Christopher Coughlan

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Independent investigation into the
death of Mr Christopher Coughlan,
a prisoner at HMP The Verne,
on 26 June 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, 2025
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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 Christopher Coughlan died in hospital of pancreatic cancer on 26 June 2024,
while a prisoner at HMP The Verne. He was 61 years old. We offer our condolences
to Mr Coughlan’s family and friends.
4. Mr Coughlan collapsed in his cell on 7 June and was taken to hospital. He was
diagnosed with terminal cancer on 19 June and remained in hospital until he died a
week later.
5. The clinical reviewer concluded that the clinical care Mr Coughlan received at The
Verne was equivalent to that which he could have expected to receive in the
community.
6. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Coughlan’s death on 26 June 2024.
8. NHS England commissioned an independent clinical reviewer to review Mr
Coughlan’s clinical care at HMP The Verne.
9. The PPO investigator investigated the non-clinical issues relating to Mr Coughlan’s
care.
10. Mr Coughlan had no identified next of kin so there was no family involvement in this
investigation.
11. We shared our initial report with HMPPS and the prison’s healthcare provider,
Oxleas NHS Foundation Trust. They found no factual inaccuracies.
Previous deaths at HMP The Verne
12. Mr Coughlan was the tenth prisoner to die at HMP The Verne since June 2022. Of
the previous deaths, eight were from natural causes and one was self-inflicted. In a
previous investigation, we identified a delay in progressing an application for early
release on compassionate grounds, which we brought to the attention of the
Governor and Head of Healthcare.
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Key Events
13. In May 2009, Mr Christopher Coughlan was sentenced to life in prison for sexual
offences. He was in good health and had limited interactions with healthcare staff
throughout his time in prison. He was offered bowel cancer screening in June 2020,
but no further information is recorded. He was offered it again in May 2022 but
declined.
14. On 18 March 2024, Mr Coughlan was moved to HMP The Verne. He was offered
bowel cancer screening in April but declined.
15. On 14 May, Mr Coughlan asked for a healthcare appointment as he said he was
having issues with his hiatus hernia and wanted medication to reduce stomach acid.
His medical record shows that a nurse appointment was given but there is no
further information to show this took place.
16. On 26 May, Mr Coughlan made another request for a healthcare appointment. He
said that he had stomach pain, reflux, vomiting and felt lethargic.
17. A GP saw Mr Coughlan on 3 June. Mr Coughlan said that he had concerns about
his hiatus hernia, reflux and fatigue, and had lost 3kg in weight since arriving at The
Verne. The GP requested blood tests and suggested an urgent OGD (Oesophagus
Gastro Duodenoscopy, a camera view of the oesophagus, stomach and small
bowel) but Mr Coughlan declined.
18. On 7 June, Mr Coughlan collapsed in his cell. Staff called an ambulance and Mr
Coughlan was taken to hospital. He was accompanied by two prison officers who
used an escort chain (a long chain with a handcuff at each end, one of which is
attached to the prisoner’s wrist and the other to an officer’s wrist.)
19. On 8 June, a hospital doctor told Mr Coughlan he had colon cancer and the
prognosis was poor.
20. On 10 June, staff reduced the restraint level from a standard escort chain to a
lightweight escort chain.
21. On 17 June, hospital staff informed the prison by phone that Mr Coughlan’s
condition had worsened. He was unable to tolerate fluids, was vomiting
continuously, and was receiving palliative care.
22. On 19 June, Mr Coughlan was diagnosed with advanced pancreatic cancer and told
that he had weeks to live. The same day, the Head of Healthcare emailed the
Offender Management Unit and the GP at the prison asking them to start an
application for early release on compassionate grounds.
23. On 24 June, a prison manager authorised that no restraints should be used on Mr
Coughlan and staff removed the escort chain.
24. On 25 June, Mr Coughlan started to receive end of life care.
25. On 26 June, Mr Coughlan died in hospital.
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Cause of death
26. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Coughlan’s cause of
death as metastatic adenocarcinoma.
27. The inquest, held on 18 December 2024, concluded that Mr Coughlan died from
natural causes.
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Findings
Clinical care
28. The clinical reviewer concluded that the clinical care Mr Coughlan received at The
Verne was of a good standard and was equivalent to that which he could have
expected to receive in the community.
Restraints, security and escorts
29. 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. A judgment in the High Court in 2007 made it clear that prison staff need to
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 suffering from a serious
medical condition. It said 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.
30. The policy on Prevention of Escape – External Escorts states that a fresh risk
assessment must be conducted when there is change in the prisoner’s condition.
Mr Coughlan’s condition declined on 17 June, and he started receiving palliative
care. From 20 June, he needed help with washing and using the toilet. However,
prison staff did not update the risk assessment until 24 June, when they noted his
health had declined and authorised the removal of restraints.
31. We consider that restraints should have been removed from Mr Coughlan when his
condition declined on 17 June. The investigator put this to the Head of Security at
The Verne, who accepted that restraints should have been removed earlier. He
agreed to remind custodial managers to review the condition of prisoners in hospital
and to check risk assessments were updated accordingly. We bring this to the
attention of the Governor.
Compassionate release
32. 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 HMPPS.
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33. Following Mr Coughlan’s terminal diagnosis on 19 June, the Head of Healthcare
sent an email to the GP at the prison and the Offender Management Unit asking for
an application for early release on compassionate grounds to be started. However,
there was no evidence that the application was started nor that the GP had
requested a report from a medical specialist as required. We accept that Mr
Coughlan’s decline was rapid, and the delay made no difference in this case.
Nevertheless, we bring it to the attention of the Governor and the Head of
Healthcare.
Adrian Usher
Prisons and Probation Ombudsman December 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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