Prison staff “falsified” records when they recorded they had carried out checks on an “at risk” inmate who claimed to be “hearing voices” the day he took his own life.

Sean Higgins, from Ashford, was found dead in his cell at HMP Rochester on February 7, 2024.

The 45-year-old prisoner, who was serving a 12-year prison sentence for attempting to stab a police officer, was diagnosed with paranoid schizophrenia and was monitored under suicide and self-harm prevention procedures known as ACCT (Assessment, Care in Custody and Teamwork).

Now an independent investigation into his death, led by the Prisons and Probation Ombudsman (PPO) Adrian Usher has revealed Higgins’ care was not of the required standard and was “poorly managed”.

A report, published last Friday (March 7), found procedures were closed despite being unresolved, even though there was clear evidence of his high risk of suicide and self-harm.

The recorded events explained how on December 29, 2023, Higgins had started to isolate after stating he was hearing voices and other prisoners were threatening him.

On January 6, 2024, prison staff began ACCT monitoring after discovering a ligature in his cell. He had told prisoners that he was in a “bad way” and was hearing voices that were telling him to kill himself.

By the end of the month Higgins told staff he felt like barricading his cell and hanging himself due to the fear of other prisoners.

Despite this, on January 30, staff closed the ACCT procedures.

Then on February 7, an officer signed that she had completed an early morning routine roll check, but CCTV showed she did not do so.

Meanwhile, another officer was due to complete a roll check at 7.30am, but again footage from the prison found this did not take place.

At 8am an officer unlocked Higgins’ door, but stated in interview she did not check on him because he was self-isolating.

It was at approximately 11.40am an officer went to serve Higgins lunch and found him hanged in his cell.

Now, the PPO has sent a list of recommendations that the prison governor should consider, including to review the quality and compliance with policy on ACCT management.

There were multiple failures to follow policies for both the prison and mental health staff

Other notable recommendations include that there should be a review on staff compliance with local roll check procedures and identify any improvements to practice required.

The report also states the prison governor informed the PPO that an investigation into the officers who failed to conduct roll checks, is ongoing.

It read: “Mr Higgins’ ACCT procedures were poorly managed.

“There was no oversight by a named case co-ordinator, and despite his symptoms and apparent paranoia, a lack of input from the mental health team.”

It went on to add: “The ACCT procedures were closed then these issues were unresolved and when there was clear evidence that his risk of suicide and self-harm was raised.”

“Staff falsified records when they recorded that they had carried out required checks on the morning of February 7.”

Meanwhile, a separate report into Higgins’ death, published on Tuesday (March 11) by Mid Kent and Medway senior coroner Patricia Harding, concluded there is a risk future deaths could occur unless action is taken.

She said: “There were multiple failures to follow policies for both the prison and mental health staff.

“He [Higgins] did not receive medication for 45 days and had not seen anyone from the mental health team for over two months.”

The inquest revealed that although HMP Rochester had addressed many of the concerns raised by the PPO ahead of the hearing, evidence given revealed some officers chairing reviews did not read relevant documentation beyond the last ACCT review prior to the review taking place.

The coroner added “Some of the officers chairing reviews did not understand how to complete the support plan paperwork, such that the ACCT was closed when some of the support plans had not started or had not been completed.”

The coroner’s investigation, opened on February 16, 2024 and concluded on February 17 this year.

As a result of her findings, the coroner said action should be taken to prevent future deaths and has given the prison 56 days to respond to this report.

HMP Rochester is a category C prison which holds adult and young male prisoners.

Higgins is the fourth prisoner to die at HMP Rochester since February 2021, and the second man to take his own life in that time.

A Prison Service spokesperson said: “Our thoughts remain with the family and friends of Sean Higgins.

“The prison has implemented all of the Ombudsman’s recommendations, including ensuring better management and support for prisoners at risk of suicide or self-harm.”