Brian Field

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Independent investigation into
the death of Mr Brian Field,
a prisoner at HMP Full Sutton,
on 4 February 2024
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
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© Crown copyright, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 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.
3. Mr Brian Field died of advanced gastric cancer on 4 February 2024 at HMP Full
Sutton. He was 87 years old. We offer our condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Field received at HMP Full
Sutton was of a good standard and equivalent to that which he could have expected
to receive in the community. The clinical reviewer noted that the medical care
provided was appropriate, compassionate and responsive, and made no
recommendations.
5. We found that the decisions to restrain Mr Field when he was taken to hospital on
19 January 2024, and subsequently while at hospital, were not justified given his
advanced age, health condition and poor mobility. In addition, when escort officers
asked for Mr Field’s restraints to be removed on 24 January, the decision to do so
was not made until over 24 hours later. This left Mr Field unnecessarily restrained,
with bruising caused by the restraint, for a prolonged period.
Recommendations
• The Governor should ensure that decisions to remove restraints are made promptly,
and where restraints are not removed, the decision is justified, and the rationale
clearly documented.
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The Investigation Process
6. HMPPS notified us of Mr Field’s death on 4 February 2024.
7. NHS England commissioned an independent clinical reviewer to review Mr Field’s
clinical care at HMP Full Sutton.
8. The PPO investigator investigated the non-clinical issues relating to Mr Field’s care.
She interviewed five members of staff from HMP Full Sutton on 9 and 11 April 2024.
Another PPO investigator took over the investigation in May 2024.
9. The Ombudsman’s office wrote to Mr Field’s 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. 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.
Previous deaths at HMP Full Sutton
11. Mr Field was the eighth prisoner to die at HMP Full Sutton since 4 February 2021.
Of the previous deaths, six were from natural causes and one was self-inflicted. In
two recent investigations, we identified similar concerns to those we have identified
in this investigation about the inappropriate use of restraints and made a
recommendation to Full Sutton to address this.
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Key Events
12. In 2001, Mr Brian Field was convicted of murder and was sentenced to life
imprisonment. On 14 December 2001, he was transferred to HMP Full Sutton. He
had multiple health conditions.
13. On 5 August 2021, a nurse saw Mr Field because he reported a poor appetite, loss
of weight and trouble swallowing. She arranged for him to see a GP.
14. On 9 August, a GP operating at Full Sutton saw Mr Field and arranged for him to
have a blood test, the results of which were abnormal.
15. On 16 August, a fast-track referral was completed for suspected lower gastro-
intestinal cancer. Mr Field had a faecal immunochemical test (FIT, which indicates
conditions, including bowel cancer), the result of which was negative.
16. On 3 September, Mr Field declined investigations for suspected lower gastro-
intestinal cancer, including a computerised tomography (CT) scan and a
colonoscopy.
17. On 9 August 2022, a nurse reviewed Mr Field due to recent complaints of chest
pain. He had an electrocardiogram (ECG) which was normal. Mr Field declined
hospital admission and was deemed to have mental capacity to make such
decisions.
18. On 18 August, a GP operating at Full Sutton saw Mr Field about his chest pain. Mr
Field declined to be referred to the hospital cardiology team and was assessed
again as having mental capacity to make this decision. The GP told Mr Field to tell
healthcare staff if he changed his mind or had further chest pain.
19. On 9 June 2023, a nurse saw Mr Field for his reported weight loss. He agreed to
have a blood test and give a stool sample.
20. On 23 June, a GP operating at Full Sutton saw Mr Field as he had iron deficiency
anaemia. Mr Field had another FIT test, the result of which was negative.
21. On 16 November, Mr Field had a blood test, the result of which was abnormal.
22. On 21 November, a prison GP reviewed Mr Field following his abnormal blood
results. Mr Field wanted to be referred to hospital for treatment. Another FIT test
was arranged to support referral for further investigations.
23. On 27 November, Mr Field’s FIT test results came back as positive.
24. On 12 December, a prison GP saw Mr Field and offered to refer him for a
colonoscopy or CT scan for suspected cancer. Mr Field told the GP that he would
prefer not to be referred for investigation. He said he knew that he may have cancer
which could shorten his life.
