Tuckwell, Peter

Independent investigation into
the death of Mr Peter Tuckwell,
a prisoner at HMP Oakwood,
on 13 February 2021
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 is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Mr Peter Tuckwell died in hospital on 13 February 2021 from COVID-19 pneumonia
while a prisoner at HMP Oakwood. He was 71 years old. I offer my condolences to
Mr Tuckwell’s family and friends.
4. The clinical reviewer concluded that the overall clinical care Mr Tuckwell received at
Oakwood was equivalent to that which he could have expected to receive in the
community.
5. However, the clinical reviewer was concerned that there was a four week delay in
December 2020/January 2021 before a prison GP told Mr Tuckwell that he had type
2 diabetes and that he was therefore at an increased risk of becoming seriously ill if
he contracted COVID-19. She concluded that this aspect of Mr Tuckwell’s care was
not equivalent to that which he could have expected to receive in the community.
She made one recommendation which we repeat below.
6. We found that the decision to send Mr Tuckwell to hospital single cuffed with an
escort chain was not justified given his poor health. We consider this also placed
an escort officer at greater risk of infection of being in close proximity to him.
7. We also found that the delay in telling Mr Tuckwell’s next of kin that he was in
hospital was not justified.
Recommendations
• The Head of Healthcare should ensure that any increase in health risk factors
relating to COVID-19 is flagged to the prisoner as soon as it is known.
• The Director and Head of Healthcare should ensure that:
• healthcare staff fully and accurately reflect the current health and mobility of a
prisoner when they complete an escort risk assessment;
• all staff undertaking risk assessments for prisoners taken to hospital
understand the legal position, and assessments fully take into account the
health of a prisoner and are based on the actual risk the prisoner presents at
the time.
Prisons and Probation Ombudsman 1
• The Director should ensure, in line with Prison Rule 22, that the next of kin of
seriously ill prisoners are informed as soon as possible when a prisoner is admitted
to hospital.
2 Prisons and Probation Ombudsman
The Investigation Process
8. NHS England commissioned an independent clinical reviewer, to review Mr
Tuckwell’s clinical care at HMP Oakwood. Her report is attached as Annex 1.
9. The PPO investigator investigated the non-clinical issues, including aspects of the
prison’s response to COVID-19 and shielding prisoners; Mr Tuckwell’s location; the
security arrangements for his journey and admission to hospital; liaison with his
family; and whether early release was considered.
10. The PPO family liaison officer wrote to Mr Tuckwell’s next of kin, his daughter, to
explain the investigation. She asked for full details of the events leading to Mr
Tuckwell’s death and raised several queries about Mr Tuckwell’s management and
care at Oakwood. We have addressed her questions in this report and the clinical
review.
11. Mr Tuckwell’s family received a copy of the initial report. They did not make any
comments.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
Previous deaths at HMP Oakwood
13. Mr Tuckwell was the 12th prisoner to die at Oakwood since February 2019. Of the
previous deaths, one was drug-related, one resulted from burns, and nine were
from natural causes (including two from COVID-19 in April and May 2020).
14. There have been four deaths since Mr Tuckwell’s death: one was drug-related and
three were from natural causes (including two COVID-19 related deaths).
15. This is the second time this year that we have made recommendations about the
inappropriate use of restraints at Oakwood. The prison told us in October 2021 that
they had reviewed the escort risk assessment process, given refresher training to
all clinical staff and communicated the message to prison staff through multiple
means.
Prisons and Probation Ombudsman 3
Background Information
COVID-19 (coronavirus)
16. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
17. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. In response to the
pandemic, HM Prison and Probation Service (HMPPS) introduced several
measures to try and contain outbreaks - to be implemented at local level, depending
on the needs of individual prisons. (A key strategy was ‘compartmentalisation’ to
cohort and protect prisoners at high and moderate risk; isolate those who are
symptomatic; and separate newly arrived prisoners from the main population.)
Other measures include social distancing and the use of personal protective
equipment (PPE).
4 Prisons and Probation Ombudsman
Key Events
18. On 11 February 2019, Mr Peter Tuckwell was sentenced to six years and three
months imprisonment for fraud. His sentence was reduced to four years and six
months on appeal. He was sent to HMP Hewell and then transferred to HMP
Oakwood on 23 July 2019.
19. At Mr Tuckwell’s reception screen at Oakwood, healthcare staff noted that he did
not suffer from any long term physical health conditions. He was obese and
healthcare staff advised him to lose weight.
