A PRISON report after the suicide death of an inmate has pointed out failures in monitoring of suicide and self-harm risk prior to his death.

A report from the Prisons & Probation Ombudsman also pointed out staff needed clearer guidance around resuscitation after “distressing and undignified” attempts were made in this case, and criticised the level of contact with the deceased’s next of kin.

Darren Pallas was 40 when he was found hanged in his cell at HMP Leeds on January 31, 2020. He’d been in jail on remand since September 2019, and was handed a 12 year sentence two months later.

He’d previously been in jail for a terrifying armed robbery on Lister Horsfall jewellers in Ilkley in 2012 where Rolex watches were targeted, for which he received a seven-and-a-half year sentence.

When he arrived in prison he had a suicide and self-harm warning form and procedures, known as ACCT, were opened by prison staff who found him to have depression, anxiety and paranoia, and was monitored until October.

On November 12 he had self-harmed and ACCT was restarted, before being closed again a week later, and on November 29 he was jailed for 12 years; at this time he said he had no thoughts of self-harm.

On January 15 ACCT was restarted when he cut himself after being told he had to share a cell; Pallas had a fear other inmates would attack him stemming from an assault during a previous sentence. This monitoring ended on January 22.

On January 29, and his partner spoke on the phone where they agreed to end the relationship due to their situation, and the next day his partner rang the prison as she was concerned for him. An officer visited Pallas and he said he had no intention of harming himself, but a day later he was found dead in his cell.

Staff tried to resuscitate him but rigor mortis had already set in and attempts were futile.

In her report, Ombudsman Sue McAllister said there were “deficiencies” in the ACCT monitoring, with his final report “incorrectly” filled in.

It was found no one from the healthcare team attended four out of five ACCT reviews, and when monitoring ended in October “there was no evidence the healthcare or mental health teams had contributed to the decision”.

When his ACCT was ended on January 22 his medication had not been reviewed but his caremap said it had been.

Ms McAllister added: “The ACCT post-closure review took place on January 29 and inaccurately repeated that all actions on the caremap had been completed.”

She told the jail ACCT must be completed properly before being closed and that staff need to work jointly to ensure this happens in future.

She added the Governor should ensure staff are clear on guidance around resuscitation, and also that all prisoners’ next of kin details are kept up to date.