Cheryl Thompson

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Cheryl
Thompson on 21 August 2023,
following her release from HMP
New Hall.
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
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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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Ms Cheryl Thompson died of multi organ failure on 21 August 2023 following her
release from HMP New Hall on 18 August 2023. She was 47 years old. We offer
our condolences to those who knew her.
5. We did not find any issues relating to how prison or probation staff managed her
release, and we make no recommendations.
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The Investigation Process
6. HMPPS notified us of Ms Thompson’s death on 22 August 2023.
7. The PPO investigator obtained copies of relevant extracts from Ms Thompson’s
prison and probation records.
8. We informed HM Coroner for Wakefield of the investigation. We have sent the
Coroner a copy of this report.
9. The Ombudsman’s family liaison officer contacted Ms Thompson’s daughter to
explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP New Hall
11. HMP New Hall is a closed prison which holds up to 381 female prisoners aged over
18 who have either been convicted or are on remand. It is managed by HMPPS.
The physical and mental health provider is Practice Plus Group, Health in Justice
and the substance misuse treatment provider is Inclusion, Midlands Partnership
NHS Foundation Trust.
Probation Service
12. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
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Key Events
13. On 19 August 2020, Ms Cheryl Thompson was remanded to HMP New Hall. On 14
October, she was convicted of robbery and was sentenced to 41 months in prison.
Ms Thompson stayed at New Hall.
14. Ms Thompson had some medical conditions including asthma and Raynaud’s
disease. (Raynaud’s disease causes some areas of the body such as fingers and
toes to feel numb and cold in response to cold temperatures or stress. Smaller
arteries that supply blood to the skin narrow which limits blood flow to affected
areas.) Her medical records indicated that she had always struggled with managing
her health.
15. On 15 May 2022, Ms Thompson was released from New Hall.
16. While Ms Thompson was in the community, her health issues increased.
Professionals working with her initially believed her problems to be linked to her
asthma and Raynaud’s disease. Ms Thompson also had a history of substance
misuse and took heroin and crack cocaine in the community.
17. Ms Thompson struggled to stay abstinent from drugs when she was in the
community. She was supported by Calderdale Recovery Steps (delivering drug and
alcohol treatment services). Ms Thomson was allocated a drug treatment worker.
18. On 6 March, the drug treatment worker accompanied Ms Thompson to a GP
appointment. The GP did not raise any concerns.
19. Ms Thompson’s Community Offender Manager (COM) told us that by May 2023,
the concerns about Ms Thompson’s health had increased. Ms Thompson struggled
with accessing medical care in the community. She did not always book or attend
her medical appointments. The COM supported her to arrange appointments with
her GP.
20. In May, the GP referred Ms Thompson to the oncology unit for tests for cancer,
however Ms Thompson missed the appointments and the consultant referred Ms
Thompson back to her GP.
21. Ms Thompson started to lose weight and reported new pain symptoms, so the COM
again supported her to arrange an appointment with her GP. She called the
oncology nurse with Ms Thompson; she also attended her consultant appointment
but was unable to attend the scan appointment so made arrangements for Ms
Thompson’s housing worker to accompany her. She also arranged to pick Ms
Thompson up from the appointment.
22. On 9 June, the COM referred Ms Thompson to the Making Every Adult Matter multi-
disciplinary team (MDT) meeting in Calderdale, who work with complex individuals
who struggle with everyday life. She made the referral because she was worried
about Ms Thompson’s health as she was not attending her health appointments.
23. Ms Thompson continued to lose weight and experience pain. The Probation Service
tried to avoid recalling Ms Thompson to prison to help her get the right support for
her health. However, there were also concerns with her persistent drug use that
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was linked to her offending behaviour, and doubts whether probation could manage
her risk effectively in the community.
24. On 27 July, Ms Thompson was recalled to prison for 28 days due to her lack of
engagement with community services and continued drug use. Ms Thompson had
failed to attend probation appointments, had not attended medical appointments,
and was not engaging with Recovery Steps drug service. Ms Thompson did not
have a diagnosis for her ill health at this time.
25. Following her arrest and while at the police station, Ms Thompson complained of
chest pain so was immediately taken to Calderdale Royal Infirmary hospital. The
police officer told the COM that Ms Thompson had suffered a mild heart attack due
to a blood clot and she was sedated and intubated. They described her condition as
life threatening and she was under constant review, however the consultant
believed her condition would improve over the next few days, which it did.
26. While in hospital on 3 August, Ms Thompson had a biopsy taken for a possible
abdominal mass or abdominal tuberculosis. The same day, hospital staff said Ms
Thompson was medically fit for discharge and she returned to New Hall.
27. When Ms Thompson arrived at New Hall, the wing staff completed hourly
observations due to her ill health. The consultant informed healthcare staff that Ms
Thompson had suspected abdominal tuberculosis and the staff entering her cell
needed to wear full PPE. Ms Thompson was able to communicate normally,
however she had limited mobility.
28. On 4 August, Ms Thompson’s breathing became irregular, she was vomiting, and
her health had deteriorated. The prison called an ambulance and the paramedics
transferred Ms Thompson to Pinderfields hospital. Two prison officers escorted her,
and she was restrained using an escort chain. On 6 August, a prison manager
authorised for the restraints to be removed due to the seriousness of Ms
Thompson’s condition. The next day, Ms Thompson was moved to the intensive
care unit under the critical care team.
29. On 8 August, a nurse at New Hall, spoke to a hospital nurse. The hospital nurse
said that Ms Thompson had a very poor prognosis, she was still being treated but
was not suitable for resuscitation. Ms Thompson was treated for sepsis, pneumonia
(an infection that inflames the lungs), cardiac failure (when the heart is unable to
pump blood around the body properly), LV thrombus (a serious complication of
acute myocardial infarction), ventricular compromise (caused by hypertension) and
acute kidney injury (AKI - sudden damage to the kidneys that causes them to not
work properly). Ms Thompson was referred to the palliative care team at
Pinderfields hospital.
30. On 11 August, a nurse received a call from the hospital. Staff there informed her
that Ms Thompson had breast cancer which had spread to other parts of her body.
She was not suitable for chemotherapy or surgery and the plan was for her to start
oral treatment. Ms Thompson was now considered suitable for palliative care.
31. That day, the Governor at New Hall approved a special purpose licence (SPL -
when the prison approves short term release to prisoners for medical, court, or
compassionate proceedings) for Ms Thompson due to her deteriorating health.
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However, two prison officers remained at the hospital with Ms Thompson for
pastoral care.
32. On 18 August, Ms Thompson was released from prison at the end of her sentence,
but she stayed in hospital as she was too unwell to be discharged. The hospital was
hoping to move Ms Thompson into a hospice when a space became available.
33. On 21 August, Ms Thompson died in hospital.
Cause of death
34. A post-mortem examination was not carried out as the coroner accepted the cause
of death provided by a doctor. The doctor gave Ms Thompson’s cause of death as
multi organ failure (when two or more organs in the body fail to support the body’s
needs) due to pneumonia (an infection that inflames your lungs) and metastatic
carcinoma of the breast (cancer started in the breast but which has spread to other
parts of the body).
35. The coroner concluded it was not necessary for an inquest to take place.
Findings
36. We did not find any issues of concern and make no recommendations. We are
satisfied that prison and probation staff supported Ms Thompson with the
deterioration of her health. The healthcare team at New Hall regularly contacted the
hospital for updates on Ms Thompson’s condition, and when she returned from the
hospital staff monitored her appropriately.
Good practice
37. Currently, COMs across the Probation Service have high caseloads working with
complex individuals, and providing support and prioritising need is imperative. We
consider that the COM who had overall responsibility for Ms Thompson’s risk
management went well above and beyond her professional duty to support Ms
Thompson in the community. She arranged medical appointments and
accompanied Ms Thompson to them (or ensured someone else was able to). She
tried to avoid recalling Ms Thompson to prison so that she could access the medical
help she needed.
Adrian Usher
Prisons and Probation Ombudsman April 2024
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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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