Individual at Wymott

Investigation into the circumstances surrounding the
death of a prisoner at HMP Wymott, in the Royal Preston Hospital on 20
August 2005
Report by the Prisons and Probation Ombudsman for
England and Wales
December 2005
This is the report of an investigation into the death of a prisoner at HMP
Wymott. The man died in the Royal Preston Hospital on 20 August 2005. The
post mortem report indicated that the man had severe peripheral vascular
disease and severe ischaemic heart disease. The man was 60 years of age
and a heavy smoker.
One of my Investigators conducted this investigation. I am grateful to a doctor
of the Chorley & South Ribble Primary Care Trust who undertook a clinical
review into the care and treatment that was afforded to the man.
I would like to extend my condolences to the man’s family for their loss. I
would also like to thank the Governor of Wymott, and his staff, in particular a
Principal Officer, for their help and co-operation during this investigation.
I make two recommendations in this report.
Stephen Shaw CBE
Prisons and Probation Ombudsman December 2005
CONTENTS
Summary
The investigation process
The prisoner
HMP Wymott
Events prior to the prisoner’s death
Events after the prisoner’s death
Clinical review and Post Mortem
Findings and conclusions
Recommendations
Summary
At approximately 8.40am on 20 August 2005, the prisoner died in the Royal
Preston Hospital. The post mortem report indicated that the man died from
Myocardial infarction and right coronary artery occlusion. He was 60 years
old.
In November 2003, the man had been given an eight year sentence for sexual
offences which he began to serve at HMP Birmingham. This was the man’s
first experience of custody and he entered prison with longstanding and
serious health problems that included heart and circulatory problems.
Nonetheless, he continued to be a heavy smoker, despite advice from
doctors. In January 2004, the man was transferred to HMP Wymott. By
December 2004 during a hospital review, the man was complaining that he
could not walk far without experiencing cramps in his legs. However, in view
of the fact that the man continued to smoke, the hospital considered there
was little justification for surgery and a decision was made to review the man’s
condition in June 2005.
In the spring of 2005, the man began to develop ulcers on his lower limbs -
specifically his left foot - that were not responding to treatment. In light of his
circulatory problems, he was diagnosed with critical ischaemia of the lower
limbs. He was referred for further investigation and treatment at the Royal
Preston Hospital and underwent corrective surgery in March and July. On
each occasion when the prisoner attended hospital he was escorted and
handcuffed.
On 15 August, the man was taken to the Royal Preston Hospital as healthcare
staff suspected that he had contracted gangrene of two of the toes on his left
foot. The man had a right femoro-popliteal bypass graft and after several days
in hospital, he was expected to make a recovery and to return to Wymott the
following week.
On 19 August, the man started to develop breathing difficulties and was given
oxygen. Despite the efforts of the hospital staff, the man died the next day.
The clinical review indicates that the man had a history of severe peripheral
vascular disease but continued to smoke heavily. The clinical reviewer
concludes that his treatment and care during the time he was in prison
appears to have been appropriate and caring until his death from natural
causes.
This report includes recommendations relating to the recording and checking
of next of kin details and to the timeliness of informing other prisoners of a
death in custody. Following disclosure of the draft report the Prison Service
has accepted the recommendations.
The investigation process
1. The investigation was opened at HMP Wymott on 1 September 2005,
when my investigator contacted the establishment to inform them that an
investigation into the death of the man would take place. Notices were
issued to staff and prisoners informing them about the investigation. In
response to the notices, my investigator visited Wymott on 5 October to
speak with two prisoners who knew the man and who wanted to raise
issues in respect of his care and treatment whilst he was at Wymott.
2. The Governor and his staff produced the man’s core record, his Medical
Record and a number of other documents for examination.
3. The Chorley & South Ribble Primary Care Trust was contacted with a
request that it conduct a clinical review into the care and treatment that the
man received in prison. A doctor carried out the clinical review.
4. One of my Family Liaison Officers contacted the brother-in-law (his next of
kin following the death of the prisoner’s sister), by telephone on 16
September. The Family Liaison Officer offered the opportunity to meet
with him and the investigator to discuss the purpose of the investigation,
and to raise any concerns or questions that the family would like explored
and addressed. The family declined this invitation and no issues or
concerns were raised.
