Coleman, Kevin

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Kevin Coleman,
a prisoner at HMP Wymott,
on 25 October 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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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. On 21 September 2018 Mr Kevin Coleman was sentenced to 13 years in prison for
sex offences. He was transferred to HMP Wymott on 15 February 2023.
4. Mr Coleman died of infective exacerbation of interstitial lung disease (this is a
condition where an infection triggers a sudden deterioration of respiratory function)
on 25 October 2023. He also had heart failure (progressive heart disease that
affects the pumping action of the heart), chronic obstructive pulmonary disease (a
lung condition that makes breathing difficult), and acute kidney injury (sudden and
rapid loss of kidney function) which contributed to but did not cause the death. He
was 87 years old. We offer our condolences to Mr Coleman’s family and friends.
5. The PPO family liaison officer wrote to Mr Coleman’s next of kin, his friend, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She had no questions but asked for a copy of our report.
6. The PPO investigator investigated the non-clinical issues relating to Mr Coleman’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
7. NHS England commissioned an independent clinical reviewer to review Mr
Coleman’s clinical care at HMP Wymott.
8. The clinical reviewer concluded that the clinical care Mr Coleman received at
Wymott was of a reasonable standard and equivalent to that which he could have
expected to receive in the community. She found that Mr Coleman’s medical
records contained evidence of individualised end of life care planning with kind,
respectful and compassionate interactions between Mr Coleman the healthcare
team.
9. The clinical reviewer made one recommendation, not related to Mr Coleman’s
death, that the Head of Healthcare will wish to address.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Coleman’s friend received a copy of the initial report. She noted one inaccuracy
in the clinical review that was amended.
12. The inquest into Mr Coleman’s death was held on 2 May 2024 and a verdict of
natural causes was recorded. The coroner concluded that Mr Coleman’s death was
due to infective exacerbation of interstitial lung disease (a condition where an
infection triggers a sudden deterioration of respiratory function). He also had heart
failure (progressive heart disease that affects the pumping action of the heart),
chronic obstructive pulmonary disease (a lung condition that makes breathing
difficult), and acute kidney injury (sudden and rapid loss of kidney function) which
contributed to but did not cause the death.
Adrian Usher May 2024
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