Anthony Paine was was serving an 18-month sentence for affray and endangering the public
18:30, 21 Jun 2025Updated 18:38, 21 Jun 2025
Anthony Paine took his own life at HMP Liverpool
A prisoner at HMP Liverpool took his own life in his cell after a litany of failures. Anthony Paine, known to his loved one as Tony, was remanded into custody in October 2017 and was serving an 18-month sentence for affray and endangering the public after climbing onto a roof and throwing tiles.
He was due to be released from the Walton prison in two weeks when he was found hanging in his cell on February 19 2018. He was pronounced dead at Aintree University Hospital some hours later. When he was brought into HMP Liverpool, he had a history of self-harm, substance misuse and mental health problems, including a diagnosis of schizophrenia.
The 35-year-old dad was on a Care programme Approach (CPA), an enhanced package of care for those with mental health problems in custody, and on October 11 he was allocated a mental health keyworker. She made several entries in his records that she was unable to see him due to heavy workload and was unable to see him in his four-and-a-half months at HMP Liverpool.
Staff at the prison started suicide and self-harm prevention procedures on February 1 after he self-harmed. He claimed he was being bullied and forced to use psychoactive substances and was moved to a different wing two days later. He was downgraded to basic regime on February 16 and was moved to a new cell with a new cellmate.
While on basic regime, he and his cellmate stayed in their cell throughout the weekend, with staff noticing he was displaying “bizarre behaviour” and making cuts to his arms, with him suspected of being under the influence of psychoactive substances.
Following the inquest into his death earlier this year, a Prison and Probations Ombudsman report has been published looking at the failings surrounding the death of the prisoner. It states how healthcare staff were unable to attend to him due to the cell being in darkness.
During this time, his suicide prevention procedure remained at three observations during the day and three observations during the night.
On the morning of his death staff increased observations to one an hour and made a request for an urgent mental health assessment. Staff made the decision to move his cellmate out of the cell at around midday. Staff checked on him on two occasions where he said he was fine, but at around 2pm an officer found him distressed and with a noose.
HMP Liverpool(Image: Liverpool Echo)
However, the officer did not take it away from him and when they returned at 2.45pm and asked him to give him the noose, he said he had got rid of it through the window. When the officer returned to collect the 35-year-old for his review, he was found unresponsive.
In the findings of the PPO report, the ombudsman, Elizabeth Moody, explained how staff had failed to respond appropriately when his risk of suicide and self-harm escalated in the hours before his death. She said: “At the very least, the frequency of observations should have been increased, and given that Mr Paine had been seen making preparations for suicide, the possibility of constant supervision should have been considered.
“It also appears no proper consideration was given to the impact of removing Mr Paine’s cellmate, the presence of whom would generally be regarded as a protective factor.”
She also stated the conditions of his cell were unacceptable, especially due to him being at risk of self-harm and suicide, they were also found not to be in accordance with the Prison Service Instruction.
Mental health support
Helplines and support groups
The following are helplines and support networks for people to talk to, mostly listed on the NHS Choices website
- Samaritans (116 123) operates a 24-hour service available every day of the year. If you prefer to write down how you’re feeling, or if you’re worried about being overheard on the phone, you can email Samaritans at jo@samaritans.org.
- CALM Campaign Against Living Miserably (0800 58 58 58) is a leading movement against suicide. It runs a UK helpline and webchat from 5pm to midnight 365 days a year for anyone who has hit a wall for any reason, who need to talk or find information and support.
- PANDAS (0808 1961 776) runs a free helpline and offers a support service for people who may be suffering with perinatal mental illness, including prenatal (antenatal) and postnatal depression plus support for their family or network.
- Childline (0800 1111) runs a helpline for children and young people in the UK. Calls are free and the number won’t show up on your phone bill.
- PAPYRUS (0800 068 41 41) is an organisation supporting teenagers and young adults who are feeling suicidal.
- Mind (0300 123 3393) is a charity providing advice and support to empower anyone experiencing a mental health problem. They campaign to improve services, raise awareness and promote understanding.
- Students Against Depression is a website for students who are depressed, have a low mood or are having suicidal thoughts.
- Bullying UK is a website for both children and adults affected by bullying.
- Amparo provides emotional and practical support for anyone who has been affected by a suicide. This includes dealing with police and coroners; helping with media enquiries; preparing for and attending an inquest and helping to access other, appropriate, local support services. Call 0330 088 9255 or visit www.amparo.org.uk for more details.
- Hub of Hope is the UK’s most comprehensive national mental health support database. Download the free app, visit hubofhope.co.uk or text SHOUT to 85258 to find relevant services near you.
- Young Persons Advisory Service – Providing mental health and emotional wellbeing services for Liverpool’s children, young people and families. tel: 0151 707 1025 email: support@ypas.org.uk
- Paul’s Place – providing free counselling and group sessions to anyone living in Merseyside who has lost a family member or friend to suicide. Tel: 0151 226 0696 or email: paulsplace@beaconcounsellingtrust.co.uk
- The Martin Gallier Project – offering face to face support for individuals considering suicide and their families. Opening hours 9.30-16.30, 7 days a week. Tel: 0151 644 0294 email: triage@gallierhouse.co.uk
- James’ Place – supports men over 18 who are experiencing a suicidal crisis by providing quick access to therapy and support. Call 0151 303 5757 from Monday to Friday between 9.30am and 5.30pm or visit https://www.jamesplace.org.uk/
The report continued: “The walls and ceiling were painted in a non-standard dark colour, there were no lights and the windows were broken. We found little evidence that staff attempted to arrange repairs to the cell or to alert senior managers to the cell conditions.
“Due to the lack of light in the cell, healthcare staff were unable to go into the cell to treat Mr Paine. Mr Paine was kept in this cell for three days and we consider that the inappropriate cell conditions may have negatively impacted on his mental health.”
Recommendations were published, with an action plan also being released as part of the report. Both the Ministry of Justice and Lancashire and South Cumbria NHS Foundation Trust accepting the recommendations issued by the ombudsman.
All recommendations issued as part of the investigation have been acted on and implemented according to the published action plan. Following an inquest at Liverpool Coroner’s Court this year, Mr Rebello concluded Mr Paine died by suicide contributed to by neglect.
A Prison Service spokesperson said: “Our thoughts are with Mr Paine’s family and friends.
“Following Mr Paine’s death, we acted quickly to make HMP Liverpool safer, including improving staff suicide prevention training, boosting mental health support, tightening cell checks and rolling out new systems to spot and fix faults in accommodation faster. All recommendations were accepted and put in place by early 2019.”
Dr Gareth Thomas, Chief Medical Officer and Deputy Chief Executive at Lancashire and South Cumbria NHS Foundation Trust said: “On behalf of the Trust I offer my sincere condolences to the family and friends of Anthony.
“We acknowledge the findings of the report and fully accept that the care Anthony received was unacceptable and well below the standard we expect and train colleagues to deliver.
“The safety of those in our care is our utmost priority and the death of any patient while under any of our services will always be regrettable. While we no longer deliver services within prisons, we are a learning organisation and have taken the findings from this report incredibly seriously.
“My profound apologies go to Anthony’s loved ones on behalf of Lancashire and South Cumbria NHS Foundation Trust.”