5. My investigator contacted Her Majesty’s Coroner to inform him of the
nature and the scope of my investigation and to request a copy of the Post
Mortem report. Upon completion, my report will be sent to the Coroner to
assist him in his enquiries into the man’s death
The Prisoner
6. The man was born in 1945. He was 60 years old when he died on 20
August 2005. The prisoner had left school at the age of 16 with no
qualifications. In later life, he became a lorry driver and was in long term
employment. At the time of his arrest, the man was retired.
7. The man had been married twice and had seven children. He was
estranged from his second wife but maintained some contact with her and
one of his daughters from that marriage. The prisoner also maintained
contact with his eldest sister, who was his nominated next of kin, mainly
through letters and telephone calls. In an interview with his personal
officer at Wymott, the man stated that he enjoyed good family support.
8. On 21 November 2003, the prisoner was sentenced at Crown Court to
eight years for sexual offences. He had no previous convictions and this
was his first experience of prison. However, he said that he was not
unduly worried about being in prison. The man served the first part of his
sentence at HMP Birmingham.
9. The prisoner continued to deny the offences for which he had been
convicted and whilst in prison did not engage in any offending behaviour
programmes. However, he did engage in other educational programmes.
10. On 5 January 2004, the man was transferred from Birmingham to Wymott.
His family live in the West Midlands and so he did not receive many
visitors. On arrival at Wymott, the man’s induction included a health
screen (an initial interview with health care staff). It was established that
the man had a range of serious health issues. In July 2000, he had an
aorta-bifemoral graft, having suffered two heart attacks. The prisoner had
also been diagnosed with angina about ten years previously. In the
1990s, the man suffered two strokes and he told healthcare staff that his
mother had died of a stroke. It was also established that the man had
diabetes that he controlled with diet. The prisoner also had a history of
high cholesterol, hypertension and circulatory problems. Indeed, the man
confirmed on arrival at Wymott that he was unable to walk for more than
200 yards or stand for a long time. He required the use of a walking stick.
Despite his poor health, staff and fellow prisoners recall that the prisoner
was determined to see to his own needs and generally kept himself to
himself. He also derived much pleasure from smoking and was described
as a very heavy smoker by staff and fellow prisoners.
11. In view of his medical history, the man was prescribed medication that
included Rampiril, Aspirin, Amlodopine, Simvastatin and Glicazide. He
was also in possession of an angina spray and a blood sugar monitoring
kit to help him manage his own diabetes appropriately. He retained these
items in his cell.
12. The man was profoundly deaf in his left ear, the result of a perforation to
his eardrum some 30 years earlier. Whilst the man was at Wymott,
attempts were made by healthcare for him to be fitted with a hearing aid.
13. On arrival at Wymott, the prisoner submitted an application under Prison
Rule 45. Because of the nature of his offences, the man wanted to be
dealt with as a vulnerable prisoner. (Vulnerable prisoners are those
whose offences or behaviour are such that they may need to be
segregated from other prisoners for their own safety and protection.) The
man’s application was approved. Initially he was accommodated on ‘G’
wing and, according to reports, he settled down quickly at Wymott.
14. Because of the nature of his offences, the man was subject to Prison
Service Order 4400 – Schedule 1 (PSO 4400) that restricted any contact
with children. This included any direct contact with his grandchildren.
15. On 14 December, the prisoner attended the Royal Preston Hospital under
escort and restraint for a clinical review of his circulation. The hospital
noted that the man had been experiencing cramp-like pains in his left leg
and that he was unable to walk for more than 100 yards. He continued to
smoke up to 30 cigarettes a day and this was not helping his circulation.
The hospital was reluctant to consider surgery on the man as his condition
was not considered to be critical. However, further consideration was to
be given to surgery on the man should he develop critical ischaemia of the
lower limbs. His next review was scheduled for June 2005.
HMP Wymott
16. Wymott is a category C training prison for adult male prisoners. It is
located near Leyland, Lancashire. A high proportion of the population are
vulnerable prisoners.
17. Wymott has special accommodation for more elderly prisoners. I Wing is
the Elderly and Disabled Community and accommodates up to 62
prisoners in a mixture of single and double cells. The regime is relaxed
and informal and association is available every weekday evening.
Healthcare arrange multi-disciplinary reviews to assess those prisoners
who have social care needs such as difficulty with bathing, and outside
carers are employed when required.
