Anthon van der Hoven

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Independent investigation into
the death of Mr Anthon van der
Hoven, a prisoner at HMP
Exeter, on 8 June 2019
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, 2024
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Anthon van der Hoven died on 8 June 2019 from the consequences of chronic alcohol
misuse with sudden cessation of alcohol consumption at HMP Exeter. He was 51 years
old. I offer my condolences to Mr van der Hoven’s family and friends.
Mr van der Hoven had been recalled to Exeter the day before his death. He had a long
history of substance misuse and regularly consumed large amounts of alcohol in the
community. The clinical reviewer found that he received an appropriate standard of
clinical and substance misuse care at Exeter which was equivalent to that which he could
have expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Elizabeth Moody
Deputy Prisons and Probation Ombudsman January 2022
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Contents
Summary ......................................................................... Error! Bookmark not defined.
The Investigation Process ................................................ Error! Bookmark not defined.
Background Information ................................................... Error! Bookmark not defined.
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. Mr Anthon van der Hoven was recalled to HMP Exeter on 7 June 2019 for
breaching the conditions of his licence.
2. Mr van der Hoven used illicit substances and consumed large amounts of alcohol
on a daily basis in the community. When he arrived at Exeter, he started an alcohol
detoxification programme and was referred to the prison’s substance misuse team.
A prison GP prescribed him methadone (heroin replacement medication) and
medication to reduce the symptoms of alcohol withdrawal. Nurses monitored him
during the night.
3. On 8 May, a substance misuse nurse completed a full assessment and a prison GP
prescribed Mr van der Hoven the same methadone dose that he received in the
community. At approximately 2.00pm, a prison officer took Mr van der Hoven to
receive his methadone and said that he looked unwell. A nurse saw him at about
2.24pm and another nurse saw him at about 2.44pm, and neither noted any
particular concerns about his presentation.
4. At 6.55pm, a prison officer completed a roll check and saw Mr van der Hoven on his
mattress on his cell floor. Mr van der Hoven was unresponsive and the prison
officer radioed a medical emergency code. Another prison officer and two prison
nurses attended and started cardiopulmonary resuscitation (CPR). Paramedics
arrived at approximately 7.04pm and pronounced Mr van der Hoven dead at
7.38pm.
5. The post-mortem concluded that Mr van der Hoven had died from the
consequences of chronic alcohol misuse with sudden cessation of alcohol
consumption.
Findings
6. The clinical reviewer concluded that Mr van der Hoven received a good standard of
clinical and substance misuse care at Exeter that was equivalent to that which he
could have expected to receive in the community.
7. When he arrived at Exeter, Mr van der Hoven started an appropriate alcohol
detoxification programme and he was prescribed medication to help with the
symptoms of withdrawal. The substance misuse team completed a full
assessment, and he was prescribed the same dose of methadone that he was
receiving in the community.
8. We are satisfied that the clinical staff who attempted to resuscitate Mr van der
Hoven attended the hot debrief and significant incident review and were given the
opportunity to access support.
Recommendations
9. We have made no recommendations.
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The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Exeter informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
11. The investigator obtained copies of relevant extracts from Mr van der Hoven’s
prison and medical records.
12. NHS England commissioned a clinical reviewer to review Mr van der Hoven’s
clinical care at the prison.
13. Our investigation was delayed while we waited for the cause of death and the final
clinical review.
14. We informed HM Coroner for Exeter and Greater Devon of the investigation. He
gave us the results of the post-mortem examination. We have sent the coroner a
copy of this report.
15. We wrote to Mr van der Hoven’s nominated next of kin, his ex-wife, to explain the
investigation and to ask if she had any matters she wanted the investigation to
consider. Mr van der Hoven’s ex-wife asked about the substance misuse and
clinical care he received in prison, in particular how his alcohol withdrawal was
managed. She also asked why he was not located in the prison’s healthcare unit.
We have addressed her questions in this report.
16. Mr van der Hoven’s family received a copy of the initial report. The solicitor
representing his wife wrote to us pointing out some factual inaccuracies and
omissions. The report has been amended accordingly. They also raised a number
of questions that do not impact on the factual accuracy of this report. We have
provided clarification by way of separate correspondence to the solicitor.
17. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Exeter
18. HMP Exeter holds up to 561 adult men and young offenders, and serves the courts
of Devon, Cornwall and Somerset. Care UK provides primary health services and
Devon Partnership NHS Trust provide mental health care.
HM Inspectorate of Prisons (HMIP)
19. The most recent full inspection of HMP Exeter was in May 2018. Inspectors found
that there had been a failure to address the issues of violence, drugs and the lack of
a sufficiently purposeful regime, and rated the prison ‘poor’ in terms of safety.
