Wilson, John

Independent investigation into
the death of Mr John Wilson,
a prisoner at HMP Forest Bank,
on 17 June 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
Our vision
To carry out independent investigations to make
custody and community supervision safer and fairer
Our values
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Impartial: we do not take sides
Respectful: we are considerate and courteous
Inclusive: we value diversity
Dedicated: we are determined and focused
Fair: we are honest and act with integrity
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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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr John Wilson died in hospital on 17 June 2022 of pneumonia (a lung infection),
while a prisoner at HMP Forest Bank. He also had a urinary tract infection,
diabetes mellitus, chronic obstructive pulmonary disease (COPD, a lung disease),
previous lung cancer and previous bladder cancer which contributed to but did not
cause his death. He was 75 years old. We offer our condolences to Mr Wilson’s
family and friends.
4. The clinical reviewer concluded that the clinical care that Mr Wilson received at
Forest Bank was equivalent to that which he could expect to receive in the
community. The clinical reviewer made no recommendations.
5. Staff at Forest Bank appropriately applied to transfer Mr Wilson to a prison with 24-
hour healthcare facilities, but there was no follow up to provide additional
information when the initial applications were turned down despite concerns that the
facilities at Forest Bank were unsafe for him. There was no evidence that prison
staff completed an application for early release on compassionate grounds and,
while there were some obstacles to the application, we are concerned that the
process was not managed efficiently. We also found that a ROTL application did
not progress once the board had approved the application.
Recommendations
• The Director and Head of Healthcare should ensure that there is an
escalation process in place for those prisoners whose needs would be
better met by a transfer to a prison with 24-hour healthcare.
• The Director should ensure that applications for ROTL and early release
on compassionate grounds for prisoners with terminal illnesses are
considered, prioritised and completed without delay, keeping a record of
action taken.
Prisons and Probation Ombudsman 1
The Investigation Process
6. NHS England commissioned an independent clinical reviewer to review Mr Wilson’s
clinical care at HMP Forest Bank.
7. The PPO investigator investigated the non-clinical issues relating to Mr Wilson’s
care, including Mr Wilson’s location, the security arrangements for his hospital
escorts, liaison with his family and whether compassionate release was considered.
8. The PPO family liaison officer wrote to Mr Wilson’s wife to explain the investigation
and to ask if she had any matters they wanted us to consider. She did not respond
to our letter.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Forest Bank
10. Mr Wilson was the ninth prisoner to die at Forest Bank since June 2020. Of the
previous deaths, four were from natural causes, one was self-inflicted, two were
drug related and one is awaiting classification. There are no significant similarities
with our findings in these deaths and the investigation into Mr Wilson’s death.
2 Prisons and Probation Ombudsman
Key Events
11. On 12 June 2017, Mr John Wilson was convicted of sex offences and sent to prison
for 15 years. Mr Wilson was sent to HMP Forest Bank.
12. On arrival at Forest Bank, healthcare staff noted a previous medical history of lung
cancer, bowel cancer, removal of the spleen and part of the colon, diabetes, high
blood pressure and epilepsy.
13. In April 2019, Mr Wilson received a diagnosis of bladder cancer.
14. On 5 December, Mr Wilson moved onto the healthcare unit at Forest Bank due to
an increased need for social care assistance. The healthcare unit consists of 19
beds in single and double cells, and one four-bed bay. Social health care assistants
attend to prisoners as per their personal care plans. No dedicated healthcare staff
are attached to the unit. Mr Wilson was given a hospital bed with an airflow
mattress.
15. On 17 October 2020, Mr Wilson said that he did not want anyone to resuscitate him
if his heart or breathing stopped and signed an order to that effect.
16. In early December 2021, the Resettlement Manager and the Head of Resettlement
emailed HMP Risley and HMP Wymott to apply to move Mr Wilson to their
establishments. Both Risley and Wymott have 24-hour healthcare facilities and Mr
Wilson would have lived on a specialist healthcare centre that is staffed with
designated healthcare staff.
17. On 6 December, Mr Wilson’s health deteriorated. A nurse spoke with Mr Wilson
about transferring him into hospital for his own safety and pain management. Mr
Wilson agreed, an ambulance was requested, and he was sent to hospital.
18. On 8 December, a CT scan showed that Mr Wilson had brain cancer. Mr Wilson
stated that he did not want treatment.
19. On 10 December, a Custodial Manager (CM) at Wymott replied to the Head of
Resettlement’s email. He explained that they were unable to take Mr Wilson due to
a COVID-19 outbreak and a lack of a suitable cell to care for him. He said that they
may be able to reconsider after New Year.
