Keene, David

Independent investigation into
the death of Mr David Keene,
a prisoner at HMP Swaleside,
on 6 August 2022
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
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.
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 His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit if appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Mr David Keene died in hospital on 6 August 2022 of extensive metastatic
carcinoma (cancer which has spread around the body) caused by renal cell
carcinoma (kidney cancer) while a prisoner at HMP Swaleside. He was 64 years
old. We offer our condolences to Mr Keene’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Keene received at
Swaleside was equivalent to that which he could have expected to receive in the
community. She made three recommendations which did not directly affect Mr
Keene’s death but will need to be addressed by the Head of Healthcare.
5. We were concerned that the risk assessment to consider the level of restraints for
Mr Keene when he went to hospital on 20 July 2022 was not completed by
healthcare staff. It was also not considered by an authorising manager. The
decision to restrain Mr Keene was not justified given his terminal cancer diagnosis
and deteriorating health.
6. Swaleside did not provide the investigator with all the documentation about the use
of restraints when Mr Keene was in hospital, which meant that we could not
determine whether the decision-making process on those occasions was
appropriate.
Recommendations
• The Governor and the Head of Healthcare should ensure that all staff
undertaking risk assessments for prisoners taken to hospital understand the
legal position on the use of restraints and that in all cases:
• healthcare staff complete the medical information section of the escort
risk assessment to say whether the prisoner’s current medical
condition affects their mobility and risk of escape; and
• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk.
Prisons and Probation Ombudsman 1
The Investigation Process
7. NHS England and NHS Improvement (NHSE&I) commissioned an independent
clinical reviewer, to review Mr Keene’s clinical care at HMP Swaleside.
8. The PPO investigator investigated the non-clinical issues relating to Mr Keene’s
care.
9. Mr Keene did not have any nominated next of kin.
Previous deaths at HMP Swaleside
10. Mr Keene was the 16th prisoner to die at Swaleside since August 2020. There have
been six since. Of the previous deaths, eight were from natural causes, six were
self-inflicted and one was a drugs death.
11. In two previous investigations, Swaleside did not provide the PPO with all of the
evidence we had requested to progress our investigation and made
recommendations to the Governor as a result. In December 2022, Swaleside said
that relevant staff had received additional training to ensure that they fully
understood which evidence needed to be collected for an investigation. Swaleside
also said that a new member of staff would lead on actions following a death and
ensure the PPO received all of the evidence required.
2 Prisons and Probation Ombudsman
Key Events
12. On 22 August 2018, Mr David Keene was remanded in custody for sex offences. He
was later sentenced to 21 years in prison. In June 2020, he was transferred to HMP
Swaleside.
13. On 2 March 2021, Mr Keene received a diagnosis of metastatic melanoma (skin
cancer which spreads around the body) and clear cell sarcoma of the right kidney
(kidney cancer). Two days later, he refused any further investigations or treatment.
He was deemed to have the mental capacity to make this decision and referred to
the GP for review.
14. On 25 May, a nurse saw Mr Keene with a member of the mental health in-reach
team to carry out a mental capacity assessment. The nurse noted that the in-reach
worker determined that he had the capacity to refuse medical treatment.
15. On 15 June, Mr Keene said he did not with anyone to resuscitate him if his heart or
breathing stopped and signed an order to that effect.
16. On 17 July 2022, a nurse saw Mr Keene as part of the care plan for his illness. She
noted that he was in pain all the time and seemed to have deteriorated. She
completed his clinical observations however she did not record a National Early
Warning Score (NEWS). (NEWS2 is a tool to detect and respond to clinical
deterioration. A score above 7 indicates the need for an emergency response.) She
discussed his disease progression with him, and he stated that he would like to die
in a hospice. She agreed to refer him to a hospice, which she did the same day.
17. On 18 July 2022, a nurse saw Mr Keene to complete a welfare check. She noted
that Mr Keene wanted to stay on the wing until he got accepted into a hospice and
that he was still in pain despite medication. She did not record a NEWS.