2020
20. On 26 March 2020, Oakwood went into lockdown due to the COVID-19 pandemic
and implemented a special regime.
21. The same day, a member of the safer custody team conducted a welfare check and
explained the details of the special regime to Mr Tuckwell, as well as reminding him
to use his cell bell in the event of an emergency. Mr Tuckwell raised no issues.
22. On 28 April, a prison manager told Mr Tuckwell that healthcare staff had identified
him as being in the at risk group of contracting COVID-19 and he was offered a
separate regime. Mr Tuckwell said that he was aware of the risks but was managing
this as he was social distancing from others. He signed a disclaimer form confirming
that he had declined to shield.
23. On 14 May, Mr Tuckwell had a meeting with the prison manager after he had
written to the Director with concerns about the implications of the shielding
disclaimer form he had signed. After talking with the prison manager, Mr Tuckwell
confirmed that he did not wish to shield but would continue to social distance from
others. He signed another disclaimer form to confirm this.
24. On 3 September, Mr Tuckwell’s security categorisation was lowered from category
C to D. His transfer to open conditions was delayed because he requested a move
to an open prison in Scotland so that he could be closer to his family.
25. In September, Oakwood was in full lockdown with a restricted regime. Prisoners
were allowed out of their cells in small groups at a time to collect meals and
medication and for exercise.
26. On 5 September, Mr Tuckwell told an officer, his keyworker, that he was self-
isolating from everyone because he was at high risk due to his age. He said that he
thought he had COVID-19 already but healthcare staff had refused to allow him to
have a test. He said that until he had confirmation that he did not have COVID-19,
he would continue to self-isolate. However, the officer noted that after the meeting,
Mr Tuckwell joined other prisoners on the wing and went down to the servery to
collect his meal. Mr Tuckwell also told prison staff that he was minimising his
contact with others.
27. In October, all prisoners were issued with washable face masks and were required
to wear them at all times when out of their cell. On 23 October, Mr Tuckwell was
provided with a face covering.
Prisons and Probation Ombudsman 5
28. On 2 November, Mr Tuckwell took a COVID-19 test as part of a mass testing
programme at the prison. The result was negative. As a preventative measure he
self-isolated on 20 November because he had been exposed to someone who was
COVID-19 positive.
29. On 2 December, Mr Tuckwell complained of feeling unwell. Healthcare staff
arranged urine and blood tests and results showed that he had type 2 diabetes,
high cholesterol and a urine infection. A prison GP prescribed an antibiotic for the
infection and requested a face to face GP appointment to discuss the type 2
diabetes and cholesterol results.
Events from January 2021
30. On 4 January 2021, a prison GP discussed the blood and urine test results with Mr
Tuckwell. She prescribed statin medication for his cholesterol level. Mr Tuckwell
said that he did not want to take any diabetic medication and would manage his
condition through diet management and exercise. The GP arranged for repeat
blood tests and the results indicated abnormal levels for cholesterol and diabetes.
31. On 8 January, Mr Tuckwell told a nurse that he would not take any medication.
Despite repeated conversations with nurses, Mr Tuckwell refused to change his
mind and returned his medication to healthcare.
32. At approximately 6:40pm on 20 January, Mr Tuckwell fell over in his cell. He
shouted for assistance. An officer looked through his cell door and saw him on the
floor and radioed a code blue (a medical emergency code indicating that a prisoner
is unconscious or has breathing difficulties). A nurse checked his observations and
noted that Mr Tuckwell was pale and clammy, short of breath, had a high
temperature and his oxygen saturation levels were low. The nurse took a COVID-19
swab and sent it to hospital for assessment and then arranged for an ambulance to
take him to hospital.
33. Mr Tuckwell was taken to New Cross Hospital, Wolverhampton. He was escorted
by two prison officers who were wearing PPE. Mr Tuckwell was restrained using
single handcuffs and an escort chain.
34. In hospital, Mr Tuckwell tested positive for COVID-19.
35. On 21 January, the escort staff were given permission to remove the restraints.
Prison healthcare staff contacted the hospital daily for updates on Mr Tuckwell’s
condition.
36. On 22 January, Mr Tuckwell asked the escort staff to contact the prison and ask
them to tell his daughter that he was in hospital. The escort staff spoke to offender
management unit (OMU) staff at the prison who said that the security department
would complete the necessary checks to see if this was approved, and that after 36
hours Mr Tuckwell would be allowed to have the telephone number to make the call
to his daughter.
