Martin, Edward

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Edward Martin,
a prisoner at HMP Moorland, on
14 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
© Crown copyright, 2024
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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 HM 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 Edward Martin died of acute myocardial ischaemia (a reduction in the heart
muscle’s ability to pump blood around the body) caused by ischaemic heart disease
and severe coronary artery atheroma (a build-up of fatty material inside the
coronary arteries) in hospital on 14 April 2023, while a prisoner at HMP Moorland.
He was 70 years old. He also had a urinary tract infection which contributed to but
did not cause his death. I offer my condolences to those who knew him.
4. The clinical reviewer concluded that the clinical care Mr Martin received at Moorland
was of a good standard and was equivalent to that which he could have expected to
receive in the community.
5. After spending several months in hospital following a stroke, Mr Martin lived on a
specialist unit at Moorland where he was supported with comprehensive health and
social care. He was discussed at multi-disciplinary team meetings and reviewed by
GPs at Moorland.
6. The clinical reviewer has made a recommendation not directly related to Mr Martin’s
death which the Head of Healthcare will need to address.
Prisons and Probation Ombudsman 1
The Investigation Process
7. On 14 April, the PPO was notified that Mr Martin had died.
8. The investigator issued notices to staff and prisoners at HMP Moorland informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
9. The investigator obtained copies of relevant extracts from Mr Martin’s prison and
medical records.
10. NHS England commissioned a clinical reviewer to review Mr Martin’s clinical care at
the prison.
11. We informed HM Coroner for South Yorkshire East of the investigation. She gave
us the results of the post mortem examination. We have sent the Coroner a copy of
this report.
12. Mr Martin had no next of kin.
13. We shared the initial report with the Prison Service. There were no factual
inaccuracies.
Previous deaths at HMP Moorland
14. There have been twelve deaths from natural causes at Moorland in the three years
before Mr Martin’s’ death. There was also a drug related death. There are no
significant similarities between our findings in this investigation and those of the
other deaths.
2 Prisons and Probation Ombudsman
Key Events
15. On 24 January 2020, Mr Edward Martin was remanded to HMP Liverpool. On 19
August, he was sentenced to 14 years and three months in prison for sex offences.
On 26 October, Mr Martin was transferred to HMP Garth.
16. Mr Martin had high blood pressure and coronary heart disease (a type of heart
disease that is characterised by the narrowing or blockage of the coronary arteries).
He had a catheter (a flexible tube which is used to empty the bladder and collect
urine) fitted in September 2022, due to an enlarged prostate gland. He also had
anxiety and depression.
17. On 20 November 2022, healthcare staff sent Mr Martin to hospital because they
thought that he may have had a stroke. Hospital staff reached the same conclusion,
and Mr Martin remained in hospital until 20 December.
18. On 21 December, a nurse saw Mr Martin because he said that he had chest pain
going into his left arm and back. She carried out an electrocardiogram (ECG- a test
to look at the heart’s electrical activity and rhythm) which was inconclusive, so she
sent him back to hospital. Mr Martin returned to Garth the same day.
19. On 25 December, a nurse saw Mr Martin because he said that he had taken an
overdose of all his medication. She sent him to hospital, where he was admitted. On
29 December, Mr Martin had a significant stroke, which meant he was left with
limited mobility. He remained in hospital receiving treatment for over two months.
The clinical reviewer found that there is no connection between a medication
overdose and a stroke.
20. On 13 March 2023, Mr Martin was transferred from hospital to the Intermediate
Care Rehabilitation Service (ICRS – a rehabilitation unit for the Yorkshire and
Humber region which provides 24-hour healthcare cover) at HMP Moorland.
21. An occupational therapist saw Mr Martin and saw that he was able to eat and drink
but was unable to mobilise and unable to independently get off the bed. He found
that Mr Martin required full assistance with washing, dressing and continence care.
He arranged for Mr Martin to be provided with a hoist and sling to transfer to a chair
and commode, a pressure relieving mattress, a slide for turning and repositioning
and an automated lateral turning system which enabled Mr Martin to be turned at
prescribed intervals, even during sleep.
22. On 14 March, a nurse created care plans for Mr Martin’s complex needs.
23. On 13 April, a nurse saw Mr Martin because he was unwell and had vomited. She
noted that his National Early Warning Score (NEWS, a tool to detect and respond to
clinical deterioration) was 15, which indicated a high clinical risk. She sent Mr Martin
to hospital by ambulance.
24. On 14 April, after Mr Martin’s health very rapidly deteriorated, he died in hospital.
Post-mortem report
Prisons and Probation Ombudsman 3
24. A post-mortem examination established that Mr Martin died of acute myocardial
ischaemia (a reduction in the heart muscle’s ability to pump blood around the body),
caused by ischaemic heart disease (the blood vessels supplying the heart are
narrowed or blocked) and severe coronary artery atheroma (a build-up of fatty
deposits on the walls of the arteries around the heart). He also had a urinary tract
infection (an infection of the bladder, kidneys and the tubes connected to them)
which contributed to but did not cause his death.
Inquest
25. At an inquest held on 15 February 2024, the Coroner concluded that Mr Martin died
from natural causes.
4 Prisons and Probation Ombudsman
Findings
Clinical care
26. The clinical reviewer concluded that the clinical care Mr Martin received at
Moorland was of a good standard and was equivalent to that which he could have
expected to receive in the community.
27. At Moorland, Mr Martin lived in the ICRS unit, where he was supported with
comprehensive health care and social care. He was discussed at multi-disciplinary
team meetings and reviewed by GPs at Moorland.
28. The clinical reviewer has made a recommendation not directly related to Mr
Martin’s death which the Head of Healthcare will need to address.
Adrian Usher
Prisons and Probation Ombudsman November 2023
Prisons and Probation Ombudsman 5
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