18. Healthcare in Wymott was transferred to the Chorley & South Ribble
Primary Care Trust in April 2005. All staff who work in healthcare are
clinically qualified. A full time doctor is available each weekday. Two GPs
from a local practice provide medical cover during the weekends and
evenings. Appointments to see a doctor are normally triggered by wing
application. Although there is no in-patient facility at Wymott, prisoners
who need in-patient facilities are accommodated in the Healthcare Centre
at HMP Garth that is situated next to Wymott.
19. In December 2003, Her Majesty’s Chief Inspector of Prisons inspected
Wymott. Her report described the establishment as a good, well managed
prison.
Events prior to the prisoner’s death
20. On 6 September 2004, the man was transferred from G Wing to I Wing.
As noted, I Wing accommodates elderly and disabled prisoners and those
deemed to be vulnerable because of the nature of the offences they have
committed. A nursing care assistant is employed by the prison to attend to
the hygiene needs of some prisoners on a weekly basis. The man had a
single cell.
21. In an interview with his personal officer soon after his arrival on I Wing, the
man stated that he was experiencing some pain in his leg and that
healthcare were not doing enough for him. Despite his concerns, the man
worked in the laundry. He was described as a quiet, polite prisoner who
kept himself to himself. He was not a discipline problem to staff.
(However, he was on occasion challenged by staff about his personal and
cell hygiene.) In light of his good behaviour, the prisoner was placed on
enhanced privileges in April 2005. Fellow prisoners have confirmed that
he was a popular man who enjoyed smoking, despite acknowledging that
this was detrimental to his health.
22. On 11 March 2005, the prisoner was told that his sister (his nominated
next of kin) had died. Following this sad news, the man was visited on the
wing by a member of the Chaplaincy staff. Fellow prisoners have said that
the man was devastated by his sister’s death, as she was his closest link
to the outside world. The man subsequently nominated his brother-in-law
as his next of kin.
23. By 14 March, the prisoner had developed an inflamed ulcer on his left
kneecap. The ulcer was treated with the appropriate medication and
dressings. In light of his previous history of circulation problems, his ulcers
were reviewed regularly by healthcare staff.
24. On 22 March, the man attended his sister’s funeral in Birmingham
escorted by two prison officers. He was handcuffed to an officer, in
compliance with the prison’s security and operating procedures.
25. On 23 March, the prison doctor was concerned that the man might have
developed ischaemia of the left foot, as his ulcers were not responding to
treatment. In view of this diagnosis, the man was admitted to the Royal
Preston Hospital as an emergency case. As standard prison practice, the
man was handcuffed and escorted by two prison officers.
26. The man underwent a femoral fema cross over graft operation on 24
March. It was hoped that the operation would improve the circulation of
blood to his lower limbs and give him better mobility and quality of life.
After a period of post-operative recovery, he was discharged back to
Wymott on 29 March. The man attended hospital again on 3 April to have
clips removed from his groin area and to have his wounds assessed. The
review determined that the wounds were healing and that there was no
sign of infection in the groin area. He was advised once again by staff to
give up smoking and to take exercise in order to improve his circulation.
27. On 9 April, the prison doctor was asked to attend I Wing in order to assess
the condition of the man’s left foot which was becoming ulcerated and
inflamed. The doctor prescribed a course of antibiotics and the man was
subject to regular review in order to determine whether the ulcers were
healing. It was also noted that ulcers were developing on the man’s right
foot and there was the appearance of necrotic skin around his toes.
28. By 18 May, it was recorded that the man was responding well to the
treatment. There appeared to be an improvement to his right kneecap and
both feet. During this time, the man continued to work on a part- time
basis.
29. On 16 June, the man attended the Royal Preston Hospital for a six
monthly clinical review of his circulation. The man told the consultant that
he had not noticed a reduction in pain in his left leg since his operation in
March and that his left foot felt numb. The man was discharged from
hospital on the same day.
30. On 22 June, the prison doctor wrote a letter to Chorley & South Ribble
District General Hospital stating that he suspected that the prisoner was
suffering from chronic ischaemia of the lower limbs. The man had been
complaining of pains in his left leg and had noticed a significant reduction
in the distances that he could walk. The ulcers on his left foot looked
inflamed and discoloured and did not appear to be responding effectively
to treatment. No pulses could be detected in his left leg. The prison
doctor gave a full and comprehensive medical history of the man and
asked the hospital to investigate further.
31. In response to the prison’s concerns, the hospital arranged for the man to
have an angiogram on 29 July. Due to faulty hospital equipment, the scan
could not be arranged any earlier.