37. On 23 January, Mr Tuckwell asked the escorting staff if his daughter had been told
he was in hospital. The staff checked with the prison security department and they
said that staff in the safer custody unit would let them know.
6 Prisons and Probation Ombudsman
38. The same day, Mr Tuckwell’s daughter contacted the prison and asked about her
father’s wellbeing. A prison family liaison officer (FLO), called Mr Tuckwell’s
daughter back and told her that Mr Tuckwell had been in hospital since 20 January
and that he was not considered to be seriously unwell so they needed to get
consent from prison managers to agree that she could contact him. The FLO gave
Mr Tuckwell’s daughter the hospital contact details and told her to call the hospital
for an update on his health.
39. The FLO offered support as Mr Tuckwell’s condition deteriorated in hospital.
40. On 24 January, Mr Tuckwell was moved to the hospital’s intensive care unit and
was placed on a CPAP machine to support his breathing. On 28 January, he was
placed on life support as he was critically ill. Prison healthcare staff were told that
Mr Tuckwell’s prognosis was very poor.
41. Mr Tuckwell’s life support was switched off and at 1.50pm on 13 February, a
hospital doctor confirmed that Mr Tuckwell had died.
Post-mortem report
42. The Coroner accepted the cause of death provided by hospital clinicians and no
post-mortem examination was carried out. The hospital clinicians gave Mr
Tuckwell’s cause of death as COVID-19 pneumonia.
Inquest
43. At an inquest held on 21 March 2024, the Coroner concluded that Mr Tuckwell died
from natural causes.
Prisons and Probation Ombudsman 7
Findings
Clinical Findings
Management of Mr Tuckwell’s risk of infection from COVID -19
44. The clinical reviewer concluded that the care Mr Tuckwell received at Oakwood was
equivalent to that which he could have expected to receive in the community.
45. Prisons were expected to identify new and existing prisoners assessed as at
particular risk if they contracted COVID-19 and offer them the opportunity to shield.
In line with this policy, Mr Tuckwell was identified as clinically vulnerable because of
his age and obesity and was appropriately advised to shield. He declined to shield
and said that he would practice social distancing. He signed a disclaimer to that
effect on two occasions. We are satisfied that the risks were explained to Mr
Tuckwell and that he had the mental capacity to make this decision.
46. The clinical reviewer noted that on one occasion Mr Tuckwell asked healthcare staff
to test him for COVID-19. He was not experiencing any symptoms at the time of his
request so he was not eligible to be tested. This was in line with the guidance at the
time.
47. Mr Tuckwell was tested for COVID-19 on 2 November as part of a mass testing
programme, under the direction of Public Health England, due to an outbreak of the
virus on the wing where he lived. His results were negative.
48. Mr Tuckwell became unwell in January 2021. At that time, there were 69 people
who were COVID-19 positive at Oakwood. Twenty-seven prisoners who were
infected with the virus lived on the same wing as Mr Tuckwell. The clinical
reviewer considered that it was likely that the COVID-19 outbreak that started in
November 2020 had continued and was still spreading in the prison at the time Mr
Tuckwell tested positive for the virus.
49. Healthcare staff wore PPE, in line with national requirements, during their contact
with Mr Tuckwell. A restricted regime was in place on all the wings at the time that
he became unwell. When he displayed possible COVID-19 symptoms, he was
immediately sent to hospital for further assessment.
50. In spite of the measures to control the risk of infection and protect prisoners, it is
likely that Mr Tuckwell contracted COVID-19 at Oakwood as he had not left the
prison. We are satisfied that Oakwood implemented the expected measures to
help control the risk of infection and that Mr Tuckwell was managed appropriately.
51. The clinical reviewer did, however, find one area of concern.
Mr Tuckwell’s type 2 diabetes diagnosis
52. The clinical reviewer was concerned that in December 2020 when test results
indicated that Mr Tuckwell had developed type 2 diabetes, there was a four week
delay before a prison GP saw him to tell him about his diagnosis and that this
increased his risk of serious illness if he caught COVID-19. The clinical reviewer
8 Prisons and Probation Ombudsman
concluded that the four week waiting time was not equivalent to that which he could
have expected in the community. We recommend:
The Head of Healthcare should ensure that any increase in health risk factors
relating to COVID-19 is flagged to the prisoner as soon as it is known.
