Anthony Bancroft

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Anthony
Bancroft on 5 March 2024
following his release from HMP
Stocken
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Mr Anthony Bancroft died of acute myocardial ischaemia on 5 March 2024 following
his release from HMP Stocken on 20 February 2024. He was 64 years old. We offer
our condolences to those who knew him.
5. We did not find any issues of concern relating to the pre and post-release planning.
Findings
6. The clinical reviewer concluded that Mr Bancroft received a good standard of care
leading up to his release, and it was equivalent to what he could have expected to
receive in the community. Mr Bancroft was given adequate information and advice
while in prison and on release to encourage good health and harm reduction.
7. We make no recommendations.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
8. HMPPS notified us of Mr Bancroft’s death on 11 March 2024.
9. The PPO investigator obtained copies of relevant extracts from Mr Bancroft’s prison
and probation records.
10. NHS England commissioned a clinical reviewer to review Mr Bancroft’s clinical care
at the prison.
11. We informed HM Coroner for Leicester of the investigation. She gave us the results
of the post-mortem examination. We have sent the Coroner a copy of this report.
12. The Ombudsman’s office contacted Mr Bancroft’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Bancroft’s family
wanted to know what address Mr Bancroft was released to, as they believed he had
nowhere to live when he was released.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
14. Mr Bancroft’s family received a copy of the initial report. They did not make any
comments.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Stocken
15. HMP Stocken is a category C prison which holds male prisoners who have been
convicted. It is managed by HMPPS. Practice Plus Group Health in Rehabilitation
Services provides physical and mental health care.
Probation Service
16. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Stocken was in January 2023. Inspectors
reported the quality of health services had improved in many areas since the last
inspection and was reasonably good. Partnership working had been strengthened
and local delivery board meetings now took place regularly. They found daily
handovers were well attended by all teams, sharing patient information and any
service updates, and complex patients were reviewed regularly through a strong
multidisciplinary approach.
HM Inspectorate of Probation
18. The most recent inspection results of the NPS East Midlands Region was published
in January / February 2023.Only two of the six Probation Delivery Units were
inspected. These were Derby City who were rated by the Inspectors as ‘Requires
Improvement’ and Leicester, Leicestershire and Rutland who were rated by the
Inspectors as ‘Inadequate’. Although staff were committed and dedicated to their
roles, high workloads over a prolonged period of time had taken its toll, leading to
low morale across the Probation Delivery Units.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
19. On 30 September 2022, Mr Anthony Bancroft was remanded to HMP Leicester
charged with robbery. On 10 November, he was sentenced to 36 months in prison.
20. A nurse conducted Mr Bancroft’s initial health screen and noted he had
hypertension (high blood pressure) and prescribed medications to treat and
manage his condition. Mr Bancroft also had an underlying heart condition involving
blocked veins and diabetes. He was prescribed atorvastatin (used to prevent
cardiovascular disease). Mr Bancroft had a long history of substance misuse while
in the community. He was suspected of being under the influence of drugs while in
prison, but he declined support from the substance misuse team.
21. On 11 November, Mr Bancroft was transferred to HMP Ranby.
22. Mr Bancroft arrived at Ranby too late in the evening for healthcare staff to complete
his full initial health screen. A nurse noted that he had coronary heart disease and
Acute Cardio Syndrome (a type of coronary heart disease). She created a
secondary prevention care plan which included annual blood tests and an ECG
(electrocardiogram), and a hypertension care plan.
23. During his initial and secondary health screens on 12 and 14 November, healthcare
staff noted Mr Bancroft’s medical conditions, and that he had blocked arteries. He
received appropriate medication for this condition. Mr Bancroft said that he was
feeling stable and had not attended any regular hospital appointments for this
condition. Over the months that followed healthcare staff attempted to engage Mr
Bancroft in managing his conditions as he often failed to take his prescribed
medications and declined to attend reviews for his long-term conditions.
24. On 30 August, Mr Bancroft was transferred to Stocken.
25. Mr Bancroft was taken to the wing before healthcare staff completed his initial
health screen. Staff told him that healthcare staff would complete it following day.
26. The next day, Mr Bancroft refused to attend his initial health screen. Healthcare
staff encouraged him to attend several times, but Mr Bancroft declined.
27. On 5 September, Mr Bancroft refused to see an Advanced Clinical Practitioner
(ACP) for his long-term conditions review and did not attend the clinic for his blood
tests.
28. On 22 September, the ACP visited Mr Bancroft on the wing to discuss why he had
not been attending his long-term conditions reviews. Mr Bancroft said that he was
fine and did not need them. She explained the reason for the reviews, which was to
make sure his conditions were being managed adequately. She told Mr Bancroft
that she would book one more appointment for him, but if he declined to attend, his
next review would be held in one years’ time. Healthcare staff noted that Mr
Bancroft had the capacity to make decisions about his care.
