Alan Hines

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Independent investigation into
the death of Mr Alan Hines,
a prisoner at HMP Oakwood,
on 7 April 2023
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Mr Alan Hines died on 7 April 2023, of invasive adenocarcinoma of the cardia of the
stomach with multi focal sclerotic bony metastases (stomach cancer that had
spread to his bones), at HMP Oakwood. He was 71 years old. We offer our
condolences to Mr Hines’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Hines received at Oakwood
was equivalent to that which he could have expected to receive in the community.
She found that the healthcare team should be commended for the good standard of
palliative and end of life care they provided to Mr Hines.
5. We found that the decision to restrain Mr Hines when he was taken to hospital was
not justified given his advanced age and poor health. We have made similar
findings in several recent investigations at Oakwood and, in March 2024, made two
national recommendations regarding the use of restraints during hospital escorts at
Oakwood and healthcare input into the risk assessment process.
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The Investigation Process
6. HMPPS notified us of Mr Hines’ death on 7 April 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr Hines’
clinical care at HMP Oakwood.
8. The PPO investigator investigated the non-clinical issues relating to Mr Hines’ care.
9. The PPO family liaison officer wrote to Mr Hines’ wife to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Hines’ wife did not
have any specific questions and said that she would like a copy of our report.
10. We shared the initial report with HM Prison and Probation Service (HMPPS). They
did not identify any factual inaccuracies.
11. We also shared the initial report with Mr Hines’ wife. She did not respond.
Previous deaths at HMP Oakwood
12. Mr Hines was the 12th prisoner to die at HMP Oakwood since 7 April 2020. Of the
previous deaths, nine were from natural causes and two were apparent drug related
deaths. Up to 2 April 2024, there have been a further seven deaths of prisoners at
Oakwood, all of which were due to natural causes. In four of our previous reports,
we made recommendations about the inappropriate use of restraints on elderly and
unwell prisoners.
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Key Events
13. On 21 November 2018, Mr Hines was admitted to HMP Birmingham on remand. He
was convicted of a number of sex offences and sentenced to seven and a half
years in prison.
14. In February 2020, Mr Hines was diagnosed with Waldenstrom macroglobulinemia, a
rare slow growing blood cell cancer.
15. On 6 May 2021, Mr Hines was transferred to HMP Oakwood.
16. In September 2021, Mr Hines was diagnosed with an abdominal aortic aneurysm (a
bulge in the main blood vessel of the body).
17. On seven occasions in January and February 2023, Mr Hines attended outpatient
hospital appointments. We have not seen documents about the hospital visit of 12
January, but single handcuffs were applied to Mr Hines during the six other hospital
visits (this means that one standard handcuff is attached to the wrist of the prisoner
with the other handcuff attached to the wrist of an officer). Healthcare staff did not
indicate on the escort risk assessment forms that there were any medical reasons
that would prevent staff from applying normal cuffing procedures, except during a
‘procedure/scan’ on 13 and 16 February 2023.
18. On 1 March, a gastroenterology consultant informed Mr Hines that he had a
cancerous tumour in his stomach that had spread to his lungs and bones. He could
only be treated with palliative care as the cancer was at an advanced stage.
Nursing staff created a palliative care plan. A ReSPECT form was completed. This
included an instruction not to resuscitate Mr Hines should his heart and breathing
stop.
19. On 2 March, the Head of Safety was appointed as a family liaison officer.
20. On 3 March, a nurse emailed the Head of Security and asked that staff not apply
handcuffs to Mr Hines because he was a palliative care patient who presented a
greater risk of sustaining fractures, and to assist in maintaining his dignity.
21. On 6 March, Mr Hines became unwell and attended hospital via ambulance, leaving
the prison at around 10.00am. A nurse noted that he was handcuffed following his
admission and that healthcare staff were unable to complete the medical aspect of
the risk assessment because he was transferred as an emergency. Later that day,
the nurse emailed the Head of Safety and said that “due to [Mr Hines’] deterioration
it is really NOT [her capitals] appropriate for him to be cuffed”.
22. At 12.12pm, prison staff removed the handcuffs and Mr Hines remained
unrestrained for the rest of the hospital escort. The Head of Safety supported
telephone contact with and a visit from Mr Hines’ wife. On 8 March, Mr Hines
returned to Oakwood.
23. On 2 April, the Head of Safety arranged for Mr Hines’ wife to visit him in the prison
at his cell.
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24. On 5 April, the community palliative care team visited Mr Hines and recorded that
he was now actively dying and suitable for hospice admission. No hospice beds
were available at the time. (On 6 April, a hospice bed became available that Mr
Hines would have been able to move into on 7 April.) Mr Hines’ cell door was left
open during the night, with staff instructed to make regular wellbeing checks.
25. At around 5.00am on 7 April prison and healthcare staff identified that Mr Hines was
no longer breathing. Paramedics attended and, at 5.55am, confirmed that Mr Hines
had died.
26. The Head of Safety notified Mr Hines’ wife of his death.
Post-mortem report
27. The Coroner certified Mr Hines cause of death as invasive adenocarcinoma of the
cardia of the stomach with multi focal sclerotic bony metastases.
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Findings
Clinical care
28. The clinical reviewer concluded that the clinical care Mr Hines received at Oakwood
was equivalent to that which he could have expected to receive in the community.
She found that the healthcare team at Oakwood should be commended for the
good standard of palliative and end of life care they provided to Mr Hines. The
clinical reviewer made one recommendation, regarding the provision of a pressure-
relieving mattress, which the Head of Healthcare will wish to address.
Restraints, security and escorts
29. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
30. Mr Hines was 71 years old. He had a history of poor health and was diagnosed with
cancer. Staff did not identify a heightened risk of escape. On many of his hospital
visits in 2023, healthcare staff did not identify any medical reasons that would
outweigh normal cuffing requirements. It is particularly concerning that restraints
were used for the first hours of an emergency admission in March 2023, three days
after healthcare staff had explicitly requested that they not be used on future
escorts.
31. Mr Hines’ symptoms and medical history, in line with the High Court judgement,
meant that his risk could have been effectively managed by the officers
accompanying him without the use of restraints.
32. In four recent investigations, we have highlighted that restraints were
inappropriately used on older or terminally ill prisoners at Oakwood. In March 2024,
we issued two national recommendations regarding the use of restraints at
Oakwood and the wider lack of meaningful healthcare contribution to the risk
assessment process throughout England and Wales. We do not repeat those
recommendations here but hope that meaningful action will result from the
recommendations we have made.
Inquest
33. The inquest into Mr Hines death concluded on 13 June 2024, returning a verdict of
natural causes.
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Adrian Usher
Prisons and Probation Ombudsman April 2024
6 Prisons and Probation Ombudsman
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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