A prisoner locked up for arson took his own life on Christmas Day after prison staff made a string of mistakes. 

Gary Bell was found unresponsive in his cell at HMP Holme House on Christmas Day, 2019. 

The 44-year-old had been locked up for five years after lighting a fire that gutted a business premises, as well as causing major damage to a flat above it. Both residents of the flat escaped unharmed, but their pet cat perished in the blaze. 

It is not known how or why the fire started, but it is believed Bell and his accomplice had been looking for things to steal when Bell used his lighter to see in the dark.

At Teesside Crown Court, the judge said Bell might have either dropped the flame or brushed against something with it.

After being sentenced to five years imprisonment, Bell had his leg amputated above the knee, due to recurrent infections in an old knee injury. 

But when he told staff that his pain from the recent surgery was not being effectively managed, he was not referred for specialist pain management advice. 

Though painkillers were prescribed, there was no physiotherapy or occupational therapy input after his amputation, as there should have been.

Bell told staff that the pain from his leg was so bad that he was suicidal and engaging in self-harm.

On November 25, staff started suicide and self-harm prevention procedures (known as ACCT) after Bell cut his arm and told staff that his pain was not being managed and that he was struggling mentally with the loss of his leg.

Staff stopped ACCT procedures on December 6 but restarted them when Bell cut his arm again 11 days later. 

On December 21, Bell was found in his cell after attempting to kill himself. He was still conscious and did not require hospital treatment.

Staff increased observations to four an hour, however, during an ACCT case review the next day, it was agreed the observations should be reduced to two an hour. On Christmas Eve, staff reduced observations again, to hourly. 

On Christmas Day, Mr Bell was found again in his cell having attempted to kill himself. Staff performed CPR, which was continued by ambulance paramedics.

The paramedics managed to restore a pulse and took Mr Bell to hospital where he was placed in an induced coma - but he never regained consciousness, and died in hospital on December 28. 

Now, a report into his death from the Prisons and Probation Ombudsman highlights a string of errors in the run-up to his death. 

Though the ombudsman's clinical reviewer said that "overall, staff managed the ACCT procedures well," it "may have been wiser" for Bell to have stayed on two observations an hour until after Christmas Day, as the holidays are often difficult for prisoners. 

The report also notes that "[the PPO] is concerned that the agreed frequency of observations was not always recorded in the ACCT documentation and some observations were not carried out at the agreed frequency."

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Recommendations were made to the Governor at Holme House prison, including: 

  • Ensure that staff record the agreed frequency of ACCT observations on the front of the ACCT document and in the case review notes. 
  • Make sure observations are carried out at the correct frequency. 
  • Vary times of ACCT checks, while remaining within set observation periods, to avoid prisoners being able to predict when they will be checked.

A Prison Service spokesperson said: “Our sympathies remain with the friends and family of Gary Bell.

“Since Mr Bell’s passing HMP Holme House has introduced new observation and monitoring procedures to ensure staff are better able to support prisoners at risk of suicide and self-harm.”

At an inquest into his death, Bell's brothers paid tribute to him, saying he was a "loving person" who would do "anything for anyone".