Non-clinical Findings
Security risk assessments and the use of restraints
53. 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.
54. 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 he has a serious medical
condition. The judgment indicated 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. These requirements are reflected in Prison
Service Instruction (PSI) 33/2015 on external prisoner movements.
55. The medical section of the risk assessment for Mr Tuckwell’s last journey to hospital
was ticked to indicate that there were no medical reasons to prevent the use of
handcuffs or for him to remain handcuffed during treatment or admission. It also
indicated that he had the physical ability to attempt an escape (unaided) from the
escorting staff if the handcuffs were removed. However, no explanation was given
for this. It also failed to alert staff that Mr Tuckwell was suspected of having the
COVID-19 virus.
56. The security assessment noted that Mr Tuckwell was a medium risk to the public.
He was assessed as low risk for risk to hospital staff, hostage taking, risk of escape
and likelihood of outside assistance. A prison manager decided that Mr Tuckwell
should be restrained and accompanied by two escorting officers for the journey and
treatment/consultation.
57. On 21 January, when hospital staff told the escort officers that Mr Tuckwell had
COVID-19, the restraints were removed and the escort officers sat in the
corridor outside the ward.
58. We recognise that many factors have to be taken into account in determining the
level of restraints. However, Mr Tuckwell was a Category D (the lowest security
categorisation) prisoner, on the enhanced level of the incentives scheme and, given
his age, breathing difficulties and two escort officers, we question whether the use
of any restraints was proportionate when he was escorted and then admitted to
hospital on 20 January.
59. We find it difficult to understand how Mr Tuckwell was assessed as a medium risk
to the public, given the fact that he had no convictions for violence, that he had
displayed no recent behavioural problems in prison and was classified as the lowest
Prisons and Probation Ombudsman 9
security categorisation. We cannot see the justification for using an escort chain
which needlessly placed one of the escort officers at greater risk of being physically
closer to someone with symptoms of COVID-19.
60. We, therefore, consider that the authorising manager’s decision to use restraints
was unsound. We repeat our recommendation from our previous investigation at
Oakwood where we found a similar inappropriate use of restraints:
The Director and Head of Healthcare should ensure that:
• healthcare staff fully and accurately reflect the current health and mobility
of a prisoner when they complete an escort risk assessment;
• all staff undertaking risk assessments for prisoners taken to hospital
understand the legal position, and that assessments fully take into
account the health of a prisoner and are based on the actual risk the
prisoner presents at the time.
Contact with Mr Tuckwell’s next of kin
61. Prison Rule 22 says that prisons should inform the next of kin immediately if a
prisoner becomes seriously ill. Prison Service Instruction 64/2011 says that if a
prisoner suffers an unpredicted or rapid deterioration in their physical health, an
appropriate member of prison staff should engage with their next of kin to provide
information and support. In March 2020, this obligation was reinforced in national
Prison Service guidance on family liaison and communicating with prisoners’
families during the pandemic.
62. We accept that it was unclear how serious Mr Tuckwell’s condition was when he
was taken to hospital on 20 January. However, we consider that when Mr Tuckwell
tested positive for COVID-19 on 21 January, particularly given his clinical
vulnerability, the prison should have appointed a FLO and contacted his family. We
are concerned that they did not contact his family until after his daughter had rung
the prison on 23 January. Despite prison managers claiming they needed Mr
Tuckwell’s consent for family contact, our investigation found that this had already
been provided. We recommend:
The Director should ensure, in line with Prison Rule 22, that the next of kin of
seriously ill prisoners are informed as soon as possible when they are
admitted to hospital.
Early release on compassionate grounds
63. Release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. The criteria
for early release for determinate sentenced prisoners are set out in Prison Service
Order (PSO) 6000. An application for early release on compassionate grounds must
be submitted to the Public Protection Casework Section (PPCS) of HMPPS.
64. On 8 February, the prison submitted an application for Mr Tuckwell’s early release
on compassionate grounds to PPCS. At this time, Mr Tuckwell was terminally ill and
nearing the end of his life. However, we have been told that the application got lost
10 Prisons and Probation Ombudsman
in the PPCS email system. We cannot say whether Mr Tuckwell would have been
granted compassionate release but his application should have been considered
before he died.
65. While the loss of his form was not acceptable, we note that PPCS have put
measures in place to ensure that this cannot happen again. We do not, therefore,
make a recommendation.
Sue McAllister CB
Prisons and Probation Ombudsman April 2024
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