A report into the death of a prisoner at HMP Garth has identified a "missed opportunity" in the weeks before he died, and revealed that a prison officer falsified records after failing to perform checks.
Aaron Taylor, 32, died by suicide at the prison near Leyland in August 2023. The Prisons and Probation Ombudsman investigation found that Mr. Taylor should have been placed under suicide and self-harm monitoring procedures after self-harming just three weeks before his death, but a miscommunication meant no one started the proceedings.
Recall and early signs
Mr. Taylor was initially recalled to HMP Preston in January 2023 for breaching licence conditions related to a 10-year sentence for wounding with intent. The report states the recall made him "angry" after living for 14 months in the community. Prison staff put him on suicide watch after he told them he would "kill himself given the chance."
Mr. Taylor, from Preston, had been told he was subject to a full recall, meaning he would serve a seven-year sentence. He said he "did not have it in him" and would not be around to serve the sentence.
On February 3, Mr. Taylor told staff another prisoner had sexually assaulted him. His clothing was taken as evidence, and he was taken to Royal Preston Hospital. He declined the offer to stay at the hospital, refused to name the perpetrator, and police did not proceed with the investigation.
Transfer to Garth and further incidents
A day after Mr. Taylor was transferred to Garth, he told staff he had been assaulted in his cell. He had scrapes on his head and torso and believed he was attacked after being labelled a "grass" due to the ongoing investigation into the incident at Preston.
Mr. Taylor had an "extensive" history of self-harm. Between March and May, he was twice placed under observation after self-harming, telling staff his "head had gone." That summer, he twice isolated himself from the rest of the prison population, saying he felt under threat on the wing because he was in debt. He was moved to another part of the section.
After another incident of self-harm on August 4, a nurse failed to place Mr. Taylor under suicide and self-harm monitoring procedures, assuming a prison officer had done so. The officer was not aware that Mr. Taylor had self-harmed. A week later, the wound became infected and Mr. Taylor was taken to hospital for surgical intervention.
Final day and falsified records
On August 27, the day before Mr. Taylor was found dead, the wing was on a "split regime" due to low staffing levels, with prisoners allowed out of their cells for just half a day. Mr. Taylor was locked in his cell shortly after midday.
The Ombudsman's report states that the prison officer working the night shift was tasked with observing two prisoners on suicide watch and completing regular checks at dawn, but did not complete these checks and falsified records to show he had done so. The officer previously told an inquest he was under "extreme pressure" at the time and that his wife had told him that evening she wanted a divorce. He was removed from his job following the incident.
Another officer unlocking cells on the morning of August 28 tried to open Mr. Taylor's observation panel and found it blocked with toilet paper. He did not attempt to get a response from Mr. Taylor. The Ombudsman said the officer "did not take appropriate action." A third officer, conducting welfare checks, followed behind a minute later. She entered the cell and found Mr. Taylor had died.
Assessment and response
Mr. Taylor was placed on suicide watch three times at HMP Garth. The Ombudsman found staff managed the process well, and that Mr. Taylor "did not present as in crisis in the days before his death" and there was not "sufficient evidence for staff to consider him a high suicide risk." However, the clinical reviewer found that Mr. Taylor's suicide risk was "high."
Mr. Taylor was the 15th prisoner to die at HMP Garth in three years, and his was the third self-inflicted death. The prison holds long-term and life prisoners.
Greater Manchester Mental Health NHS Foundation Trust provided mental health care at the prison at the time. The Ombudsman called on the Trust to ensure all staff are aware of their responsibilities around suicide and self-harm monitoring procedures, including communicating with wing staff if there are concerns.
Responding to the Ombudsman, the Trust said all concerns around self-harm and suicide are communicated to wing staff, and healthcare staff have been informed this is to be written in the wing observation book. The Trust added all healthcare staff have been provided with suicide and self-harm monitoring procedures training, including refreshers on responsibilities. Greater Manchester Mental Health NHS Foundation Trust declined to comment. The ECHO understands the Trust no longer provides mental health services at the jail.
A Prison Service spokesperson said: "Our thoughts remain with the family and friends of Aaron Taylor. The vast majority of prison staff are honest, professional, and hardworking, but any that fall below our high standards will face consequences. This government is investing up to £300 million in 2025-26 to improve prison conditions, alongside strengthening mental health support for prisoners. All allegations of sexual assault in prisons are taken extremely seriously and we do not hesitate to take immediate action where necessary."
