On 29 September 2022, Kevin was discovered deceased in his cell, having died as a result of ligature asphyxiation. He had a long history of mental ill health, paranoia and self-harm behaviours. He was on an Assessment, Care in Custody and Teamwork (ACCT) plan. However:

- Information about Kevin's needs was not being shared between staff at handover
- The ACCT plan itself was unavailable to staff on the day of his death - a day known to be a trigger date for Kevin - as it had been removed for quality assurance
- Staff were not trained in ACCT observations, and some were simply completing "signs of life" checks"
- After Kevin's death, records were falsified to state that ACCT checks had been carried out