Flanagan, Ryan

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ryan Flanagan,
a prisoner at HMP Chelmsford,
on 23 March 2021
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Ryan Flanagan died on 23 March 2021 in Broomfield Hospital, having been found
unresponsive in his cell at HMP Chelmsford on 17 March. He had suffered heart failure,
which caused brain damage. Mr Flanagan was 37 years old. I offer my condolences to Mr
Flanagan’s family and friends. Our investigation was suspended during police
investigations, and I apologise for the delay in issuing our report.
Mr Flanagan was awaiting an operation on his back, but otherwise had not complained of
any health issues. On 17 March, he did a workout in his cell with no apparent problems.
Later that evening he had to interrupt a telephone call to his parents as he had chest pain.
Shortly afterwards, his cellmate found him on the cell floor. Staff, then paramedics,
provided first aid and transferred Mr Flanagan to hospital. He did not regain
consciousness.
We are concerned that there appears to have been a delay in using an emergency
response code, an issue we have raised with Chelmsford before, as well as a delay going
into Mr Flanagan’s cell. We are also concerned that Mr Flanagan’s family were informed
that he had gone to hospital by another prisoner and had to confirm this themselves with
the prison. The Governor should address problems with the prison’s CCTV system and
ensure that effective action is being taken to prevent prisoners having access to mobile
telephones.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman November 2022
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
Summary
Events
1. On 18 January 2020, Mr Ryan Flanagan was remanded to HMP Chelmsford. At a
reception health screening, he reported a compressed disc in his lower back, for
which he sometimes took painkillers and was awaiting a date for an operation. At a
secondary health screening, he said that he had previously stayed in a psychiatric
hospital.
2. Mr Flanagan said that his medication for his back pain was not strong enough, so at
the end of January, the doctor prescribed a stronger painkiller. In February, he said
that pain relief was still not strong enough, and the doctor prescribed pain relief
cream.
3. In July, Mr Flanagan asked to see the mental health team, complaining about
lockdown restrictions. Staff gave him in-cell activity packs and reiterated the support
available. In August, Mr Flanagan complained again about back pain. Staff chased
up the anticipated operation on his compressed disc. At a medication review in
December, a doctor prescribed Mr Flanagan pregabalin (a drug to combat pain from
nerve damage). In February and March 2021, staff found drug paraphernalia and a
mobile phone in the cell Mr Flanagan shared.
4. On the evening of 17 March, Mr Flanagan did a workout in his cell, washed, ate,
and then telephoned his parents using a mobile phone. He ended the call
prematurely, complaining of pain in his chest. At approximately 8.30pm, his
cellmate noticed that Mr Flanagan was lying unresponsive on the cell floor. He
shouted for help, which alerted other prisoners who also tried to attract attention. A
prison officer went to the cell and called for further assistance. Other staff arrived,
went into the cell, and attempted to revive Mr Flanagan. Joined by medical staff
they continued until ambulance paramedics arrived and took over. They transferred
Mr Flanagan to hospital.
5. Mr Flanagan remained in a coma. His condition did not improve, and following
discussion between doctors and his family, the decision was taken to switch off life
support. Mr Flanagan died at 12:45am on 23 March.
Findings
Mr Flanagan’s healthcare
6. Until he collapsed, there were no indications that Mr Flanagan was in ill-health.
There was a suggestion that two days before Mr Flanagan collapsed, he mentioned
chest pain to another prisoner. On the evening he collapsed, he had to interrupt a
telephone call to his parents. There is no record of him reporting these incidents
and staff could not have anticipated what happened.
7. During his time in Chelmsford, Mr Flanagan had frequent interaction with healthcare
services about his back pain. There were no other concerns about Mr Flanagan’s
physical or mental healthcare. The clinical reviewer concluded that Mr Flanagan’s
Prisons and Probation Ombudsman 1
healthcare was equivalent to that he could have expected to receive in the
community.
