Prisoners are at their most vulnerable in their early days in a prison. Nearly a third who kill themselves do so within the first week. Prisoner moves, therefore, are fraught with risk, particularly if they are unwanted or unexpected.
Mr Wardally, a prisoner with mental health problems, moved four times in a seven-week period. Only one of those moves was planned and in his best interests. Within a week of the other three moves he tried to hang himself, succeeding on the third occasion.
Administrative and communication blunders appear to have played a large part in this. But it also appears, from the draft Ombudsman's report, that the timing of the Wandsworth inspection was a factor in not returning him to a prison where he felt safer and was known to mental health services.
Clearly – as the Ombudsman recommends – if there is new evidence, further disciplinary proceedings need to be considered. But the report also shows the importance of independent and transparent investigations into such matters – and the forthcoming inquest will undoubtedly wish to examine how and why decisions were made in the last few weeks of Mr Wardally's life, and the effect this may have had on his state of mind and tragic death.
Dame Anne Owers is the former Chief Inspector of Prisons