White, Lenford

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Lenford White,
a prisoner at HMP Manchester,
on 19 March 2020
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
© 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 Lenford White died in hospital on 19 March 2020 of small intestine failure, while a
prisoner at HMP Manchester. This was caused by surgical complications for the treatment
of an inflammation of the lining of the abdominal wall. He also had prostate cancer and
heart disease, which did not cause but contributed to his death. Mr White was 65 years
old. I offer my condolences to his family and friends.
The clinical reviewer found that the clinical care that Mr White received at Manchester was
not equivalent to that which he could have expected to receive in the community. I am
concerned that Mr White’s missed hospital urology appointment just before he went to
prison was not identified when he arrived at HMP Forest Bank, nor when he later
transferred to HMP Manchester. I am also concerned that staff at Manchester did not
notify Mr White’s next of kin when he became seriously ill and was admitted to hospital in
August 2019.
Our investigation has been delayed for various reasons arising from the COVID-19
pandemic. I am sorry for the additional distress this is likely to have caused Mr White’s
family.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman July 2022
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
Summary
Events
1. On 17 August 2018, Mr Lenford White was remanded to HMP Forest Bank, charged
with sex offences. He had missed a scheduled urology appointment for an
ultrasound prostate scan in the community a few days earlier.
2. On 15 November, he was sentenced to 10 years in prison and sent to HMP
Manchester. Healthcare staff at Forest Bank and Manchester did not identify the
outstanding appointment when they completed initial health screens.
3. In May 2019, Mr White was admitted to hospital twice, both times for urinary
infections. During the second admission on 21 May, Mr White became increasingly
unwell, and a scan of his stomach identified a small bowel obstruction. He had
surgery to remove it.
4. On 12 June, Mr White returned to Manchester. His discharge summary noted that
he had prostate cancer.
5. On 15 July, when Mr White attended hospital for a routine appointment, a nurse
noted that he seemed unaware that he had prostate cancer. The nurse completed
prostate cancer blood tests and arranged a follow-up appointment. Mr White was
unable to attend this appointment because he had been readmitted to hospital.
6. On 15 August, Mr White attended a scheduled hospital appointment for blood tests,
and was admitted to hospital because his blood test results showed that he had
kidney failure and prostate cancer.
7. He remained in hospital, where he died on 19 March 2020 as a result of small
intestine failure caused by complications of surgical treatment.
Findings
8. The clinical reviewer concluded that the care Mr White received at Manchester was
not equivalent to that which he could have expected to receive in the community.
9. Forest Bank and Manchester failed to identify that Mr White had an outstanding
urology appointment which he should have attended just before he was taken into
custody. This potentially contributed to longer term uncertainty about his prostate
cancer diagnosis.
10. The clinical reviewer made several recommendations about healthcare
administration which the Head of Healthcare will need to address.
11. We are concerned that Manchester did not inform Mr White’s next of kin when he
became seriously ill and was admitted to hospital in August 2019.
12. Mr White’s next of kin was concerned that the prison suddenly prohibited family
meals that were taken to him in hospital after his surgery in May 2019. Although we
found no evidence that Manchester stopped Mr White’s family taking meals to him,
we are satisfied that doing so would have been in line with Manchester’s local
security policy.
Prisons and Probation Ombudsman 1
Recommendations
• The Heads of Healthcare for Forest Bank and Manchester should ensure that a
dedicated clinician updates SystmOne with a summary of all information about
newly arrived prisoners, recording appropriate diagnoses, community
appointments and GP updates.
• The Governor of Manchester should ensure that staff notify a prisoner’s next of kin
as soon as possible if he becomes seriously ill and is admitted to hospital, and that
the local family liaison policy reflects this position in line with Prison Rule 22.
2 Prisons and Probation Ombudsman
The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Manchester informing
them of the investigation and asking anyone with relevant information to contact
him/her. No one responded.
14. The investigator did not visit HMP Manchester due to the COVID-19 pandemic.
She obtained copies of relevant extracts from Mr White’s prison and medical
records.
15. NHS England commissioned a clinical reviewer to review Mr White’s clinical care at
the prison. The clinical reviewer conducted joint interviews with the investigator via
video link on 3 June 2020.