20. On 14 December, the Head of Healthcare at Risley replied to the Head of
Resettlement’s email. He explained that they had no capacity for Mr Wilson and
that to consider him in the future they would need a copy of his healthcare
assessments and care plans to discuss with the care providers.
21. On 7 January 2022, a nurse noted that the hospital consultant had phoned to
update them of Mr Wilson’s condition. She noted that Mr Wilson was in the last two
months of his life due to bladder cancer.
22. On 18 January, a nurse noted that healthcare staff were preparing an application for
early release on compassionate grounds and that Forest Bank had asked the
hospital consultant for a letter of support.
Prisons and Probation Ombudsman 3
23. On 10 February, Mr Wilson returned to Forest Bank from a two month stay in
hospital. A nurse noted that Mr Wilson required the assistance of two people to
mobilise. She noted that he had been released without a care package in place, or
instruction on how to use a back brace with which he had been issued due to a
back fracture. She also noted that a safeguarding referral had been made to
Salford City Council and a Datix had been submitted due to an unsafe discharge.
(Datix is an incident reporting and risk management tool used by healthcare. It
allows reporters to record incidents and includes the option to record safeguarding
concerns. It then notifies managers of the incident in order to start an
investigation.)
24. On 17 February, a nurse reviewed a hospital discharge letter which stated that Mr
Wilson had a prognosis of 6-12 months. A palliative care plan was created to
consider Mr Wilson’s needs. She noted that the letter stated that Mr Wilson’s back
fracture was unstable and that Forest Bank had not been aware of this. A palliative
care plan completed that day states that compassionate release should be
arranged if appropriate.
25. On 18 February, Mr Wilson was transferred back to hospital, as Forest Bank could
not meet his healthcare needs with the primary care services that they provided. Mr
Wilson was discharged back to Forest Bank on 18 March.
26. On 23 March, Mr Wilson was transferred back to hospital due to a deterioration in
his presentation and a high need for support and social care which Forest Bank
were unable to provide. He was discharged back to Forest Bank on 28 April.
27. On 14 May, a prison GP reviewed Mr Wilson due to high potassium levels and a
deterioration in his presentation. He sent Mr Wilson to hospital.
28. On 24 May, a nurse spoke to the ward sister at the hospital. She noted that the
ward sister told her that Mr Wilson would be discharged later that evening and that
hospital managers had overridden her decision to keep him in hospital. She
advised the ward Sister of unsafe discharge and limited staffing and equipment at
Forest Bank.
29. On 25 May, prison staff met to discuss an application for release on temporary
licence (ROTL) in order to reduce the need for officers to accompany Mr Wilson in
the hospital. On the same day, Mr Wilson was discharged back to Forest Bank.
30. On 26 May, Forest Bank made a referral for Mr Wilson to transfer to HMP
Manchester for 24-hour healthcare. This referral was declined by Manchester, as
he did not meet their criteria.
31. The same day, a nurse reviewed Mr Wilson, as he was experiencing tightening
around his chest and a productive cough. She noted that he had a National Early
Warning Score (NEWS2) of five, which requires an urgent clinical review. (NEWS2
is a tool to detect and respond to clinical deterioration. A score above seven
indicates the need for an emergency response.) Due to Mr Wilson’s extensive
medical history, the sound of the cough, his mobility and the new onset chest pain,
she sent Mr Wilson to hospital. He was discharged back to Forest Bank the
following day.
4 Prisons and Probation Ombudsman
32. On 27 May, the ROTL application was sent to the prison Director. He reports that
they did not make a final decision on the ROTL as Mr Wilson was due to be sent
back to the prison.
33. On 31 May, a prison GP reviewed Mr Wilson when he reported that he was very
lethargic with decreased fluid intake and urinary output. She requested that he was
sent to hospital.
34. On 14 June, Mr Wilson was discharged back to Forest Bank.
35. At approximately 3.30pm on 15 June, a nurse and a prison GP went to see Mr
Wilson because officers reported that he was choking. The GP noted that Mr
Wilson was awake and able to speak though he was generally weak and having
difficulty coughing. He listened to Mr Wilson’s chest and requested an ambulance
to send Mr Wilson to hospital for a chest x-ray and antibiotics. The nurse noted that
she had spoken to a colleague, who confirmed there would be a meeting the next
day to discuss early release on compassionate grounds for Mr Wilson, to prevent
him going in and out of hospital. We were not provided with any information about
the outcome of this meeting or whether it took place.
36. On 17 June, Mr Wilson died at Salford Royal Hospital.
Post-mortem report
37. The post-mortem report concluded that Mr Wilson died of pneumonia (a lung
infection). He also had a urinary tract infection, diabetes mellitus, chronic
obstructive pulmonary disease (COPD, a lung disease), previous lung cancer and
previous bladder cancer which contributed to but did not cause his death.