25. On 18 January 2024, a nurse saw Mr Field after the Disability Liaison Officer told
healthcare staff that Mr Field had not left bed for two weeks. When she reviewed
the wing observation book, she found that Mr Field had had a fall on 14 January
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which had not been reported to the healthcare team. She reminded the wing’s
Senior Officer (SO) that all falls should be urgently reported. She took observations
and advised Mr Field to rest. He was given a call bell to alert officers when he
needed help, and a social care referral was submitted as his mobility had
deteriorated.
26. On 19 January, a prison GP saw Mr Field as he had fallen over during the night and
been incontinent. The GP diagnosed him with iron deficiency anaemia. He was
admitted to hospital for an urgent blood transfusion. Before he left, the GP
completed a medical risk assessment and ticked a box to indicate he had no
medical objections to the use of restraints. An SO completed the security risk
assessment and identified that Mr Field posed a high risk to the public due to his
index offence. He also noted that Mr Field was a fully compliant prisoner with an
enhanced Incentives and Earned Privileges (IEP) status, he had no history of
disciplinary hearings, no behavioural concerns and there had been no incidents
when he had previously attended hospital.
27. The SO recommended that an escort cable (a long metal cable with a handcuff at
each end, one of which is attached to the prisoner and the other to an officer)
should be used as Mr Field’s health was deteriorating. As he was a category A
prisoner, the Deputy Governor decided that Mr Field should be escorted by an SO
and two officers. Mr Field was taken there in a wheelchair and restrained using an
escort cable.
28. On 21 January, Mr Field was unsteady on his feet and fell while going to the toilet.
A hospital doctor advised that he should not attend the toilet on his own. An escort
officer on bed watch duty phoned an SO in the Security Department to ask for Mr
Field’s restraints to be removed due to his fragility and age. When the Head of
Security visited the hospital that day, the escort officer raised her concerns with
him, and he told her that this would be looked into. (There is no record of their
conversation, but subsequent records indicate the restraints were not removed.)
29. On 22 January, a bed watch officer contacted the security team for authorisation to
remove Mr Field’s restraints for a CT scan. An SO phoned back after speaking to
the healthcare team and said that the escort cable did not need to be removed. The
records do not explain the rationale for this decision.
30. On 23 January, a hospital consultant told escort officers that Mr Field’s results
indicated possible terminal cancer, but they needed a biopsy to confirm this. During
a management check, the Head of Special Units decided that the escort cable
should remain in place. Escort records indicate that he considered Mr Field’s
category A status, age and current medical advice when deciding this.
31. On 24 January, a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order
was put in place. An escort officer on bed watch duty asked for Mr Field’s restraints
to be removed due to his age, frailty, possible terminal cancer and bruising on his
arm caused by the restraints. The restraints could not be moved to his other arm as
he had a cannula in place.
32. On 25 January, an SO phoned the bed watch officers and told them that the escort
cable could be removed, but they should consider reapplying it on Mr Field’s return
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to prison. A family liaison officer contacted Mr Field’s next of kin to inform them of
his condition.
33. On 26 January, a nurse visited Mr Field. She spoke to a hospital nurse, who told
her that Mr Field had a mass in his liver and in his pancreas. Mr Field was offered
palliative treatment but wanted to return to Full Sutton. He was discharged from
hospital that day and admitted to the prison’s inpatient palliative care suite. (We do
not know for sure if restraints were reapplied for the journey from the hospital to
prison, but one member of staff told us that they had been.)
34. On 27 January, an end-of-life care plan was created for Mr Field.
35. On 29 January, Mr Field’s daughter and son visited him in prison.
36. On 30 January, a prison GP saw Mr Field to discuss his diagnosis. Mr Field told the
GP that he would go back into hospital for a blood transfusion or for treatment of an
infection but did not want further investigation or treatment of his cancer.
37. On 3 February, a nurse attended Mr Field’s cell and found him unresponsive. She
reported that Mr Field did not appear in distress or pain. Wing staff agreed to
continue welfare checks and to tell healthcare staff if there were any changes in his
presentation.
38. At approximately 8.40am on 4 February, Mr Field died.
Post-mortem report
39. The post-mortem report concluded that Mr Field died of advanced gastric cancer.
Mr Field also had a liver abscess which did not cause but contributed to his death.
40. At inquest held on 1 October 2024, the Coroner concluded that Mr Field died of
natural causes.
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Non-Clinical Findings
Restraints, security and escorts
41. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility.
42. The Graham judgment in the High Court in 2007 made it clear that prison staff must
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when he has a serious medical
condition. It stated that medical opinion about the prisoner’s ability to escape must
be considered as part of the assessment process and kept under review as
circumstances change.
Emergency escort on 19 January
43. When Mr Field went to hospital on 19 January 2024, a prison GP completed a
medical risk assessment, but ticked a box to indicate that he had no medical
objections to the use of restraints. He told us that this might have been an error on
his part as Mr Field was very pale and weak and looked severely anaemic. As this
was a one-off, human error, we make no recommendation about this.
44. Although an SO recognised Mr Field’s deterioration in health, he recommended the
use of an escort cable on the basis of his perceived high risk. While the escort
assessment indicated that Mr Field was a compliant prisoner with no recent
behavioural concerns, the assessment of high risk appears to have been based on
his historic index offence. We identified that Mr Field also had a personal
emergency evacuation plan (PEEP) in place as he had limited mobility, he was
taken to the ambulance by wheelchair, and he had not left his bed for two weeks.
There is therefore no evidence that the decision to restrain Mr Field was based on
the actual risk he presented at the time of his admission to hospital or that the
Graham judgment was followed.
45. In a recent investigation, we identified similar concerns about the assessment of
risk during escorts. We made a recommendation to the Governor of Full Sutton to
ensure that staff understand the legal position on the use of restraints and take into
account a prisoner’s current level of risk. We therefore do not repeat this
recommendation but await the prison’s response.
Restraints during hospital admission
46. Escort officers repeatedly asked for Mr Field’s restraints to be removed between 21
and 24 January. However, it was not until 25 January that an SO told them to
remove the escort cable. Despite Mr Field complying with all instructions, behaving
well throughout his hospital admission and a doctor advising of his poor mobility, Mr
Field remained restrained in hospital for six days. We consider that the decision to
maintain the restraints was not justified.
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47. The Head of Security told us that he discussed the possibility of removing Mr Field’s
restraints with a colleague on 21 January, and they agreed that the restraints did
not need to be reduced as Mr Field’s risk had not reduced and he was not that
poorly at the time. He could not confirm whether this decision was communicated to
an SO and there is no record of any further action being taken.
48. The Head of Special Units told us that on 23 January, he decided that Mr Field’s
restraints should remain in place because they did not interfere with his medical
treatment and due to the risk he presented to the public as a category A prisoner.
Prison staff told us that as Mr Field had not completed any offender behaviour
programmes, his risk and category had not decreased since his offence. While we
recognise this, the index offence (while incredibly serious) had taken place in 1968,
some 55 years earlier. Mr Field’s behaviour in prison was good and his age, frailty,
health condition and poor mobility significantly reduced his risk. There is no
evidence that prison staff took these factors into account in their decision-making.
49. Decisions to remove restraints should be made promptly. Over 24 hours had
passed between the escort officer's request on 24 January for Mr Field’s restraints
to be removed and the decision being taken to do so on 25 January. Although we
appreciate that this decision required input from various internal and external
teams, the request should have been prioritised and actioned quickly to avoid Mr
Field remaining restrained for an unnecessarily prolonged period, particularly as he
had bruising caused by the restraints.
50. It is unclear from the paperwork whether Mr Field was restrained on his return to the
prison but one of the escort officers told us that he believed the escort cable was
applied as a precaution. There is no evidence that Mr Field’s condition had
improved and no record of any rationale for the decision to reapply restraints.
51. During Mr Field’s hospital admission, escort officers asked for his restraints to be
removed on three occasions. There is a lack of justification recorded for the
decision to keep the restraints in place, despite clear evidence that the restraints
should have been removed. We make the following recommendation:
The Governor should ensure that decisions to remove restraints are made
promptly, and where restraints are not removed, the decision is justified, and
the rationale clearly documented.
Governor to note
52. When Mr Field fell on 14 January 2024, a F213 form (which records injuries to
prisoners) was not completed, and the healthcare team was not notified until 18
January. The officer who recorded Mr Field’s fall in the wing observation book told
us that he did not complete a F213 form as Mr Field had declined healthcare
intervention. He is now aware that he should nonetheless have completed one and
told the healthcare team.
53. Records consistently indicate that an escort chain was used to restrain Mr Field, but
Full Sutton told us that this was an escort cable (which has been introduced more
recently). It would be helpful for records to indicate with accuracy which type of
restraint was used.
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Good practice
54. HMP Full Sutton provided the information we needed for our investigation and
responded to our further questions in a very timely manner.
Adrian Usher
Prisons and Probation Ombudsman July 2024
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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