19 July 2022

NOTE: This press release contains detailed reporting of self-harm

Before HM Area Coroner for Essex, Sean Horstead and a jury
Essex Coroner’s Court, Chelmsford
4–18 July 2022

Lance Clark, 53, died on 28 November 2019 of a haemorrhage (severe blood loss) after he self-harmed with a razor whilst in prison on remand at HMP Chelmsford. Staff were not aware of guidance on access to razors for prisoners being monitored under suicide and self-harm procedures, known as ACCT.

An inquest has concluded finding serious failures by prison and healthcare staff. His is one of 14 self-inflicted deaths at HMP Chelmsford since 2016.

Lance Clark was a much-loved father and family man. He was mixed race and had a long history of anxiety, depression and self-harm.


During nearly two weeks of evidence the inquest jury heard that, in his four months at HMP Chelmsford, Lance self-harmed in the same way on 14 occasions using a razor blade or a sharp item, and was taken to hospital for treatment on eight occasions due to the severity of his self-harm injuries.

Prison staff were aware of advice from medical professionals that if Lance continued to cut himself in the same place it was likely to become fatal. However, both prison and mental health staff consistently underestimated and misjudged his level of risk. This was despite him being managed under ACCT procedures for suicide and self-harm.

At 18 of his 25 ACCT case reviews it was agreed that Lance’s level of risk was “low” and only twice did the case review consider that Lance was at high risk of self-harm. There was evidence that prison and mental health staff failed to identify Lance’s key risk factors or put measures in place that might have reduced his risk.

The Prisons and Probation Ombudsman investigation found that Lance’s inability to manage his stress other than by self-harming, and his worries about antidepressant and the stress of his upcoming trial “remained acutely unresolved” after the “premature” closure of Lance’s ACCT.

Lance did not have a formal mental health review, and received virtually no help in managing his stress. He did not receive any intervention or treatment from IAPT (counselling) or Full Circle (substance misuse support) despite referrals from the prison psychiatrist on the one occasion (in August 2019) that Lance’s case was discussed.

Lance was not managed under enhanced ACCT procedures, which would have involved senior prison managers and ensured all relevant support was available for Lance. Lance’s ACCT case manage told the jury he had not heard of the enhanced ACCT procedure, and the Head of Healthcare at the time had never heard of Lance at all.

The Prisons and Probation Ombudsman (PPO) found that, as a result of the issues with the ACCT, more junior staff “were largely left to manage the complex problems [Lance] posed without adequate support”.

No-one discussed trying to involve Lance’s family in the ACCT process, and his family were not told that he had been repeatedly hospitalised after self-harming. Lance had no input at all from his allocated key worker, and an email about possible support for him from a prison psychologist went unanswered.

Despite Lance’s history of self-harm, neither prison nor mental health staff discussed Lance’s access to razors during ACCT case reviews. A Prison Service safety briefing in April 2019 which required that access to razors must be discussed at ACCT case reviews was not circulated to any prison or mental health staff.

An External Agency Investigation Request was submitted by Broomfield Hospital raising concerns around Lance’s access to razor blades, following frequent attendances at hospital with cuts inflicted by razor blades. HMP Chelmsford responded that no action was required.

No preventative care or support was provided to Lance, he did not receive any 1:1 time with a mental health nurse throughout his time at HMP Chelmsford, and no mental health plan or risk management strategy was put in place when Lance’s ACCT monitoring was stopped on 22 October 2019.

Lance repeatedly told prison and mental healthcare staff that he was stressed about his upcoming trial, which was due to be heard on 25 November 2019 but went into the court’s “warned list” (meaning it did not have a fixed date).

On the evening of 27 November 2019, the day before his death, Lance threw a plate of food at the wall in the prison servery. This was totally out of character. The next morning, after a brief discussion amongst prison staff, a junior officer went to Lance’s cell door and dismissed Lance from his job as a wing cleaner.