38. At an inquest held on 7 September 2023, the Coroner concluded that Mr Wilson
died of natural causes.
Prisons and Probation Ombudsman 5
Findings
Location
39. The clinical reviewer was satisfied that Forest Bank and the hospital healthcare
team had regular communication between them regarding Mr Wilson’s care,
treatment, and the most appropriate location to meet his needs. We are satisfied
that Mr Wilson was correctly located on the healthcare wing at Forest Bank and had
suitable social care equipment to support his care needs.
40. However, Forest Bank highlighted in December 2021 that they felt Mr Wilson
required a higher level of care than they could provide. Prison resettlement staff
made contact with Risley and Wymott, which both have 24-hour healthcare
facilities. Neither of those prisons were able to take Mr Wilson at that time. Risley
requested that healthcare assessments and care plans were provided so that they
could review them to consider a future transfer. Wymott stated they would not be
able to take Mr Wilson but could reconsider in the New Year. We have not seen
any evidence that these documents were sent to Risley to consider, or that either of
these applications for transfer were followed up again after December 2021.
41. During the period from 6 December to his death on 17 June, Mr Wilson spent
approximately 5 months in hospital with short discharges back to Forest Bank. On
at least two occasions, nursing staff felt the discharges were unsafe. It is
disappointing that Forest Bank did not make further attempts to move Mr Wilson to
a prison with 24-hour healthcare which might better meet his needs.
42. We make the following recommendation:
The Director and Head of Healthcare should ensure that there is an escalation
process in place for those prisoners whose needs would be better met by a
transfer to a prison with 24-hour healthcare.
Compassionate release
43. Early release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. A clear
medical opinion of life expectancy is required. The criteria for early release are set
out in the Early Release on Compassionate Grounds Policy Framework. Among
the criteria is that the risk of reoffending is expected to be minimal, further
imprisonment would reduce life expectancy, there are adequate arrangements for
the prisoner’s care and treatment outside prison, and release would benefit the
prisoner and his family. An application for early release on compassionate grounds
must be submitted to the Public Protection Casework Section (PPCS) of HM Prison
and Probation Service (HMPPS).
44. Mr Wilson’s medical records note that a compassionate release application was
being completed after the hospital consultant told Forest Bank in early January that
he was in the last two months of his life. The hospital discharge letter received at
Forest Bank in mid-February confirmed that Mr Wilson had a prognosis of 6-12
months. This longer prognosis meant that an application was not suitable at this
6 Prisons and Probation Ombudsman
time. Forest Bank told the investigator that the application was not progressed as it
was unlikely that early release on compassionate grounds would be granted due to
Mr Wilson’s high risk of harm and his offence details.
45. On 15 June, a nurse recorded in the medical records that there was due to be a
meeting to discuss compassionate release for Mr Wilson on 16 June. No
information was provided to the investigator about the meeting on 16 June.
46. We recognise that it was appropriate not to complete an application for
compassionate release in February 2022, as Mr Wilson’s prognosis at the time
meant that he did not meet the criteria for early release. However, there is little
evidence that this was reviewed over the following months. While there might have
been obstacles to overcome relating to the application for compassionate release
for Mr Wilson, we are concerned that the compassionate release process was not
managed efficiently. We have seen no evidence that the compassionate release
application form was completed, and Forest Bank did not provide any record of
related discussions or decisions. We are concerned that no prison manager took
effective control of the process. We were not therefore able to identify why this did
not progress and cannot judge whether compassionate release was considered
appropriately or not.
47. Release on temporary licence (ROTL) can be granted for precisely defined and
specific activities which cannot be provided in the prison. A risk assessment is
completed to ensure that the prisoner’s temporary release does not present
unacceptable risks. The Director of the prison is able to grant the temporary licence
and will decide on whether the prisoner is to be accompanied by staff.
48. An application for ROTL was considered on 25 May by a board of prison staff.
Forest Bank confirmed that the board supported granting Mr Wilson ROTL, however
this was not signed off by the prison Director. This application was sent to him on
27 May. He reports that it was not signed off as Mr Wilson was due back to the
prison. However, very soon afterwards Mr Wilson was admitted to hospital for two
weeks with no evidence that ROTL was further considered.
49. We make the following recommendation:
The Director should ensure that applications for ROTL and early release on
compassionate grounds for prisoners with terminal illnesses are considered,
prioritised and completed without delay, keeping a record of action taken.
Mark Judd
Acting Assistant Prisons and Probation Ombudsman May 2024
Prisons and Probation Ombudsman 7
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