16. We informed HM Coroner for Manchester of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
17. Our family liaison officer contacted Mr White’s daughter to explain the investigation
and to ask if she had any matters she wanted us to consider. She asked for a copy
of our report. She also asked about the care Mr White received in relation to his
prostate cancer and about family visits. We have addressed her questions in this
report and in the clinical review where they fall within the PPO’s remit. We have
explained that the care Mr White received in hospital is outside the PPO’s remit and
questions about this should be directed to the hospital.
18. Mr White’s daughter received a copy of the draft report. They did not make any
comments.
19. 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.
Prisons and Probation Ombudsman 3
Background Information
HMP Manchester
20. HMP Manchester is a high security and training prison and holds up to 750
prisoners. Greater Manchester Mental Health NHS Foundation Trust provides
primary care and mental health services.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Manchester was in June and July 2018.
Inspectors reported that there had been a deterioration for most ‘healthy prison’
outcomes since their last inspection in 2014. However, the inspectors noted that
interactions between healthcare staff and prisoners were professional, and clinical
records and care plans were very good. They noted that continuity of care was also
good, with most locum GPs and agency nurses working at the prison regularly.
They also noted that a dedicated nurse provided annual health checks and age-
related screening.
Independent Monitoring Board
22. 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 the year to February 2020, the IMB reported
that Manchester delivered an excellent healthcare service to prisoners.
Previous deaths at HMP Manchester
23. Mr White was the thirteenth prisoner to die at Manchester since March 2018. Of
those deaths, seven (including Mr White’s) were from natural causes, four were
self-inflicted, one was drug-related and the cause of one death was unascertained.
There are no similarities between our findings in the investigation of Mr White’s
death and those of the previous deaths.
24. Since Mr White died, there have been nine more deaths at Manchester, six from
natural causes, one drug-related, one self-inflicted and the cause of another was
unascertained.
4 Prisons and Probation Ombudsman
Key Events
25. On 17 August 2018, Mr Lenford White was remanded to HMP Forest Bank, charged
with sexual offences. A nurse completed his initial health screen. She recorded his
history of osteoarthritis (a condition that causes joint pain) and that he had had
urinary retention (a sudden inability to pass urine).
26. On 15 November, Mr White was sentenced to ten years in prison and transferred
from Forest Bank to HMP Manchester. A nurse completed his initial health screen.
Mr White said that he had had urinary retention. He declined a secondary health
screen but was seen in the prison’s over-50s clinic on 4 January 2019.
Physical health
27. The day after Mr White’s arrival at Manchester, healthcare staff sent a letter Mr
White’s community GP practice requesting a summary of his community medical
record. The GP practice replied with a summary of Mr White’s significant medical
history and included a letter from the urology department at Manchester Royal
Infirmary dated 31 July. The letter said Mr White had experienced an episode of
acute urinary retention. It noted that he had been temporarily catheterised (a
procedure to drain urine into an attached collection bag). While being treated for
urinary retention, it was identified that he had a nodular (lumpy) prostate gland. He
was given an appointment at the hospital’s urology clinic for blood tests and an
ultrasound scan to test for prostate cancer. Mr White was also prescribed
tamsulosin, a medicine to help with prostate problems. The GP practice noted that
days before he went to prison, Mr White had not attended his scheduled urology
appointment on 14 August.
28. On 20 November, a prison GP reviewed the community medical history summary
and referred Mr White to hospital to review his arthritis. However, no one identified
or followed up the proposed investigations for prostate cancer. The GP told the
investigator that there was no standard approach to identifying missed community
appointments for new prisoners or new diagnoses that a prisoner received in
hospital when they returned to prison.
29. The prison GP said she did not recall Mr White’s case due to the passage of time
but that she usually reviewed the month or two before a prisoner’s arrival at the
prison and chased up anything that was missing within that timeframe. She said
that prison GPs generally assumed that prisoners had the mental capacity to inform
healthcare staff of any outstanding community appointments.
30. On 3 January 2019, a prison GP reviewed Mr White because he had symptoms of
urinary urgency (a sudden and urgent need to pass urine) and dysuria (pain,
burning or discomfort when passing urine). The GP prescribed antibiotics for a
urinary tract infection.