32. In the meantime, on 24 June, the man submitted an application under
Prison Service Order 4400 asking that consideration be given for him to
see his grandchildren. The man was advised by staff on the wing that his
application would in all probability be refused because of his offence. The
man stated he required a formal refusal in order to convince his daughter
that he had explored this avenue and done all within his means to obtain
access. The application was submitted to the administration unit. On 1
July, the man was formally told that he was only allowed visits from
immediate family and that this did not include his grandchildren.
33. On 8 July, while his ulcers were being dressed, a physical deterioration in
the man’s left foot and right knee was noticed. The man also complained
that the analgesics he was taking were not strong enough and that he was
unable to sleep at night because of discomfort and pain. The prison
doctor prescribed stronger pain relief. Regular reviews of his ulcers were
also maintained.
.
34. The man’s ulcers continued to deteriorate despite treatment. By 20 July,
there was aggressive ulceration and redness noted on his knee. His left
foot was painful and the skin was dead in appearance.
35. On 23 July, the prisoner’s ulcers were assessed once again by a prison
doctor and a nurse who decided to review his condition in 48 hours. If
there was no noticeable improvement, consideration would be given to
sending him to hospital for further urgent investigation and treatment.
36. By 24 July, there appeared to be a slight improvement in the man’s ulcers.
However, on 25 July, the prison doctor diagnosed critical left leg
ischaemia. The man was taken to the Royal Preston Hospital by
ambulance and subsequently admitted to a ward for further tests and
monitoring of his condition. On 26 July, the prisoner was reminded by the
consultant that he was due to have an angiogram on 29 July and that,
following this investigation, consideration might be given to surgery.
37. On 27 July, the man was advised that his blood pressure was low and that
he needed to drink more water. He found it difficult to lie in bed and more
comfortable to be sitting in a chair. On 28 July, the prisoner received two
visitors to his bedside.
38. On 29 July, the man had an angiogram. Later that day he was told that he
required an urgent exploratory operation to improve the flow of blood to his
left leg, as it appeared that his artery was blocked. The operation was
scheduled for 1 August.
39. On 31 July, prison escort staff noted that the prisoner was apprehensive
about further surgery, commenting that he had had undergone a similar
operation in March with limited success.
40. On the afternoon of 1 August, the man had an operation to flush out an
occlusion to previous by-pass surgery. During the course of his stay at the
Royal Preston Hospital, the medical record notes that the man underwent
an exploration of the right groin, thrombolectomy of the right limb and
femoral cross over graft refashioning of right groin anastomosis. It was
hoped that this latest surgery would improve the circulation of blood to his
legs.
41. By 4 August, it was reported that the man’s condition was stable and he
was making a good recovery. The Healthcare Centre maintained frequent
telephone contact with the hospital in order to enquire about his health and
to update the man’s medical record. The prisoner remained as an
inpatient in the Royal Preston Hospital, subject to prison escort bedwatch,
in line with the Prison Service’s security and operating procedures.
42. On 5 August, a prison chaplain and a prison governor visited the man.
The bedwatch observation log states that the prisoner was getting bored
being in hospital and was looking forward to returning to Wymott.
43. On 6 August, the bedwatch log records that the hospital received a
telephone call from the man’s daughter, enquiring after her father and
asking if he was allowed visitors. Escorting officers sought advice from
Wymott and confirmed that no children were allowed to visit the prisoner
as he was subject to the restrictions of PSO 4400.
44. During the early evening of 7 August, the man was visited by his daughter,
her partner and their two young children, the prisoner’s grandchildren. An
officer on escort duty asked if the man had received the Governor’s
permission to see his grandchildren. The prisoner confirmed that he had
not received such permission and understood that he was subject to the
conditions of PSO 4400. The terms of the order stipulated that the man
was to have no contact with children. Escorting officers confirmed the
exact conditions of PSO 4400 with the Control Room at Wymott.
45. Escorting officers explained the visiting restrictions that were imposed on
the prisoner to his daughter and her partner. The children were taken
away from his bedside. However, the bedwatch log records that the
prisoner’s daughter’s partner remonstrated with hospital staff in an attempt
to overturn the prison’s decision on the basis that the man was in a
hospital and not in prison. The decision not to allow the prisoner’s
grandchildren to visit him was upheld. After the visit, escort staff
impressed upon the man that he must not have contact with children. The
prisoner acknowledged this and stated that his grandchildren would not
visit him again. Although in the circumstances it is difficult to believe there
was any present danger to children or any prospect of their being
‘groomed’ by the man, I believe this matter was handled sensitively and
appropriately.
