He was found hanging at around 9.20pm the next day.

The report said: “We have identified premature closure of ACCT and failings in post-closure monitoring in previous investigations at Chelmsford. We are aware that Chelmsford has introduced various measures to try to improve the quality of ACCT management, including ACCT champions and increased quality assurance, but this case demonstrates that poor decision-making and failure to complete basic procedures persist.”

A Prison Service spokesperson said: “Our thoughts remain with the family and friends of Mohammed Eumda. Since January 2023, HMP Chelmsford has improved staff training in suicide and self-harm prevention, improved safety checks, and added extra mental health support for prisoners."

The Prison Service and HMP Chelmsford’s healthcare provider, Castle Rock Group, have accepted both recommendations in the PPO report, and a number of improvements have been made at HMP Chelmsford since January 2023.

It says new instructions and best practices for monitoring vulnerable prisoners have been shared with staff, procedures for quality checks have been reviewed and “the deputy governor has reminded all managers of the standards expected in keeping prisoners safe”.

Castle Rock Group has been asked for comment.