'Clearly dead' HMP Chelmsford prisoner given CPR
- Published
A report found a "missed opportunity" to protect the inmate two days before his death
Prison staff "inappropriately" tried to resuscitate an inmate who was "clearly" dead, a report found.
Ashley Ansell-Austin, 36, hanged himself at HMP Chelmsford on 16 October 2017.
Despite showing signs of rigor mortis, nurses performed CPR. The Prison and Probation Ombudsman said their actions were "undignified for the deceased".
Its also found a "missed opportunity" to help Mr Ansell-Austin two days before his death.
The prison has accepted the report's recommendations. The Ministry of Justice said the site had increased its mental health provision and ability to carry out assessments.
Mr Ansell-Austin had a history of attempted suicide and was placed on a prevention procedure on 4 October.
This ended on 12 October but two days later there were "clear indications his risk had increased again", the report said.
An urgent mental health assessment was requested when he refused medication but it was not carried out, constituting "a significant oversight" and a "missed opportunity" to protect him.
'Obvious signs'
Mr Ansell-Austin, who was serving a sentence for robbery and possession of a bladed article, is the fifth inmate to commit suicide at the prison since January 2016.
Nurses performed CPR in his cell, believing they had to do so while waiting for paramedics, regardless of circumstances.
On arrival, medics recorded "obvious signs of death" - pooling of blood, cold to the touch and signs of rigor mortis in the jaw, hands and feet.
The report said: "The investigation found that healthcare staff inappropriately tried to resuscitate Mr Ansell-Austin, when it was obvious he was dead."
It added that while it understood the "commendable wish" to continue resuscitation until death was confirmed, "trying to resuscitate someone who is clearly dead is distressing for staff and undignified for the deceased".
The ombudsman said three previous investigations at the prison found "inadequacies in the management" of the self-harm prevention procedure.
The report recommended it ensure urgent mental health referrals were looked at quickly, and that suicide and self-harm risk management was in line with national guidelines.
A Prison Service spokesman said: "Every death in custody is a tragedy and our thoughts are with Ashley Ansell-Austin's family and friends.
"We will make sure we learn any possible lessons from Mr Ansell-Austin's death."