29. On 26 September, Mr Bancroft declined to attend his long-term conditions review.
The ACP sent him a letter informing him that he would be removed from the
monitoring list. Enclosed with the letter was information advising him of the risks of
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
poor compliance, how to monitor his blood pressure and how to look after his heart,
diabetes and high cholesterol. Over the weeks that followed, Mr Bancroft declined
to attend the chronic kidney disease monitoring clinic, hypertension clinic, diabetic
clinic and the peripheral vascular disease clinic.
30. In December, staff told Mr Bancroft that he would be released in February 2024.
31. On 18 December Mr Bancroft attended a substance misuse assessment because
staff suspected that he had been using drugs in prison. Mr Bancroft asked the
substance misuse team if he could be prescribed a opiate substitute prior to his
release, to support his abstinence from drugs in the community.
32. On 2 February 2024, Mr Bancroft’s Community Offender Manager (COM)
completed a Duty to Refer to Leicester Council. (DTR-The Homelessness
Reduction Act 2017 introduced a duty on specified public authorities to refer service
users who they think may be homeless or threatened with homelessness to local
authority homelessness teams.) Following this referral, the COM received
confirmation the DTR had been submitted. Mr Bancroft was assigned a housing
officer, but a housing assessment was not completed.
33. On 13 February, a GP at the prison saw Mr Bancroft and prescribed 2mg of
Espranor (used to treat opiate addiction) which was increased to 4mg on 19
February. Mr Bancroft had agreed to have blood tests and vital observations taken
to be prescribed this medication, which he complied with. Mr Bancroft’s blood
pressure was raised. The GP altered his medication but even after the medication
was altered, Mr Bancroft’s blood pressure was still not within the recommended
range. The GP gave him advice about his diet and lifestyle and emphasised that he
needed to follow this up with his community GP following his release.
34. On 20 February, Mr Bancroft was released from Stocken, four days early under the
End Of Custody Supervised Licence scheme (ECSL - a scheme introduced in 2023
that allowed certain prisoners to be released up to 70 days before the end of their
sentence). He was released with all his prescribed medication. A discharge
summary was also sent to his community GP. Mr Bancroft declined a naloxone kit
on release. He left the prison before healthcare staff could prescribe his Espranor,
so they contacted Turning Point, a local drug support service, so that Mr Bancroft
could attend their office that day and receive his medication.
35. Mr Bancroft was released homeless and initially stayed with his brother while
probation staff explored other housing options for him. A member of the pre-release
team at Stocken supported Mr Bancroft with a housing assessment for Blaby
Council, however he asked her to close the referral because his local connection
was with Leicester Council.
36. The COM completed a CAS3 (accommodation service offering those leaving prison
temporary accommodation for up to 84 nights) referral to Nacro (accommodation
service for the homeless) and he was offered a room in Leicester. However, this
accommodation was later assessed as unsuitable. Mr Bancroft died before long-
term accommodation could be secured for him.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Circumstances of Mr Bancroft’s death
37. On 28 February, a member of the public found Mr Bancroft lying on the floor in a
public area unresponsive. They called 999, got a defibrillator from nearby and
started CPR.
38. Paramedics arrived and took over Mr Bancroft’s care. Mr Bancroft was taken to
hospital and remained there for six days. On 5 March, it was confirmed that Mr
Bancroft had died.
Post-mortem report
39. The post-mortem report concluded that Mr Bancroft died of acute myocardial
ischaemia (a restriction in the blood flow to the heart) caused by critical coronary
atherosclerosis (arteries become narrowed, making it difficult for blood to flow
through them). Hypertension, type two diabetes mellitus and chronic drug use were
also listed as contributing factors.
40. The coroner concluded no inquest was required.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Clinical care
41. The clinical reviewer concluded that Mr Bancroft received a good standard of care
leading up to his release, equivalent to what he could have expected to receive in
the community.
42. Healthcare staff tried to engage Mr Bancroft in managing his long-term conditions,
but Mr Bancroft declined to attend his reviews and later stopped taking his
prescribed medication. Mr Bancroft was deemed to have the capacity to make
these decisions. Although Mr Bancroft chose to not engage with healthcare staff, he
was given appropriate advice about how to manage his health conditions in the
community, and all his clinical notes were available for the community GP to
access.
Accommodation
43. Homelessness on release from prison is a significant and complex challenge. While
prison and probation staff can submit referrals to local authorities and charities,
there are occasions when accommodation is not found, because they are not
assessed in a timely manner due to the lack of accommodation available.
Fortunately for Mr Bancroft he was able to stay with his brother and was supported
through various other accommodation referrals.
44. We consider that Mr Bancroft’s COM appropriately prepared for his release. He
liaised with external support agencies, completed necessary housing referrals pre
and post release to try and ensure Mr Bancroft received suitable accommodation.
Probation staff approved Mr Bancroft’s request to stay with his brother on release,
while more suitable and long-term accommodation was found for him.
45. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman October 2024
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE