Bonner, Arthur

Independent investigation into
At hreepo rdt ebya tthhe Porifs oMnsr a nAd rPtrhobuarti oJno Ohmnbu dsman
Bonner, on 15 August 2023,
following his release from
HMP Hollesley Bay
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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Mr Arthur John Bonner died at home of lung cancer on 15 August 2023, following
his release from HMP Hollesley Bay on 7 August. He was 70 years old. I offer my
condolences to his family and friends.
5. We did not identify any clinical or non-clinical issues of concern. We make no
recommendations.
Prisons and Probation Ombudsman 1
The Investigation Process
6. HMPPS notified us of Mr Bonner’s death on 18 August 2023.
7. The PPO investigator obtained copies of relevant extracts from Mr Bonner’s prison
and probation records.
8. The Ombudsman’s family liaison officer contacted Mr Bonner’s wife and daughter to
explain the investigation and to ask if they had any matters they wanted us to
consider. They said that in March/April 2022, Mr Bonner had complained about pain
and there were delays with follow up investigations until his diagnosis. They felt this
had impacted his life expectancy. They also said they were frustrated when
contacting Mr Bonner’s community offender manager (COM). Concerns about
hospital decisions are not within the remit of this investigation but we have
addressed all other concerns in this report.
9. Mr Bonner’s family received a copy of the initial report. They raised a number of
issues/questions that do not impact on the factual accuracy of this report and have
been addressed through separate correspondence.
10. 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.
2 Prisons and Probation Ombudsman
Background Information
HMP Hollesley Bay
11. HMP Hollesley Bay is an open prison located in Suffolk. There are nine residential
units holding up to 655 adult and young adult men. Prisoners who move to
Hollesley Bay are trusted to live in open conditions. Many of the prisoners are
temporarily released on licence to work in the local community and maintain their
family ties in preparation for their eventual release from custody.
Probation Service
12. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
HM Inspectorate of Prisons
13. The most recent inspection of HMP Hollesley Bay was in November 2018.
Inspectors described Hollesley Bay as a successful and effective prison. Inspectors
noted that release on temporary licence (ROTL) was used extensively to support
resettlement and family ties. Reintegration planning for those approaching release
was good.
HM Inspectorate of Probation
14. The most recent inspection of the North and North East Lincolnshire Probation
Delivery Unit was in March 2023. Inspectors found that despite heavy caseloads,
staff were committed and engaged to deliver quality, personalised and responsive
probation work.
Prisons and Probation Ombudsman 3
Key Events
15. On 4 July 2016, Mr Arthur John Bonner was convicted of sexual offences and was
sentenced to 14 years, six months in prison. On 23 September 2021, he was
transferred to HMP Hollesley Bay. Mr Bonner was granted several periods of short
release for overnight home stays and town visits to maintain family ties.
16. On 11 April 2022, Mr Bonner told a nurse he felt unwell. The nurse conducted a
COVID-19 test and the result was positive. She told Mr Bonner to rest in his cell.
Healthcare staff conducted daily welfare checks until Mr Bonner recovered.
17. On 30 June, a GP at the prison completed a hospital referral for tests as Mr Bonner
told him that he had lost weight, felt lethargic and generally felt unwell. At the
hospital, respiratory specialists arranged a CT scan where they noted there was a
mass in his right lung. Prison healthcare staff arranged for Mr Bonner to attend
hospital for ongoing tests.
18. In October, hospital specialists diagnosed Mr Bonner with lung cancer. Tests
showed that he had an aggressive form of cancer that had spread from his lungs to
his liver and legs. The hospital clinical oncologist told Mr Bonner that the cancer
was incurable. The hospital lung cancer specialist nurse noted that Mr Bonner was
deteriorating quickly and that they were trying to manage his pain in his abdomen
and right thigh.
19. GPs at the prison reviewed and adjusted Mr Bonner’s medication frequently to try to
alleviate his pain and discomfort.
Pre-release planning
20. Mr Bonner was involved in the planning for his release. On 5 January 2023, Mr
Bonner’s Prison Offender Manager (POM) met him for a planned supervision
appointment. They discussed his risks and needs in the community following his
release.
21. On 17 January, Mr Bonner met his Community Offender Manager (COM) at her
office as he was released on temporary licence. They discussed his recent home
leave which had gone well. They had monthly supervision appointments at her
office when Mr Bonner was on temporary release from Hollesley Bay.
22. Healthcare and prison staff held a multi-disciplinary team meeting with Mr Bonner
on 6 July. He told staff that he was waiting for an update from the hospital
oncologist, and he wanted to be comfortable and his symptoms to be managed.
Healthcare staff contacted hospital staff for updates and created care plans to help
and support Mr Bonner.
23. When Mr Bonner was on temporary day release on 15 July, his family were
concerned about how ill he looked. They took him to hospital, and he was admitted
as an inpatient. Healthcare staff at Hollesley Bay contacted the hospital for updates
about Mr Bonner’s care.
4 Prisons and Probation Ombudsman
24. On 25 July, hospital specialists told healthcare staff at Hollesley Bay that Mr Bonner
had terminal cancer. Prison staff commenced an application for compassionate
release. Mr Bonner’s COM had to obtain information about possible licence
conditions for his compassionate release. Once these were obtained, she
supported the application.
25. On 26 July, a governor and a nurse visited Mr Bonner in hospital for a welfare
check. They spoke to Mr Bonner’s family who also attended and offered their
support.
Post-release
26. On 7 August, Mr Bonner was transferred to a hospice and was then released after
his compassionate release application was approved.
27. On 11 August 2023, Mr Bonner’s COM visited Mr Bonner at his home address and
she explained the terms of his licence conditions. Mr Bonner confirmed he
understood the licence requirements.
Circumstances of Mr Bonner’s death
28. On 15 August 2023, Mr Bonner’s family informed HMPPS that Mr Bonner had died
at home.
Cause of death
29. Mr Bonner’s cause of death was given as carcinomatosis due to malignant tumour
of the lung.
Adrian Usher
Prisons and Probation Ombudsman April 2024
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