Substance misuse
8. Mr Flanagan had a history of substance misuse, but on arrival in prison said he had
no current issues. While there was some intelligence about Mr Flanagan’s possible
involvement in the drug trade in Chelmsford, there was no evidence of him actually
taking any illicit substances. Post-mortem reports did not make any significant
findings on drugs and concluded that they did not contribute to his death. We are
also concerned that Mr Flanagan was in possession of a mobile phone on more
than one occasion while in prison.
Emergency response
9. When a prison officer went to Mr Flanagan’s cell, he made a dynamic risk
assessment and decided he did not feel safe to enter until assistance arrived. This
seems a reasonable decision in the circumstances, but we are concerned that staff
were not clear on the policy for entering cells.
10. The first prison officer to arrive at Mr Flanagan’s cell said that he radioed an
emergency code. The electronic evidence provided to us did not bear this out, and
we cannot be confident that such a message was transmitted. We have raised this
issue with Chelmsford before. The CCTV footage was of too poor a quality to
clearly see whether this caused a delay in assistance reaching Mr Flanagan.
Liaison with Mr Flanagan’s family
11. When Mr Flanagan went to hospital, another prisoner telephoned his parents to tell
them before the prison family liaison officer made contact.
Recommendations
• The Governor should review the local security strategy and ensure that everything
possible is being done to prevent mobile phones entering the prison.
• The Governor should ensure that all prison staff are made aware of, and
understand, their responsibilities during medical emergencies, including that staff:
• understand and use the appropriate emergency code when they
discover a medical emergency;
• are clear when they may unlock cell doors; and
• enter cells as quickly as possible in life-threatening situations where it
is safe to do so.
• The Governor should ensure that CCTV cameras are properly maintained and fit
for purpose.
• The Governor should ensure that an appropriate member of staff, preferably a
designated family liaison officer, contacts a prisoner’s family to notify them
immediately when a prisoner is seriously unwell.
2 Prisons and Probation Ombudsman
The Investigation Process
12. The investigator issued notices to staff and prisoners at HMP Chelmsford informing
them of the investigation and asking anyone with relevant information to contact
him. He obtained copies of relevant extracts from Mr Flanagan’s prison and medical
records. He liaised with officers from Essex Police investigating Mr Flanagan’s
death and had access to notes of police interviews.
13. The investigator interviewed one member of staff and one prisoner at Chelmsford.
NHS England commissioned a clinical reviewer to review Mr Flanagan’s clinical
care at the prison.
14. We informed HM Coroner for Essex of the investigation. He gave us the results of
the post-mortem examination. We have sent the coroner a copy of this report.
15. One of the Ombudsman’s family liaison officers contacted Mr Flanagan’s father, to
explain the investigation and to ask if he had any matters he wanted the
investigation to consider. Mr Flanagan’s father asked about Mr Flanagan’s medical
care, and about the emergency response. These issues are addressed in this
report. He also asked a specific medical question, which is addressed in the clinical
review.
Prisons and Probation Ombudsman 3
Background Information
HMP Chelmsford
16. HMP Chelmsford is a local prison that takes prisoners directly from the courts. It
holds 750 men. The Castle Rock Group is commissioned to provide 24-hour
healthcare, which includes a range of primary care and secondary mental health
services. The prison has a 12-bed inpatient unit.
HM Inspectorate of Prisons
17. HM Inspectorate of Prisons (HMIP) carried out an unannounced inspection of
Chelmsford in May and June 2018. Inspectors found that safety was poor and noted
several areas of significant concern. The Chief Inspector of Prisons considered
invoking the Urgent Notification (UN) protocol (which alerts the Secretary of State
that immediate action to rectify problems is required). However, a new Governor
was in post and Chelmsford had been put under special measures by HM Prison
and Probation Service (HMPPS), which meant that HMPPS had identified
Chelmsford as needing additional, specialist support to improve its performance. He
therefore did not issue a UN.
18. The most recent inspection of HMP Chelmsford was an unannounced inspection in
August 2021. Inspectors found that serious concerns remained, and the Chief
Inspector of Prisons invoked the Urgent Notification protocol. There were concerns
over safety, purposeful activity, rehabilitation, and respect. There were issues
around the use of emergency codes. Inspectors found that times answering cell
bells were too long with inadequate oversight of response times.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to August 2021, the IMB reported
that the withdrawing of mandatory drug testing during the COVID-19 pandemic
meant that there was no reliable data on drug use in the prison. Intelligence reports
indicated that illegal drugs were readily available.
Previous deaths at HMP Chelmsford
20. Mr Flanagan was the ninth prisoner at Chelmsford to die since the beginning of
2019. Two of the previous deaths were due to natural causes and one was due to
drug use. The others were self-inflicted. We have made recommendations in
previous cases about delays in calling a medical emergency code. There has since
been a further self-inflicted death at Chelmsford.
4 Prisons and Probation Ombudsman
Key Events
21. On 18 January 2020, Mr Ryan Flanagan was remanded to HMP Chelmsford on
charges of conspiracy to commit burglary. At a reception health screening, he told
the nurse that he suffered from a compressed disc in his lower back, for which he
sometimes took painkillers. He was awaiting a date for an operation. Otherwise, he
said he had no physical or mental health problems. A doctor prescribed him
paracetamol and naproxen (medication that reduces inflammation).
22. On 20 January, Mr Flanagan had a secondary health screening. He said that he
had previously stayed in a psychiatric hospital (Mr Flanagan had been diagnosed
with schizophrenic disorders in 2007 but the medical record contains no further
information). In 2017, he had a history of mental and behavioural disorders due to
substance misuse.
23. On 26 January, Mr Flanagan said that his medication for his back pain was not
strong enough. On 29 January, the doctor prescribed co-codamol (a combination of
paracetamol and codeine, a stronger painkiller than paracetamol alone). In
February, he told a healthcare assistant that he still felt that his pain relief was not
strong enough. She referred Mr Flanagan to the doctor, who prescribed algesal
cream (pain relief applied to muscle and joint pain). After a court appearance in
March, Mr Flanagan again complained of back pain.
24. Mr Flanagan received two warnings for not attending work. In April, he was involved
in a fight with another prisoner and spent some time in the segregation unit. He was
caught using a mobile phone, which he handed to officers. Intelligence reports
indicated suspicion that Mr Flanagan was involved in the trade in illicit drugs in the
prison. He was suspected of having further access to a mobile telephone.
25. In July, Mr Flanagan asked to see the mental health team. He said he was bored
during lockdown restrictions and was unhappy with how a manager had treated a
clothing issue he had raised. A healthcare support worker encouraged him to
remain occupied, gave him in-cell activity packs, and detailed the support that was
available to him.
26. In August, Mr Flanagan complained to the prison doctor about his back pain but
declined any further pain relief. A new referral was made to chase up his anticipated
operation on his compressed disc.
27. Mr Flanagan suffered pain from a cracked tooth and, in December, had the tooth
extracted. That month, a doctor reviewed Mr Flanagan’s medication, and prescribed
pregabalin (a drug used to treat pain caused by nerve damage). The same month,
Mr Flanagan was involved in a fight with another prisoner. Intelligence indicated that
this might have been in relation to a debt relating to the trade in illicit substances.
28. On 8 January 2021, Mr Flanagan tested positive for COVID-19. His medical records
do not contain any further information. In interview, his cellmate, who also tested
positive, said that after feeling unwell for about a week they seemed to return to
normality. Mr Flanagan returned to his work as a cleaner.
29. On 11 February, intelligence reports showed that staff found a bag with a green
substance and cigarette papers in the cell. The cellmate said that they were his. On
Prisons and Probation Ombudsman 5
10 March, a further report shows that staff found a mobile phone and a quantity of
needles in the cell. Mr Flanagan admitted ownership. Staff confiscated these, and
Mr Flanagan said that the needles had been in his possession for some time, and
he had forgotten about them. He was placed on report (to face a disciplinary
charge).
30. A note on Mr Flanagan’s medical record showed that on 24 February, he was
notified of a pain management appointment at Broomfield Hospital for 18 March. On
5 March, Mr Flanagan told a nurse that he was concerned that he might be
transferred to a different prison before he had had his back operation. The nurse
told him that the healthcare department could put a medical hold on any transfers if
an operation was scheduled.
31. On 16 March, a nurse saw Mr Flanagan about his back pain. The nurse recorded
that the pregabalin he was currently prescribed was insufficient pain management
and recommended that this be supplemented with paracetamol.
32. On 17 March, the cellmate returned to their cell at approximately 4.00pm, and Mr
Flanagan at around 5.00pm. Around 6.15pm, Mr Flanagan began a physical
training session in the cell. The cellmate said that he did not appear to suffer any
difficulties while doing so. After washing and eating, Mr Flanagan watched
television. Mr Flanagan’s father told the investigator that at 8.13pm, he telephoned
his parents (using a mobile phone). After a few minutes’ conversation, he said that
he had pain in his chest and would have to end the call and call back later.
33. Shortly before 8.30pm, the cellmate noticed that Mr Flanagan was lying on the cell
floor. He sometimes did so to stretch his back, but usually lying face up, whereas on
this occasion he was on his front. The cellmate asked if he was okay, and Mr
Flanagan did not respond. He went to him, and Mr Flanagan had gone red. He
began to shout and call for help. He turned Mr Flanagan onto his side. Mr Flanagan
had a pulse but did not appear to be breathing. He pressed his cell bell, shouted,
and kicked the door. This alerted other prisoners, who also shouted, and some
pressed their cell bells.
34. An Operational Support Grade (OSG) said in her police statement that she and a
prison officer were compiling the numbers to submit a roll check when they heard a
cell bell activated. They continued their assessment, but after approximately two
minutes the officer said that he needed to respond to the cell bell. The officer said
that he heard noise and was directed by other prisoners to Mr Flanagan’s cell. He
looked through the observation panel and could see Mr Flanagan on the floor and
the cellmate shouting. The officer said that he called a code blue (an emergency
code which indicates a prisoner is not breathing or is having difficulty breathing).
Radio traffic recordings do not contain this message. In her police statement, the
OSG said that the officer called to her within 30 seconds of going to answer the cell
bell.
35. The officer said in interview that he did not know either prisoner, and made a
dynamic risk assessment that it was not safe for him to enter the cell at that stage.
The OSG joined him and used her radio to call a code blue emergency. This was at
8.24pm. This prompted the control room to call an ambulance. The control room log
does not record what time an ambulance was requested; Ambulance Service
records showed that the call was received at 8.26pm. The officer, who is first aid
6 Prisons and Probation Ombudsman
trained, used his radio to reiterate that medical staff were needed. Another officer
arrived at the cell approximately two minutes after the OSG. She thought that the
protocol was that three prison officers (not including OSGs) should be present to
unlock a cell with two prisoners, but decided that in the circumstances they should
enter the cell. As she was radioing for permission to open the door, she saw
another prison officer arriving on the landing so unlocked the door. They went into
the cell, asked the cellmate to leave, and began to perform cardiopulmonary
resuscitation (CPR). The radio recordings indicate that the officer said that they
were entering the cell two minutes from the OSG making the code blue call.
36. A nurse had responded to the emergency call, and the prison log showed that he
arrived at the cell two minutes after the prison officers went into the cell. He could
not detect a pulse nor any sign that Mr Flanagan was breathing. They applied a
defibrillator (a machine that monitors and, in some circumstances, can restart the
heart). He and the officers continued to attempt to revive Mr Flanagan until the
ambulance crew arrived and took over. Having detected a pulse, they transferred
him to the ambulance and on to Broomfield Hospital. Mr Flanagan was put into an
induced coma in the High Dependency Unit.
37. At approximately 10.00pm, a prisoner telephoned Mr Flanagan’s parents, telling
them what had happened. They contacted the prison and, having been told where
Mr Flanagan was, subsequently travelled to the hospital.
38. Mr Flanagan remained in a coma. His condition did not improve, and following
discussion between doctors and his family, the decision was taken to switch off life
support. Mr Flanagan died at 12:45am on 23 March. His family were with him.
Contact with Mr Flanagan’s family
39. On the morning of 18 March, Chelmsford appointed a family liaison officer, who
contacted Mr Flanagan’s father. In line with Prison Service guidance, Chelmsford
offered a contribution to the costs of Mr Flanagan’s funeral.
Support for prisoners and staff
40. After Mr Flanagan’s death the duty governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
41. The prison posted notices informing other prisoners of Mr Flanagan’s death, and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Flanagan’s death.
Information after Mr Flanagan’s death
42. When staff searched Mr Flanagan’s cell after he had died, a vape found in the cell
was found to contain traces of tetrahydrocannabinol (the main psychoactive
component of cannabis). They also found a mobile phone, which was handed to the
police. It is not possible to determine whether these belonged to Mr Flanagan or his
cellmate.
Prisons and Probation Ombudsman 7
43. Intelligence reports after Mr Flanagan had gone to hospital recorded that prisoners
told staff that Mr Flanagan had been using steroids in prison.
Post-mortem report
44. Post-mortem tests showed that Mr Flanagan died from hypoxic brain injury, further
to cardiorespiratory arrest and dilated cardiomyopathy. His brain had been starved
of oxygen after his heart failed due to underlying heart disease. There were no
traces of psychoactive substances in his system. There were traces of fentanyl,
midazolam and pregabalin. The first two are used in intensive care for pain relief
and sedation, and Mr Flanagan had been prescribed pregabalin. The pathologist
said that “there were no significant findings on toxicology”. Steroids were not tested
for post-mortem.
8 Prisons and Probation Ombudsman
Findings
Mr Flanagan’s healthcare
45. During his time in Chelmsford, Mr Flanagan had frequent interaction with healthcare
services about his back pain. The only other issues he raised were some gastric
problems early in his time there, and dental issues.
46. Until he collapsed, there were no indications that Mr Flanagan was in ill-health or at
risk. Some needles had recently been found in his cell but there had been no
evidence to suggest that he was using illicit drugs. There were no reports of him
being intoxicated or appearing to be under the influence of anything.
47. His cellmate said that after Mr Flanagan died, he heard that two days before Mr
Flanagan collapsed, he had mentioned chest pain to another prisoner. There is no
record of him telling anybody else, and the prison were unable to identify the
prisoner. He did not tell the healthcare team. On the evening he collapsed he had to
interrupt a telephone call to his parents, again complaining of chest pain. Once
more, there is no evidence that he sought help at that time or told a member of
staff. In the circumstances, there is nothing to suggest that staff could have
anticipated what happened.
48. The clinical reviewer said that there were no concerns with Mr Flanagan’s physical
or mental healthcare, which was equivalent to that which he could have expected in
the community.
Substance misuse
49. After Mr Flanagan died, some intelligence reports suggested his involvement in
drug trading. In February, there was a drug find in his cell, but his cellmate admitted
ownership. In March, there were some needles found in the cell, which Mr Flanagan
owned up to, but no associated drugs. When he was taken to hospital a vape found
in the cell was found to contain traces of tetrahydrocannabinol (the main
psychoactive component of cannabis). Post-mortem toxicology tests did not detect
any traces in Mr Flanagan’s system. Traces of fentanyl, midazolam and pregabalin
were detected. Mr Flanagan had been prescribed pregabalin. Both fentanyl and
midazolam are used to sedate patients in intensive care and could have been
administered in hospital. The pathologist noted that the toxicological findings were
not significant and did not contribute to his death.
50. Mr Flanagan had a history of substance misuse. On arrival at Chelmsford, he did
not disclose any current substance misuse issues, so was not referred to the
substance misuse team. Although there was some intelligence to suggest that Mr
Flanagan might have been involved in the drug trade in Chelmsford, there was no
actual evidence of this. Nor was there any evidence of his taking any illicit
substances himself.
51. We are also aware that intelligence reports indicated that Mr Flanagan used
steroids. While there is some research to suggest a link between steroid use and
heart problems, there was no actual evidence of Mr Flanagan using them. Post-
Prisons and Probation Ombudsman 9
mortem blood tests would not detect the presence of steroids, so we are unable to
comment further.
Mobile telephones
52. We are concerned that Mr Flanagan was found in possession of a mobile phone in
April 2020, one was found in his cell in March 2021, and one was found in his cell
after he died. There were further intelligence reports that indicated that he was
suspected of having access to one. When he was taken to hospital, another
prisoner telephoned Mr Flanagan’s parents on a mobile phone. We are concerned
with the apparent ease with which prisoners seem able to access mobile phones,
which are often used by prisoners who are organising illicit items coming into
prison. We make the following recommendation:
The Governor should review the local security strategy and ensure that
everything possible is being done to prevent mobile phones entering the
prison.
Emergency response
Cell bells
53. The purpose of emergency cell bells is to enable prisoners to contact staff quickly in
an emergency. All emergency cell bells should be answered as quickly as possible
and not longer than five minutes from the time that the emergency bell is activated.
HMIP noted in their latest inspection of Chelmsford that there were delays in
answering cell bells.
54. Mr Flanagan’s cellmate said that he pressed his cell bell to attract staff attention.
The OSG said in her police statement that she and the officer heard a cell bell, but
attempted to finish a task they were involved in before the officer said that he
needed to leave to respond to the cell bell. She said this was approximately two
minutes. The timings of the cell bell records do not appear to be accurate (they
were not reset when the clocks changed for British Summer Time). But from the
records it seems that the officer arrived at the cell and answered the cell bell within
three minutes of it being pressed.
Emergency response codes
55. Prison Service Instruction (PSI) 3/2013, Medical Emergency Response Codes,
requires Governors to have a two-code medical emergency response system. As is
usual, Chelmsford use code blue to indicate an emergency when a prisoner is
unconscious, or having breathing difficulties, and code red when a prisoner is
bleeding. Calling an emergency code should automatically trigger the control room
to call an ambulance and should alert healthcare staff to attend with the appropriate
equipment.
56. The officer said that, on arriving at Mr Flanagan’s cell, he called a code blue
emergency. The recordings of the radio traffic provided did not include this
message, the first reference being a radio message from the OSG. It is possible
10 Prisons and Probation Ombudsman
that he shouted the code but did not use the radio. The control room log showed
that the OSG used the code at 8.24pm, and the Ambulance Service records
showed that the request for an ambulance was received at 8.26pm.
57. The landing was covered by CCTV cameras, but the quality of the recordings
provided was too poor to clearly see the sequence of events. The officer and the
OSG both indicated in interview that the time between them arriving at the cell was
minimal. Nevertheless, we are unable to be certain how long it was between the
officer arriving at the cell and the control room calling for an ambulance. In
emergency situations time can be crucial, and any delays must be kept to a
minimum.
58. We have commented several times in previous reports of investigations in
Chelmsford on staff failing to follow the correct emergency procedures in calling
emergency codes. In response to our recommendations, Chelmsford undertook a
programme of training that involved an emergency scenario exercise to reinforce
staff knowledge of what to do when faced with such a situation, including correct
use of radios. This began in October 2019 and was scheduled to be an annual
event. We acknowledge that the officer was a new member of staff, only completing
his training and starting his role less than a month before the emergency with Mr
Flanagan. It is, though, disappointing that once again we are commenting on the
same issue.