31. On 17 January, Mr White attended a GP consultation with a prison GP. His
osteoarthritis and anti-inflammatory medication were discussed and changed from
naproxen to ibuprofen. He was also prescribed omeprazole (a medication that
protects the lining of the stomach from becoming irritated through taking regular
Prisons and Probation Ombudsman 5
anti-inflammatory medication). The GP requested blood tests to check Mr White’s
general blood count, cholesterol levels and liver and kidney function.
32. On 29 January, Mr White attended a routine NHS health check in prison.
33. On 7 February, a prison GP reviewed the results of Mr White’s health check and
noted his cholesterol was high and that his liver and kidney function results were
slightly outside the normal range. He recorded he discussed Mr White’s blood
results with him and that he needed to repeat blood tests in a few months. Mr
White had repeat blood tests in February, March and April to check his liver and
kidney functions.
Hospital admission – 2 May
34. On 2 May, a prison GP reviewed Mr White because he had urinary symptoms
again. This time, he also had worsening abdominal pain, a swollen abdomen and
bladder, and was unable to retract his foreskin. He arranged for him to go to
hospital straightaway, where he was treated with oral antibiotics and was
catheterised. The next day, Mr White was discharged from hospital and returned to
prison with a catheter in place.
35. On 7 May, Mr White complained that the catheter was rubbing against his foreskin,
causing soreness. A prison GP reviewed him. Mr White told him about his recent
hospital visit but that he did not know about his treatment plan. The GP asked
administrative staff to chase up Mr White’s hospital discharge letter.
36. Mr White’s hospital discharge letter explained that he was catheterised and given
oral antibiotics. The letter did not mention symptoms caused by problems with the
prostate gland and it said a follow-up was not needed. Mr White’s prison medical
record about his return to Manchester is very brief, with no reference to a catheter
nor any catheter care plan.
Hospital admission – 21 May
37. On 20 May, a prison nurse removed Mr White’s catheter, without difficulty. Later, at
10.41pm, prison staff informed healthcare staff that he was in pain. At 1.05am the
next day, prison staff told healthcare staff that Mr White was sweating and wanted
to go to hospital. At 1.45am, a nurse saw Mr White in his cell. He told her that he
had not passed urine since his catheter was removed the previous day. She
recorded Mr White’s vital signs and noted that his National Early Warning Score
(NEWS2, a tool to detect and respond to clinical deterioration) was 1, indicating a
low clinical risk and arranged for a prison GP to review Mr White the following
morning.
38. On the morning of 21 May, a prison GP reviewed Mr White and noted his abdomen
was tender and his bladder distended. The GP sent him to hospital straightaway for
re-catheterisation. At hospital, Mr White was treated for a urinary infection. He
became increasingly unwell with a raised temperature, disorientation and confusion.
A CT scan of Mr White’s abdomen showed that he had a small bowel obstruction
for which he had surgery on 23 May.
6 Prisons and Probation Ombudsman
39. While in hospital, Mr White developed supraventricular tachycardia (an extremely
fast heart rate) and was transferred to the coronary care unit for monitoring. He
was given adenosine, an intravenous drug to slow his heart rate. He also
developed a sub-splenic collection (a collection of fluid between the spleen and the
left kidney) which was treated with intravenous fluids and antibiotics.
40. Mr White’s daughter said that after his surgery in May, his family took him meals to
help his recovery. She said that the prison stopped this suddenly, without
explanation.
41. On 12 June, Mr White returned to Manchester, with a small surgical wound. His
discharge summary noted that he had prostate cancer. It was also noted that a
cystoscopy (a procedure to examine the inside of the bladder) had been arranged,
as well as a follow-up appointment with the general surgical team.
42. On 15 July, Mr White attended hospital for his cystoscopy. A Macmillan urology
nurse specialist also completed prostate cancer blood tests as she had noted that a
previous discharge letter said that Mr White had prostate cancer. (Mr White
seemed unaware of this.) She arranged an outpatient, follow-up appointment for
two to four weeks’ time. She wrote to prison GPs informing them of the tests and
follow-up plan. However, Mr White was unable to attend the follow-up appointment
because he was re-admitted to hospital on 15 August.