18. On 20 July, a nurse reviewed Mr Keene with a hospice palliative specialist nurse
and a hospital palliative nurse because his condition had deteriorated. They noted
that he had a swollen stomach and swelling to his feet. They advised admission to
the hospital. The nurse spoke to a GP at Swaleside and asked him to review Mr
Keene that afternoon to make a decision about going to hospital.
19. Later that day, a nurse and a prison GP saw Mr Keene. They completed clinical
observations but did not complete a NEWS. The GP requested that Mr Keene was
sent to hospital for an abdominal scan. He was transferred to the inpatient
healthcare unit at Swaleside whilst they awaited the escort to hospital.
20. Before Mr Keene went to hospital, prison staff completed an escort risk
assessment. Healthcare staff did not complete the medical section (which provides
information on the prisoner’s existing health concerns, their mobility and whether
there are any medical reasons why restraints should not be applied) which
remained blank. A security intelligence collator completed the security risk
assessment and noted that Mr Keene was low risk of hostage taking and escape
and was a low risk to hospital staff and the victim of his offences. He recorded that
he was medium risk to the public and to females. He advised that Mr Keene was to
be escorted by two officers and restrained for the escort using double cuffs and an
Prisons and Probation Ombudsman 3
escort chain. Double cuffing is when the prisoner’s hands are handcuffed in front of
them, and one wrist is attached to a prison officer by an additional set of handcuffs.
An escort chain is a long chain with a handcuff at each end, one of which is
attached to the prisoner and the other to an officer. He advised that the restraints
should not be removed for medical treatment and that the prison should be
contacted in all circumstances that removal of the restraints might be considered.
No authorising governor signed off the risk assessment to authorise the use of
restraints.
21. At 2.20am, on 21 July, officers at Mr Keene’s bedside removed his restraints to
undergo a CT scan. The restraints were replaced after the scan. At this stage it was
noted that Mr Keene was not double cuffed but that the escort chain was in use.
22. At 10.51pm, Officer A, who was with Mr Keene, called the prison to ask if he could
get permission to remove the double cuff from Mr Keene. No one was available to
answer the question and he did not receive a call back. He tried calling again at
11.11pm. It is not clear when the double cuff had been put back on before this call.
23. At 12.27am on 22 July, Officer A spoke to the duty manager in charge of the prison
who refused the removal of the cuff stating that the risk assessment would be
reviewed the next day.
24. At 2.30pm, a Custodial Manager (CM) spoke to the Head of Residence, who agreed
that the restraints could be reduced to an escort chain until Mr Keene returned to
Swaleside. There is no risk assessment documentation to support this decision.
25. On 22 July, hospital doctors gave Mr Keene a life expectancy of 2 weeks.
26. At 2.35am on 25 July, two officers were sitting by Mr Keene’s bedside. Officer B
reported that Mr Keene had abruptly woken up and pulled on the escort chain in a
violent manner. He warned Mr Keene to ‘behave well’ and told him that if he did not,
he would call the prison to get permission to reapply the double cuffs. He reported
that Mr Keene calmed down.
27. At 5.00am, Officer B reported that Mr Keene had deliberately attempted escape by
slipping his cuff halfway down his hand. He called the prison and spoke to a CM,
who gave permission to put the double cuff restraint back on.
28. On 26 July, a CM competed a management check and noted that Mr Keene
remained compliant and that, due to his illness and current condition he felt it was
appropriate to remove the escort chain. It is not clear when the double cuffs had
been removed prior to this and the escort chain reapplied. The CM authorised that
Mr Keene was no longer restrained. He remained unrestrained until he died. There
is no risk assessment documentation to support this decision.
29. On 6 August Mr Keene collapsed in the bathroom at the hospital and died.
Post-mortem report
30. The post-mortem report concluded that Mr Keene died of extensive metastatic
carcinoma caused by renal cell carcinoma.
4 Prisons and Probation Ombudsman
Clinical Findings
Clinical care
31. The clinical reviewer found that the care that Mr Keene received at Swaleside was
of the standard he could reasonably have expected to receive in the community.