20. However, Inspectors reported that partnership working between the health
providers and the prison and commissioners was good. GP services were good
and very effectively led by the lead GP. Prisoners said that the overall quality of
health services was good, and inspectors observed satisfactory interactions
between health care staff and prisoners.
21. The integrated substance misuse team was well led and provided good support,
and partnership working with the prison was good. New arrivals who needed
clinical support for substance misuse were identified promptly and referred for first
night prescribing. There was consistent daytime and night-time monitoring.
regardless of location, and recording was excellent. Specialist nurses completed
assessments promptly and made regular reviews.
22. Following the inspection HM Chief Inspector of Prisons invoked the Urgent
Notification Protocol and wrote to the Justice Secretary setting out his significant
concerns about safety at the prison. However, he reported that health services at
the prison had improved and were mostly good.
23. HMIP then carried out an Independent Review of Progress in April 2019 to look at
the progress made in implementing their key recommendations from the 2018
inspection. This did not look at healthcare as HMIP had not found significant
concerns. They reported that there had not been a sufficient sense of urgency in
the prison’s response to a number of key recommendations. Nevertheless, there
had been a proactive response to some recommendations in critical areas and
there were credible plans to make further improvements in the future.
Independent Monitoring Board
24. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for 2019, the IMB reported that they were
satisfied that services provided by Care UK were comparable with community
provision. Prisoners were largely satisfied with the services provided.
Previous deaths at HMP Exeter
25. Mr van der Hoven was the 14th prisoner to die at Exeter since June 2017. Of the
previous deaths, six were self-inflicted deaths and seven were from natural causes.
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26. Since Mr van der Hoven’s death, there have been four more self-inflicted deaths at
Exeter and five deaths from natural causes.
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Key Events
27. On 22 March 2016, Mr Anthon van der Hoven was remanded to HMP Exeter. On
19 April, he was sentenced to five years in prison for attempted robbery. He moved
to HMP Maidstone on 31 May and was released on licence on 21 September 2018.
He was recalled to Exeter on 7 June 2019 for breaching his licence conditions.
28. A prison nurse completed Mr van der Hoven’s initial reception screen when he
arrived at Exeter. Mr van der Hoven had a long history of using illicit substances
(heroin, crack cocaine and benzodiazepines) and said he was consuming large
volumes of alcohol every day. He said he had previously received support from the
substance misuse team at Maidstone and had completed methadone reduction
therapy there.
29. Mr van der Hoven also had a history of hypertension and post-traumatic stress
disorder. He said he had suffered a fit on a least one previous occasion when he
was sober, which was possibly related to alcohol withdrawal.
30. Prison nurses contacted Mr van der Hoven’s community pharmacist who confirmed
that he was prescribed 70mls of methadone (heroin replacement medication) a day.
31. A prison GP assessed Mr van der Hoven and noted that he was sweating, trembling
and yawning. The GP noted that these were signs of alcohol withdrawal and
prescribed medication to reduce his symptoms. Mr van der Hoven’s urine tested
positive for methadone and benzodiazepines (sedatives) and he was referred to the
prison’s substance misuse team.
32. A prison doctor assessed Mr van der Hoven as suitable for a normal location wing
and he was allocated a single cell on the first night induction unit. Prison nurses
checked Mr van der Hoven three times during the night and did not note any
concerns.
Events of 8 June
33. On the morning of 8 June, Mr van der Hoven was seen by his prison Offender
Manager, who explained the licence recall process, by an officer, who completed
his induction, and by the prison chaplaincy team, who recorded that Mr van der
Hoven was in bed, awake and that he confirmed that he wished to attend chapel.
34. At 9.45am, nurses gave Mr van der Hoven 20mls of methadone.
35. At 12.00pm, a substance misuse nurse assessed Mr van der Hoven and noted that
he had received 20mls of methadone that morning. Mr van der Hoven said he felt
uncomfortable and weak. The nurse noted that Mr van der Hoven was displaying
moderate tremors and appeared mildly anxious. He was not sweating, was walking
normally and he was able to maintain eye contact. Mr van der Hoven was
prescribed 70mls of methadone in the community and the substance misuse nurse
noted that he would continue to receive the same dose. Nurses gave Mr van der
Hoven 35mg of chlordiazepoxide (for alcohol withdrawal).
36. At 1.30pm, a prison GP agreed to continue to prescribe Mr van der Hoven 70mls of
methadone and noted that he was not displaying any signs of intoxication or over-
sedation that morning.
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37. At approximately 2.00pm, an officer went to Mr van der Hoven’s cell to take him to
receive his methadone from the medication hatch. At the prison’s hot debrief after
Mr van der Hoven’s death, it was noted that the officer said that Mr van der Hoven
was having trouble speaking, was sweating and was struggling to walk. (We were
not able to interview the officer about this, as he left the Prison Service shortly after
Mr van der Hoven’s death, and he did not respond to our requests for an interview.)