43. Between 15 July and his readmission to hospital on 15 August, Mr White’s medical
record shows that he continued to report difficulty in passing urine and was only
passing small amounts. Records show that although Mr White’s surgical scar was
dressed frequently, a scar lesion formed. Mr White had abdominal pain and dysuria
and in July, his scar began to open. Healthcare staff continued to dress his scar
and examine him.
44. On 29 July, a Healthcare Assistant (HCA) saw Mr White and noted his difficulty
passing urine, constipation and abdominal pain. A prison GP reviewed him and
recorded that he had had these symptoms for a week. Mr White’s urine was tested
and found to contain white blood cells and blood, indicating a possible urine
infection. The GP prescribed antibiotics and noted Mr White’s upcoming urology
and general surgery appointments. He also recorded that he should be medically
reviewed if he became unwell or his condition worsened.
45. On 5 August, the HCA saw Mr White again and noted that he had abdominal pain,
that liquid was coming out of his surgical scar and he had a burning sensation when
passing urine. She noted that he was due to see a prison GP. A prison GP
reviewed Mr White and recorded that the consultation focussed on a lump on Mr
White’s thigh and his urinary symptoms were not discussed.
46. On 9 August, Mr White complained of pain and difficulty passing urine. A nurse
booked a GP review for the next day and noted that Mr White’s NEWS2 was 1,
indicating a low risk of clinical deterioration. Mr White did not see a doctor the next
day because there were no officers available to take him to the healthcare
department. On 12 August, a prison GP recorded in Mr White’s medical record that
neither nursing staff nor Mr White had raised concerns over the weekend.
Prisons and Probation Ombudsman 7
15 August 2019 – 19 March 2020
47. On 15 August, Mr White attended a scheduled hospital appointment for blood tests,
after which he went back to Manchester. Later that day, the hospital requested Mr
White return to hospital because of his blood test results. He travelled to hospital
by ambulance, unrestrained and escorted by two officers.
48. At 10.14pm, it was recorded that Mr White had been re-admitted to hospital
because he had kidney failure. It was also recorded that his blood test results
suggested he had prostate cancer and that urgent scans were being arranged.
49. Between 22 November and 4 December, Mr White was managed under suicide and
self-harm prevention procedures because he kept removing his stoma (an opening
in the abdomen with a bag over it to collect faeces) which caused hospital staff
serious concern. ACCT procedures were closed on 4 December.
50. Mr White remained in hospital, where he died on 19 March.
Contact with Mr White’s family
51. Mr White’s daughter and her uncle had scheduled a visit to see Mr White in hospital
on 19 January 2020. She told us that when they arrived, an officer and a nurse told
them that Mr White was no longer allowed visitors and a visit was not scheduled.
52. On 16 February, Manchester appointed a family liaison officer (FLO) as Mr White’s
health had deteriorated and the usual family liaison officer was away. She
contacted Mr White’s daughter that day, told her about Mr White’s deterioration and
arranged to meet her at hospital. Mr White’s daughter told her that the hospital had
informed her on 14 February that Mr White had advanced prostate cancer. She
asked her if the prison healthcare team also knew, when was he diagnosed and
why she, as his next of kin, had not been informed sooner. The FLO explained that
she was unable to discuss Mr White’s health with her for confidentiality reasons and
that she should speak to hospital staff about his health. She also told her that she
would check with the prison’s Head of Healthcare for them to speak to her.
53. On 17 February, the FLO noted in the family liaison log that she had informed Mr
White’s daughter that the 19 January visit had been cancelled for medical reasons
because a hospital nurse had said that Mr White had an infection and was not
allowed visits as he risked infecting others. The nurse had said that visits could be
reassessed once Mr White had moved to another ward.
54. Just after Mr White’s death, hospital staff telephoned his daughter and broke the
news of his death to her. The FLO travelled to hospital and met Mr White’s
daughter and extended family. She offered her condolences and support.
55. The prison contributed to the costs of the funeral in line with national instructions.
Support for prisoners and staff
56. The prison posted notices informing other prisoners of Mr White’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 White’s death.
