An inmate at HMP Lincoln died after a prison officer falsely claimed he was being kept under constant supervision and mistakes were made over his care, a watchdog has found.
Luke Ashcroft, 33, who suffered from bipolar disorder and schizophrenia, died in hospital on 1 July 2020 seven days after he was found unconscious in a segregated unit.
An inquiry by the Prison & Probation Ombudsman (PPO) found staff failed to properly assess whether he was medically fit to be segregated, and relevant checks were not carried out.
Prison officer Luke Thomas was convicted of misconduct in a public office in 2023 after falsifying records. He was sentenced to eight months in jail, suspended for 18 months.
According to the Local Democracy Reporting Service, Ashcroft was sentenced to 40 months for burglary in 2018 and was released on licence in May 2020 but was recalled two days later for taking drugs.
He had a psychiatric condition called delusional parasitosis - a false belief that the body is infested with insects - and a week before his death, he told mental health workers he heard voices that spiders were living inside him after entering his body through a wound.
On 22 June, Ashcroft barricaded himself in his cell and was later taken to the Care and Separation Unit.
Two days later, a psychiatrist assessed he was suffering an acute psychotic episode and a nurse began the suicide and self-harm monitoring protocol, known as ACCT, after Ashcroft said he had had enough of the spiders and wanted to kill himself.
CCTV showed Thomas checked him only once per hour between 03:00 and 06:00 BST but claimed on records he was doing four or five checks, according to the Ombudsman’s report.
Ashcroft’s emergency bell was also not answered for more than 20 minutes, an investigation found.
When a new officer came on duty on 25 June, he found the prisoner lying on the floor unconscious. Ashcroft was taken to hospital but died on 1 July.
An inquest into Ashcroft’s death found he died by misadventure and had not intended to take his own life.
The PPO found healthcare staff did not make clear to prison officers how unwell he was, and that he was unfit to be segregated.
However, it found the overall healthcare he received was as good as if he was out of prison.
In its report, the PPO said: We are pleased to see that managers at Lincoln have introduced an additional assurance process using CCTV to check if recorded ACCT observations have actually been carried out.
"We, therefore, make no recommendation."