Boswell, Malcolm

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Malcolm Boswell,
a prisoner at HMP Bure,
on 12 July 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 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 Malcolm Boswell died in hospital of hepatorenal syndrome (kidney failure
caused by advanced liver disease) on 12 July 2023, while a prisoner at HMP Bure.
He was 82 years old. We offer our condolences to Mr Boswell’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Boswell received at Bure
was of a good standard and equivalent to that which he could have expected to
receive in the community. However, she made a recommendation about care
planning for prisoners with liver and kidney disease which the Head of Healthcare
will wish to address.
5. We found no non-clinical issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
The Investigation Process
6. HMPPS notified us of Mr Boswell’s death on 12 July 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
Boswell’s clinical care at HMP Bure.
8. The PPO investigator investigated the non-clinical issues relating to Mr Boswell’s
care.
9. The PPO family liaison officer wrote to Mr Boswell’s daughter to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
10. We shared our initial report with HMPPS. They found no factual inaccuracies.
Previous deaths at HMP Bure
11. Mr Boswell was the fourth prisoner to die at HMP Bure since July 2021. All the
previous deaths were from natural causes.
2 Prisons and Probation Ombudsman
Key Events
12. On 10 February 2020, Mr Malcolm Boswell was convicted of sexual offences and
sentenced to 21 years in prison. On 24 September, he was moved to HMP Bure.
13. Mr Boswell had several pre-existing medical conditions when he arrived at Bure,
including end stage kidney disease, which was diagnosed in the community in
2019, and non-alcohol related fatty liver disease, diagnosed in the community in
2009. He also had hypothyroidism (decreased production of thyroid hormones),
type 2 diabetes, high blood pressure, and anaemia. Due to the extent of his ill
health, Mr Boswell had a Do Not Attempt Resuscitation (DNACPR) instruction in
place on transfer to Bure, which meant that he did not want anyone to resuscitate
him if his heart or breathing stopped.
14. In January 2021, Mr Boswell was moved into a ground floor suite due to his medical
needs and poor mobility. Mr Boswell received ongoing treatment for his kidney
disease both at Bure and at Norfolk and Norwich University Hospital.
15. On 14 June, Mr Boswell revoked his DNACPR due to feeling better in himself.
16. On 23 May 2022, Mr Boswell attended Norfolk and Norwich University Hospital and
was diagnosed with end stage liver failure by a consultant hepatologist (doctor
specialising in liver disease). Palliative care was started by the hospital. Mr Boswell
then began attending hospital appointments once a fortnight to have fluid drained
from his stomach as part of his palliative care.
17. On 30 May, Mr Boswell reinstated his DNACPR order following his diagnosis of liver
failure. This remained in place until his death.
18. On 7 October, due to Mr Boswell’s deteriorating health, staff submitted an
application for his early release on compassionate grounds to the Public Protection
Casework Section (PPCS) of HMPPS. At this time, Mr Boswell had a prognosis of
approximately 12 months left to live. On 25 November, PPCS refused the
application on the grounds that Mr Boswell’s risk to the public was deemed too high,
his life expectancy too long, and his health condition was known to the judge when
Mr Boswell was sent to prison.
19. On 13 March 2023, a consultant reviewed Mr Boswell and observed that Mr
Boswell’s kidney function was gradually deteriorating. The consultant was not able
to offer any treatment for this due to Mr Boswell’s advanced liver disease.
20. On 5 May, staff submitted a further application for Mr Boswell’s early release on
compassionate grounds to PPCS. His life expectancy at this time was estimated to
be around nine months. On 16 June, PPCS refused the application on the same
grounds as before.
21. On 27 June, Mr Boswell attended Norfolk and Norwich University Hospital for his
routine fluid drainage appointment. He had a blood test done which returned
abnormal results, and Mr Boswell was admitted to hospital.
22. On 1 July, Mr Boswell’s condition deteriorated rapidly, and he was placed on end-
of-life care in hospital.
Prisons and Probation Ombudsman 3
23. Mr Boswell died in hospital on 12 July.
Cause of death
24. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Boswell’s cause of death
as hepatorenal syndrome (kidney failure) caused by non-alcoholic hepatic
steatohepatitis (advanced liver disease).
Adrian Usher
Prisons and Probation Ombudsman December 2023
Inquest
The inquest, held on 4 April 2024, concluded that Mr Boswell died from natural causes.
4 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