38. At 2.24pm, a nurse gave Mr van der Hoven 40mls of methadone and did not note
any concerns about his presentation.
39. At 2.44pm, a nurse gave Mr van der Hoven an intramuscular injection to reduce the
muscle cramps associated with alcohol withdrawal.
40. At 4.51pm, a nurse gave Mr van der Hoven 35mg of chlordiazepoxide.
41. At 6.55pm, an officer completed a roll check and saw Mr van der Hoven on his
mattress on the cell floor. As the officer could not get a response from Mr van der
Hoven, he entered the cell and radioed an emergency code blue (which indicates
that a prisoner is unconscious or not breathing) and the control room called an
ambulance.
42. A Senior Officer (SO) immediately went to Mr van der Hoven’s cell and assisted the
officer with cardiopulmonary resuscitation (CPR). A nurse arrived at 6.57pm and
noted that Mr van der Hoven was unresponsive and felt cold. Another nurse arrived
shortly afterwards. A defibrillator did not detect a shockable rhythm and staff
continued with CPR. Paramedics arrived at 7.04pm and took control of Mr van der
Hoven’s care. An air ambulance arrived at 7.19pm. At 7.38pm, paramedics
recorded that Mr van der Hoven had died.
Contact with Mr van der Hoven’s family
43. The prison appointed a family liaison officer (FLO) and identified Mr van der
Hoven’s ex-wife as his next of kin. The prison told us that at approximately
10.00pm, the duty governor arrived at Mr van der Hoven’s ex-wife’s address and
broke the news of his death.
44. Mr van der Hoven’s wife told us that she received a missed telephone call at 10pm
which may have been from the prison. She said that at 4am on 9 June, police
officers visited her and broke the news of his death.
45. The prison contributed to the cost of Mr van der Hoven’s funeral in line with national
guidance.
Support for prisoners and staff
46. After Mr van der Hoven’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
47. The prison posted notices informing other prisoners of Mr van der Hoven’s death
and offering support. Staff reviewed all prisoners assessed as being at risk of
suicide or self-harm in case they had been adversely affected by Mr van der
Hoven’s death.
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Post-mortem report
48. The toxicology report showed the presence of Mr van der Hoven’s prescribed
medications (mirtazapine, chlordiazepoxide, diazepam and methadone) all at low
concentrations. The level of methadone was within the range documented as
appropriate for methadone maintenance programmes and was not an excessive
dose.
49. The post-mortem examination found that the cause of death was the consequences
of chronic alcohol misuse with sudden cessation of alcohol consumption.
50. The pathologist noted that Mr van der Hoven was prescribed chlordiazepoxide in
order to reduce the risk that he would develop significant alcohol withdrawal
syndrome. He said that Individuals who regularly drink to excess are at risk of
sudden death due to a cardiac arrhythmia (irregular heartbeat). In addition, Mr van
der Hoven had an enlarged heart (one cause of which can be chronic excessive
alcohol consumption) and there is a risk of arrhythmic death in individuals with an
enlarged heart.
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Findings
Clinical and substance misuse care
51. The clinical reviewer concluded that the clinical and substance misuse care Mr van
der Hoven received at HMP Exeter was equivalent to, if not better than, that which
he could have expected to receive in the community. The clinical reviewer found
that healthcare staff delivered a comprehensive approach to Mr van der Hoven’s
clinical and substance misuse care.
52. When Mr van der Hoven arrived at Exeter, he was appropriately assessed, and
healthcare staff implemented a standard alcohol detoxification programme. Prison
GPs prescribed Mr van der Hoven medication to alleviate the symptoms of alcohol
withdrawal and nurses monitored Mr van der Hoven during the night.
53. Mr van der Hoven was appropriately referred to the substance misuse service who
completed a formal assessment. Prison GPs continued to prescribe methadone at
the same dose he received in the community.
54. We were not able to interview the prison officer who apparently said that Mr van der
Hoven was unwell when he took him to the medication hatch at about 2.00pm to
receive his methadone on the afternoon of his death. However, Mr van der Hoven
was detoxing and would therefore have felt unwell. We note that the nurses who
saw him at about 2.24pm and 2.44pm did not record any concerns about him.
Staff debrief
55. The clinical reviewer was concerned that there no reference of a staff debrief taking
place following a distressing situation such as failed resuscitation. The Regional
Governance Manager for HMP Exeter told us that following a death in custody,
clinical staff involved in the emergency response attend the prison’s hot debrief and
the significant incident review. Staff are offered support and any immediate
learning is identified. We are satisfied that the clinical staff who attempted to
resuscitate Mr van der Hoven attended the hot debrief and significant incident
review and were given the opportunity to access support. We do not make a
recommendation about this issue.
Inquest
56. The inquest, heard on 9 May 2023, concluded that Mr van der Hoven died from
natural causes.
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