YorkshireLive reported that prison service staff underestimated his risk of suicide and failed to put adequate measures in place to reduce his risk, according to Elizabeth Moody, of the Prisons and Probation Ombudsman.
He was supposed to be under observation once every hour but there were six instances when staff did not review him within an hour, with the longest gap an hour and 45 minutes.The report found healthcare staff did not try to resuscitate Adams after he had been found hanging "because they incorrectly believed he was already dead.""While we appreciate the distress of seeing a prisoner in such circumstances and that an officer must have regard for their own safety when considering whether or not to enter a cell alone, we do not.
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