Entering Mr Flanagan’s cell
59. When the cellmate raised the alarm, the prison was in patrol state (meaning
prisoners are locked in their cells for the night and staffing may be reduced). Policy
on entering cells at night is contained in Prison Service Instruction (PSI) 24/2011
Nights Function – Management and Security of Nights. The PSI says that night staff
may unlock a cell on their own if there is or appears to be immediate danger to life.
Staff must, though, perform a dynamic risk assessment and should not take action
that they feel would put them in danger. Factors to consider include how many
prisoners are in the cell and whether the prisoners are known to the member of
staff.
60. The officer said in interview that he considered whether to go into the cell before
assistance arrived. He was unable to see what was wrong with Mr Flanagan, he did
not know either prisoner very well, and the cellmate was in a highly agitated state.
In the circumstances, it seems reasonable that he waited for assistance.
61. When the OSG joined the officer at the cell, they did not open the door until another
officer joined them. This officer said in police interview that three officers were
needed to open a cell, but as she was about to radio that she and the other officer
were going into the cell as an emergency, another officer came onto the wing, so
she unlocked the cell.
62. PSI 24/2011 says that, aside from emergencies, “authority to unlock a cell at night
must be given by the Night Orderly Officer (NOO) and no cell will be opened unless
a minimum of two/three (subject to local risk assessment procedures) members of
staff are present one of whom should be the NOO”. Chelmsford’s Prisoner
Supervision and Unlocking Operating Procedure says that when F wing is in patrol
Prisons and Probation Ombudsman 11
state there will be one officer on the wing, with “additional staff required before
unlocking”.
63. The recorded timings for cell bells are not accurate. The CCTV footage was of poor
quality and while we know in which order staff arrived, we were unable to accurately
determine the time lapse between the cellmate raising the alarm and staff going into
Mr Flanagan’s cell. While we do not know if the delay made any difference to the
outcome for Mr Flanagan, it may do in other emergency situations.
64. It is important that staff are clear on when they can unlock a cell. We make the
following recommendation:
The Governor should ensure that all prison staff are made aware of, and
understand their responsibilities during medical emergencies, including that
staff:
• understand and use the appropriate emergency code when they
discover a medical emergency;
• are clear when they may unlock cell doors; and
• enter cells as quickly as possible in life-threatening situations
where it is safe to do so.
The Governor should ensure that CCTV cameras are properly maintained and
fit for purpose.
Liaison with Mr Flanagan’s family
65. Prison Rule 22 states that prisons should inform the next of kin immediately if a
prisoner becomes seriously ill. PSI 64/2011, Managing Prisoner Safety in Custody,
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. If a prisoner’s health deteriorates a family liaison
officer should be appointed immediately and next of kin should be contacted.
66. When Mr Flanagan went to hospital, another prisoner telephoned his parents. They
telephoned the prison, who confirmed which hospital Mr Flanagan had been taken
to. The prison family liaison officer did not contact them until the following morning.
Mr Flanagan was in an induced coma in the High Dependency Unit. His condition
was serious. This was an unacceptable delay. Good practice would have been for a
senior member of staff or family liaison officer to meet Mr Flanagan’s parents at the
hospital.
67. While we appreciate the difficulties around prisoners having access to mobile
telephones, we are concerned that Mr Flanagan’s family were contacted by a
prisoner before an appropriate member of prison staff. We make the following
recommendation:
The Governor should ensure that an appropriate member of staff, preferably a
designated family liaison officer, contacts a prisoner’s family to notify them
immediately when a prisoner is seriously unwell.
12 Prisons and Probation Ombudsman
Inquest
68. The inquest, heard from 15 to 26 April 2024, concluded that Mr Flanagan died from
natural causes with the following narratives:
• The culture in Chelmsford prison around answering cell bells was not sufficiently
prioritised. This led to a delay which could have possibly contributed to death.
• The culture in Chelmsford prison around entering cells in emergency situations
and code blue alerts and inadequacies in training for entering cells. This led to
further delays to the start of resuscitation. This possibly contributed to his death.
Prisons and Probation Ombudsman 13
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