46. On 8 August, the prisoner was discharged back to Wymott from the Royal
Preston Hospital with an appropriate care plan. The I Wing observation
log indicates that the man was upset that he could not see his
grandchildren whilst in hospital. He was also upset that he was not
allowed to smoke whilst he was in hospital.
47. At 10.30pm on 9 August, the medical record indicates that staff on I Wing
requested that healthcare staff look at the prisoner as he was complaining
of pain and wanted stronger analgesics. Appropriate analgesics were
prescribed.
48. On 11 August, the man returned to the Royal Preston Hospital in order to
have the staples removed from his groin area. A pressure sore on his
right buttock was reviewed and appropriate treatment was given. It was
also noted that his wounds were healing.
49. On 13 August, the prisoner’s wounds were reviewed once again in
healthcare. His dressings were changed. Healthcare staff noted that the
man’s left foot, particularly his fourth and fifth toes, was wet, and foul
smelling. The skin in this area appeared to be dead. Some of the toes on
his right foot were black in appearance and cold to the touch.
50. On 14 August, healthcare staff again reviewed the prisoner’s wounds and
dressings. They noticed that, whilst his knee and right foot appeared to be
improving, this was not the case with the left foot. The man told staff that
he had experienced a restless night and was feeling weary. He was in
pain with his foot despite being given stronger analgesics. Healthcare staff
decided to review the prisoner’s condition the next day.
51. On 15 August, the prison doctor reviewed the man’s ulcers and was
particularly concerned about his left foot that looked as if it had become
gangrenous. In view of the deterioration, the prisoner was taken by
ambulance to the Royal Preston Hospital. During the course of the day,
healthcare staff telephoned the hospital and recorded that the man was in
ward 12 where he would remain as an inpatient for up to four days
pending further tests. As on previous occasions, he was escorted by two
prison officers and subject to restraint by handcuffs. The bedwatch log
records that at 8.55pm the prisoner was moved to a side room on ward
12A.
52. On the afternoon of 16 August, the man had a right femoro-popliteal
bypass graft. He was taken to ward 12 to recover and given morphine for
the pain. The prisoner was expected to remain in hospital for
approximately five to seven days.
53. On 17 August, the man received four units of blood and it appeared as
though he was making a good recovery.
54. On 18 August, following a review by the consultant, hospital staff told the
prisoner that his wounds were healing and that he would probably return to
Wymott after the weekend. The bedwatch log records that, on 19 August,
the man was quite chatty and did not appear to have any significant
concerns.
55. Also on 19 August, the medical record states that the prisoner continued to
recover after surgery although he still required units of blood. However, at
about 6.00pm, the man was struggling to get his breath. He was given
oxygen to assist with his breathing. The prisoner told his prison escorts
that he believed that his breathlessness might have been due to a change
in his medication.
56. At 6.25pm, the man was feeling very unwell and unable to eat his food
although he was able to sip fluids. He said that, whilst he was not in any
pain, he was concerned about his breathing difficulties. He continued to
use an oxygen mask. By 10.00pm, the prisoner appeared to be a little
more relaxed and was watching television from his bed.
57. At about 4.10am on 20 August, the man was sitting upright in bed. He
was experiencing breathing difficulties and was using an oxygen mask. At
5.00am, a principal officer from Wymott visited the prisoner’s bedside as
part of the routine management check for prisoners who are on bedwatch.
58. The bedwatch observation log then records that, at about 8.40am, the man
had lost consciousness and that medical staff were unable to revive him.
He was pronounced dead at 8.40am by a doctor as a result of a suspected
cardiac arrest.
59. At 8.45am, a member of the prison escort staff telephoned the duty
governor at Wymott to inform him of the death of the prisoner. In
compliance with the establishment’s procedures, the contingency plan for
a death in custody was implemented. The National Operations Unit (NOU)
was informed of the death at 4.20pm that afternoon.
Events after the prisoner’s death
60. The duty governor at Wymott telephoned the West Midlands Police at
about 9.00am and asked them to visit the man’s sister, who the prisoner
had given as his next of kin, and tell her of the death of her brother.
