Beaumont, Francis

Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Francis Beaumont,
a prisoner at HMP Moorland,
on 28 December 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
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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
then our recommendations should be focused, evidenced and viable. This is
especially the case if there is evidence of systemic failure.
3. Mr Francis Beaumont died at HMP Moorland on 28 December 2022, of advanced
stomach carcinoma. He was 84 years old. We offer our condolences to Mr
Beaumont’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Beaumont received at
Moorland was of a reasonable standard and at least equivalent to that which he
could have expected in the community. She highlighted examples of good practice
and opportunities for improvement in areas not directly related to Mr Beaumont’s
death, for the Head of Healthcare to address.
5. We found no non-clinical issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
The Investigation Process
6. We were notified of Mr Beaumont’s death on 28 December 2022.
7. NHS England commissioned an independent clinical reviewer to review Mr
Beaumont’s clinical care at HMP Moorland.
8. The PPO investigator investigated the non-clinical issues relating to Mr
Beaumont’s care.
9. The PPO family liaison officer wrote to Mr Beaumont’s next of kin, his daughter, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond to our letter.
10. We shared the initial report with HMPPS and there were no factual inaccuracies.
Previous deaths at HMP Moorland
11. Mr Beaumont was the 13th prisoner to die at HMP Moorland since 28 December
2019. Of the previous deaths, 11 were from natural causes and one was drugs
related. There are no significant similarities between our findings in the
investigation into Mr Beaumont’s death and our investigation findings for the
previous deaths.
2 Prisons and Probation Ombudsman
Key Events
12. On 1 May 2018, Mr Francis Beaumont was given a 20-year sentence for sexual
offences and transferred to HMP Leeds. He transferred to HMP Moorland on 31
July 2019.
13. On 12 May 2021, Mr Beaumont was admitted to hospital for cellulitis (a deep skin
infection). He had an unexpected gastro-intestinal bleed which led to a diagnosis
of a large stomach ulcer.
14. On 30 July, Mr Beaumont attended hospital for an endoscopy (an examination of
the digestive system using an internal camera). He had a further gastro-intestinal
bleed during the endoscopy and was kept in hospital overnight for observation. His
discharge summary reported a probable cancerous antral (part of the stomach)
ulcer.
15. In August, Mr Beaumont received a confirmed diagnosis of cancer of the stomach.
He was added to the Multi-Professional Complex Care Case register (a multi-
disciplinary approach to managing patients with complex care needs).
16. On 25 August, hospital staff advised Mr Beaumont that he was not a suitable
candidate for radical treatment (aimed to cure rather than manage symptoms) nor
palliative chemotherapy (aims to manage rather than cure symptoms).
17. Throughout his time in prison, Mr Beaumont sometimes did not take his
medication as prescribed. Healthcare staff assessed that he had capacity to make
these choices. He indicated a number of times that he was unaware that his
cancer was not curable. Healthcare staff frequently spoke to him to make him
aware of this and to offer support.
18. On 22 May 2022, a nurse reviewed Mr Beaumont and was concerned there may
have been some disease progression. Staff called an ambulance. Mr Beaumont
refused to attend hospital or to have any treatment.
19. On 9 August, healthcare staff discussed Mr Beaumont’s presentation with a
cancer nurse specialist, who offered him a blood transfusion. Mr Beaumont’s blood
test results indicated an urgent referral to hospital for further assessment was
appropriate. He refused the transfusion or to attend hospital.
20. On 10 August, a GP at Moorland advised Mr Beaumont of the dangers and risks
associated with his refusal to attend hospital. He continued to refuse to attend
hospital several times over the following weeks.
21. On 4 September, an ambulance crew persuaded Mr Beaumont to attend hospital
after he vomited black fluid. He refused a blood transfusion and discharged
himself early in the morning of 5 September 2022.
22. On 11 September, a family liaison officer was assigned to Mr Beaumont and made
contact with his family.
23. On 12 September, a GP persuaded Mr Beaumont to attend hospital for a blood
transfusion. At hospital he refused all treatment and chose not to speak to medical
Prisons and Probation Ombudsman 3
staff. On 13 September, Mr Beaumont discharged himself and returned to
Moorland. The next day, Mr Beaumont again agreed to attend hospital for a
transfusion, but again discharged himself against advice.
24. On 1 December, the pathology laboratory reported that Mr Beaumont’s blood test
results were outside normal values. He was advised that it was crucial that he
attend hospital for further assessment but declined to do so.
25. Over the following four weeks, Mr Beaumont’s health declined. He was advised to
attend hospital several times but refused.
26. On 27 December, Mr Beaumont’s daughter visited him. Staff explained that they
were organising medication for end-of-life support. A healthcare assistant
remained with him.
27. On 28 December, Mr Beaumont’s daughter visited him. Staff discussed end of life
choices and all parties agreed that CPR would not be undertaken. They decided
that he should remain in the prison’s care suite rather than attend hospital, in line
with his wishes.
28. At 1.42pm on 28 December, healthcare staff recorded that Mr Beaumont had died.
His daughter was present.
Post-mortem report
29. The post-mortem report concluded that Mr Beaumont died of advanced stomach
carcinoma.
4 Prisons and Probation Ombudsman
Findings
30. Given his frequent refusal of treatment or to attend hospital, caring for Mr
Beaumont during his final illness was not always straightforward. The clinical
reviewer concluded that the care that Mr Beaumont received was consistent,
thorough and well documented. She found that the care was of a good standard
and equivalent to that he could expect to receive in the community.
Inquest
31. The inquest into Mr Beaumont’s death concluded on 7 December 2023. Mr
Beaumont’s cause of death was advanced stomach carcinoma.
Adrian Usher
Prisons and Probation Ombudsman January 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