8 Prisons and Probation Ombudsman
Post-mortem report
57. The post-mortem report established that that Mr White died from small intestine
failure. This was caused by complications of surgical treatment for an intra-
peritoneal inflammatory collection (an inflammation of the lining of the abdominal
wall). He also had prostate cancer and coronary artery atheroma (a build-up of fatty
deposits and plaque on the walls of the arteries around the heart) which did not
cause but contributed to his death.
Prisons and Probation Ombudsman 9
Findings
Clinical care and cancer diagnosis
58. The clinical reviewer found that the overall care that Mr White received at
Manchester was not equivalent to that which he could have expected to receive in
the community. She found that despite a number of identified examples of good
practice, Mr White’s outstanding urology appointment was not identified when he
arrived at Forest Bank nor when he transferred to Manchester. She said that,
although this did not lead directly to his death, it might have contributed to a longer
term uncertainty about his prostate cancer diagnosis. We make the following
recommendation:
The Heads of Healthcare for Forest Bank and Manchester should ensure that
a dedicated clinician updates SystmOne with a summary of all information
about newly arrived prisoners, recording appropriate diagnoses, community
appointments and GP updates.
59. Although not directly related to Mr White’s death, the clinical reviewer also made
several recommendations about improving healthcare administration, which the
Head of Healthcare will need to address.
Contact with Mr White’s family
60. Prison Rule 22 says that when a prisoner becomes seriously ill, the Governor
should “at once inform the prisoner’s spouse or next of kin”. This is reflected in PSI
64/2011, which requires prisons to contact the next of kin of prisoners who are
seriously ill.
61. On 15 August 2019, Mr White was admitted to hospital because he had grossly
abnormal blood results, which suggested he had prostate cancer. Despite this, the
prison did not inform Mr White’s daughter that he was in hospital. She only found
out by chance on 6 September when she went to visit him in prison, and he was not
there. We are very concerned that the prison told her that it would not normally
inform a prisoner’s family for at least seven days after hospitalisation. This is not in
line with Prison Rule 22.
62. We are even more concerned that Manchester had still not told her that he was in
hospital three weeks’ after he was admitted. Again, this is not in line with the
requirements of Prison Rule 22. Although we note from the family liaison log that
prison staff apologised to Mr White’s daughter for her wasted visit to the prison on 6
September, this could have been avoided if the prison had contacted her on 15
August when he was admitted to hospital. They could then have cancelled the
prison visit booked for 6 September and arranged for a hospital visit instead.
63. We make the following recommendation:
The Governor of Manchester should ensure that staff notify a prisoner’s next
of kin as soon as possible if he becomes seriously ill and is admitted to
hospital, and that the local family liaison policy reflects this position in line
with Prison Rule 22.
10 Prisons and Probation Ombudsman
Meals
64. Mr White’s daughter said that after Mr White’s surgery in May, his family took him
meals to help his recovery. She said that the prison stopped this suddenly, without
explanation.
65. The investigator found no record of family meals being stopped suddenly and asked
Manchester for a copy of its policy on food when prisoners are in hospital. Security
measures during hospital visits are generally very similar to those in place for prison
visits. Manchester’s local security strategy in such situations says, “Visitors may
not bring any items with them to hand to the prisoner during a visit on a bedwatch.
All food must be provided by the hospital canteen and products can be purchased
by the visitors for their own consumption. All toiletries must be provided for
personal use by the prisoner, prison and or hospital small items such as get well
cards, etc. may be left for the prisoner (to be searched by staff) but no other
property must be handed over to the prisoner during the visit.”
66. We found no record that Manchester stopped the family bringing meals for Mr
White. However, doing so would have been in line with prison security policy and
we make no recommendation.
Inquest
67. The inquest, held on 3 May 2023, gave a narrative conclusion. It said, "Mr Lenford
Lloyd White was admitted to North Manchester General Hospital on the 15 August
2019 due to abdominal discomfort. Complications during surgery, multiple co-
morbidities and difficulties to maintain nutrition led to bronchopneumonia, which
ultimately caused the death of Mr White."
Prisons and Probation Ombudsman 11
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