However, on visiting the address, the police found out that the man’s sister
had in fact passed away earlier in the year. The next of kin details on the
prisoner’s prison file had not been updated. In light of this, police told the
brother-in-law the news. He then told the rest of the family including the
man’s daughter who had visited him whilst he was in hospital. At 3.40pm,
the brother-in-law was contacted by a governor at Wymott offering the
prison’s condolences and offering advice and support.
61. On 24 August, a governor at Wymott sent a letter of condolence to the
family. The letter was timely, compassionate and told the family of various
support organisations. It did not mention any offer of financial support
from the prison towards funeral costs. However, the prison’s family liaison
officer, another governor grade, did make an offer of financial assistance
to the brother-in-law. He was told that there was sufficient in the prisoner’s
estate to cover any funeral costs.
62. On 25 August, the man’s daughter visited Wymott in order to collect her
father’s outstanding property and any money. This arrangement was with
the agreement of the brother-in-law.
63. Following the prisoner’s death and at the family’s request, all further
contact with the prison was broken. Consequently, the prison was not
aware of the funeral.
64. Prisoners who knew the prisoner were formally told of his death on 22
August when the regular I Wing staff was on duty. Two prisoners who
spoke to my investigator commented that they had inadvertently learnt of
the man’s death from an overheard conversation between staff, and were
left wondering if the information was correct. Given the power of the
prison grapevine and for reasons of courtesy, I believe the delay in
informing other prisoners of the death was unacceptable.
65. The two prisoners seen by my investigator also raised a general concern
that, in their experience, some prisoners on the wing did not always
receive their medication on time. However, my investigator established
that in such instances a formal complaint could be lodged with healthcare,
and that these were normally dealt with expeditiously. The prisoners were
aware of the man’s circulatory problems and acknowledged that his
excessive smoking, despite staff advice, exacerbated circulatory problems.
Clinical review and Post Mortem
66. The clinical review concludes that the prisoner was seen regularly by
healthcare staff because of his diabetes, angina and poor circulation. The
review also highlights that the man received a high standard of care and
support whilst he was in prison and that there was no indication that his
care at any time in prison was at a standard less than would have been
received in the wider community. The clinical review confirms that the
prisoner’s medical record was legible and maintained to a high standard.
67. The post mortem report indicated that the man had severe peripheral
vascular disease and severe ischaemic heart disease. The report
concluded that the stresses and strains of the operation may have
contributed to his death in that he suffered a cardiac arrest. Despite
attempts at resuscitation he died.
Findings and conclusions
68. The man entered prison with very serious health problems that were
identified and dealt with in a timely and appropriate fashion by the Prison
Service. The level of medical and nursing care afforded to the prisoner
was, according to the clinical review, of a good standard and equivalent
with the level of care he would have received in the wider community.
69. In the last months of his life, the prisoner developed critical ischaemia of
the lower limbs and, despite every effort, including advice to give up
smoking, his ulcers did not respond to treatment. In view of this
deterioration, the only course of action was surgery. This was undertaken
with the intention of improving the man’s mobility and giving him a better
quality of life. But despite surgery, the prisoner developed gangrene on the
toes of his left foot that necessitated amputation of the affected toes. The
man was expected to make a recovery from this operation and return to
Wymott. However, during post-operative recovery, the prisoner developed
breathing difficulties and in conjunction with his history of heart problems
he suffered a cardiac arrest and died.
70. The man died at the Royal Preston Hospital on the morning of 20 August.
Due to the distances involved the prison asked the West Midlands Police
to notify his next of kin. On arrival at the recorded address, the police
found that his nominated next of kin, the prisoner’s sister, had herself died
in March. The man had in fact attended her funeral in Birmingham under
escort from Wymott. Moreover, he had subsequently nominated his
brother-in-law as his next of kin after his sister’s death.
The Governor should ensure that contact details for next of kin are
checked regularly to ensure they are up to date and still current.
71. The other prisoners at Wymott were not told of the prisoner’s death for two
days. Some prisoners had overheard staff talking about it, leading to
uncertainty and possible confusion. If the media had chosen to report the
man’s death, there is every possibility they would have read it in the
newspaper or heard it on the radio first.
The Governor should remind staff that prisoners should be told of
the death of fellow prisoners in a timely manner to avoid confusion
and speculation.
Recommendations
1. The Governor should ensure that contact details for next of kin
are checked regularly to ensure they are up to date and still
current.
2. The Governor should remind staff that prisoners should be told of
the death of fellow prisoners in a timely manner to avoid
confusion and speculation.