Lance had repeatedly said his job enabled him to keep busy and reduced the time he spent alone in his cell, “spiralling” in negative thoughts. Despite being a clear protective factor for Lance, the ombudsman investigation noted concerns that “no thought seems to have been given to how his dismissal should be broken to him”.

Lance immediately self-harmed by cutting his neck and, despite attempts at resuscitation, died that morning.


The inquest jury concluded that prison and mental healthcare staff did not adequately assess Lance’s risk of self-harm, which possibly contributed to his death. The jury further concluded that prison and mental healthcare staff did not manage Lance’s risk of self-harm appropriately, which probably contributed to his death, including:  

  • The failures to manage Lance under the enhanced ACCT process;
  • The failure to implement an April 2019 safety briefing regarding prisoner access to razor blades;
  • The failure to discuss razor blade management at Lance’s ACCT case reviews;
  • The way in which the dismissal of Lance from his wing cleaner job was handled; and
  • The failure to adequately risk manage Lance’s probability of self-harm in the weeks prior to his death.

Since 2018, HMP Chelmsford has been in special measures as a result of concerns about safety, a negative staff culture, a lack of accountability and management oversight and a poor daily regime for prisoners.

The full inspection of HMP Chelmsford by HM Inspectorate of Prisons prior to Lance’s death (in May and June 2018) raised numerous concerns around how prisoners at risk of self-harm and suicide were managed.

Inspectors found repeated recommendations from the Prisons and Probation Ombudsman had not been implemented, including poor assessment and management of prisoners’ risk of suicide and self-harm. More recent inspections have continued to highlight these ongoing concerns.

Lance’s mother Pauline Clark said: My Lance was a lovely son. He was absolutely devoted to me and me to him. He was amazing, handsome and such good fun to be around. Prison was so difficult for him. Many times when visiting my Lance with family he would be very distressed.

It was known by healthcare and prison staff that Lance’s self-harming was serious and increasingly life threatening. Despite this, they failed to put in place the necessary support, leaving him vulnerable and unsupported. Lance was let down. I just hope other families don’t have to be put in this position.

Sam Hall, Solicitor at ITN Solicitors, representing Lance’s family said: “Lance and his family were let down by healthcare and prison staff at both an individual and systemic level. Appropriate measures to mitigate the risk to Lance’s life were not put in place, despite his repeated attendance at A&E and concerns raised by the hospital regarding his welfare and access to sharp items.

Reassurances have been provided by the current Governor and Head of Healthcare that there have been improvements in the assessment and management of self-harming at HMP Chelmsford since Lance’s death in 2019. Those improvements, and further improvements, are desperately needed to ensure that no one else loses their life because of failures to provide the support that should be available to them.”

Lucy McKay, spokesperson for the charity INQUEST, said: “HMP Chelmsford has long been on notice about their failure to support people in mental health crisis, which has had devastating consequences for so many. Yet recommendations arising from inquests, investigations and inspections have been ignored. This has allowed preventable deaths like Lance’s to continue.

HMP Chelmsford and prisons nationally must consider the shocking evidence of this inquest, and ensure urgent action is taken to prevent such serious failures in future. More broadly, Government must work to ensure people in such serious mental health crisis are not held in prisons but supported in specialist healthcare settings.”



For more information and a photo of Lance contact Lucy McKay on [email protected]

Lance’s family were represented by INQUEST Lawyers Group members Sam Hall of ITN Solicitors and Tom Stoate of Doughty Street Chambers. They were supported by caseworker Becky Higgins.


HMP Chelmsford background:

  • In the five year period between January 2016 and December 2021 there were 24 deaths in HMP Chelmsford. Of these, 14 were self-inflicted.
  • Following an unannounced inspection of HMP Chelmsford in August 2021, the Urgent Notification process was invoked following significant concerns about the treatment of and conditions for prisoners. Inspectors emphasised that the findings of this inspection were particularly disappointing bearing in mind the observations made in 2018.