She identified a number of points of good practice which included an assessment of
Mr Keene’s mental capacity in relation to his refusal of cancer treatment, good
communication between the healthcare team and the hospital, consistent and
regular support for Mr Keene alongside continuity of care, an understanding of his
end of life wishes and good record keeping.
32. She made four recommendations, three of which were not related to Mr Keene’s
death and the Head of Healthcare will need to address separately.
33. The clinical reviewer was concerned about the lack of healthcare input into the
escort risk assessment when Mr Keene went to hospital on 20 July. This is
addressed below in this report.
34. She was also concerned that Swaleside did not consistently use the NEWS2
system to identify deteriorating patients at the time of Mr Keene’s death. She
identified that NEWS2 scoring was not a part of the standard clinical template that
Swaleside were using at the time. However, she did not make a formal
recommendation as the Head of Healthcare has confirmed that they are now using
NEWS2 scoring templates regularly.
Non-Clinical Findings
Restraints, security, and escorts
35. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
36. Mr Keene was restrained during the escort to hospital on 20 July using a double
cuff and an escort chain. He remained restrained until 26 July, however it was not
always clear at which times the decision to change from one form of restraints to
another was made, or at what time the restraints changed.
37. When he went to hospital on 20 July, the medical section of the risk assessment
was not completed. The security section was completed advising the level of
cuffing, however there was no authorising managers decision recorded on the
Prisons and Probation Ombudsman 5
assessment. We are therefore unable to confirm whether the decision to restrain Mr
Keene on 20 July was appropriately considered or not. Public protection is
fundamental, but security measures must be proportionate to a prisoner’s individual
circumstances.
38. On 25 July Officer B perceived Mr Keene’s actions as an attempted escape and
telephoned the prison for approval to apply double cuffs again. There is no record of
this being considered as a serious risk of escape after this point as the following
day a CM made the decision to remove the restraints altogether. Despite requests,
Swaleside did not provide any risk assessments which supported a change in the
level of restraints after 20 July. This meant that we were unable to fully consider
whether decisions about the level of restraints used on Mr Keene were appropriate.
39. Mr Keene was a terminally ill patient who was told on 22 July that he had just two
weeks to live. He was very unwell, and his condition was deteriorating. He had no
next of kin, which reduced the risk of outside assistance to escape. He was
escorted by two officers. We consider that the application of double cuffs and an
escort chain from 20 to 26 July was disproportionate to the risks Mr Keene posed.
We make the following recommendations:
The Governor and the Head of Healthcare should ensure that all staff
undertaking risk assessments for prisoners taken to hospital understand the
legal position on the use of restraints and that, in all cases:
• healthcare staff complete the medical information section of the escort
risk assessment to say whether the prisoner’s current medical
condition affects their mobility and risk of escape; and
• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk.
Governor to note
40. PSI 58/2010 requires prisons to provide evidence to the Ombudsman’s office for the
purpose of our investigation. Despite requests, Swaleside did not supply all the risk
assessment documentation to the investigator which hampered our investigation.
41. In December 2022, following recommendations made by the PPO, Swaleside said
that relevant staff had received additional training to ensure that they fully
understood which evidence needed to be collected for an investigation. Swaleside
also said that a new member of staff would lead on actions following a death and
ensure the PPO received all of the evidence required. Given that these actions
came after Mr Keene’s death, and to allow time for them to embed, we make no
recommendations, but the Governor will want to assure himself that processes to
cooperate with PPO investigations are robust.
Inquest Verdict
42. The inquest into the death of Mr Keene was held on 11 October 2023. It confirmed
that the medical cause of Mr Keene’s death was extensive metastatic carcinoma
6 Prisons and Probation Ombudsman
caused by renal cell carcinoma. It concluded that Mr Keene died from natural
causes.
Adrian Usher
Prisons and Probation Ombudsman October 2023
Prisons and Probation Ombudsman 7
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