Christopher Reed

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Independent investigation into
the death of Mr Christopher Reed,
a prisoner at HMP Isle of Wight,
on 24 January 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
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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. 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 Christopher Reed died in hospital on 24 January 2022, while a prisoner at HMP
Isle of Wight. He was 63 years old. The cause of Mr Reed’s death was respiratory
failure, due to COVID-19 pneumonia and underlying chronic obstructive pulmonary
disease (COPD). I offer my condolences to Mr Reed’s family and friends.
4. The clinical reviewers found that Mr Reed’s care was equivalent to that which he
could have expected to receive in the community. However, they recommended
that prisoners who decline vaccinations and clinical investigations should be given
the opportunity to discuss and reconsider their decisions and offered support. They
also recommended a review of out-of-hours GP provision.
5. We are concerned that there was a lack of clarity about family contact after Mr
Reed’s death, resulting in a delay of several months before his funeral was
arranged. This might have been avoided if contact after his death had been properly
documented and staff had provided written information on the processes after a
death.
6. Mr Reed appears to have caught COVID-19 at Isle of Wight, as he had twice tested
negative two weeks before his positive test.
Recommendations
• The Head of Healthcare should ensure that prisoners who decline COVID-19
vaccinations are given the opportunity to reconsider their decision, and that
healthcare staff discuss and record the reasons for the refusal.
• The Head of Healthcare should ensure that if a patient refuses investigation of
potential medical conditions, healthcare staff fully explore and document the
reasons, and consider whether they need information or support to address any
concerns.
• The Head of Healthcare should review the use of the NHS 111 service to determine
whether there is a need to extend the provision of prison GPs.
• The Governor should ensure that the method of communication with bereaved
families is appropriate to their needs and that all contact is fully documented.
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The Investigation Process
7. NHS England commissioned independent clinical reviewers to review Mr Reed’s
clinical care at HMP Isle of Wight.
8. The PPO investigator investigated the non-clinical issues, including aspects of the
prison’s response to COVID-19 and shielding prisoners, Mr Reed’s location, the
security arrangements for his journey and admission to hospital, liaison with his
family and whether early release was considered.
9. The Ombudsman’s family liaison officer wrote to Mr Reed’s next of kin, his mother,
to explain the investigation and ask if there were any issues she wanted us to
consider. She did not respond.
10. The investigation was suspended while waiting for the cause of Mr Reed’s death.
Previous deaths at HMP Isle of Wight
11. Mr Reed was the nineteenth prisoner at Isle of Wight to die since January 2020. Of
the previous deaths, fourteen were from natural causes (three due to COVID-19)
and four were self-inflicted. There have since been six deaths (four from natural
causes, one self-inflicted and one to be determined. There are no similarities
between the findings in this investigation and those of the previous deaths.
COVID-19 (coronavirus)
12. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
13. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. In response to the
pandemic, HM Prison and Probation Service (HMPPS) introduced several
measures to try and contain outbreaks - to be implemented at local level, depending
on the needs of individual prisons. (A key strategy was ‘compartmentalisation’ to
cohort and protect prisoners at high and moderate risk; isolate those who are
symptomatic; and separate newly arrived prisoners from the main population.)
14. In September 2021, the Government advised that it was no longer necessary for the
clinically vulnerable to shield, on the basis that vaccination had reduced the risk.
HMPPS initially continued to routinely offer shielding to clinically high-risk prisoners.
This has been replaced by a system of individual risk assessments by clinical staff,
to determine the measures necessary to support such prisoners. The agreed
adjustments are documented in a Personal Management Plan, which is then
facilitated by operational staff.
15. In Mid-November 2021, Isle of Wight had an outbreak of COVID-19. The prison was
placed in lockdown and there was mass testing of prisoners. On 2 December,
following a review, the restrictions were lifted, and symptomatic testing replaced
mass testing.
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Key Events
16. Mr Christopher Reed was convicted of sexual and other violent offences on 25
September 2018 and remanded to HMP Lewes. It was not his first time in prison.
He was later sentenced to 15 years imprisonment. On 27 December, Mr Reed was
transferred to HMP Isle of Wight. He then spent a year in HMP High Down and
returned to Isle of Wight (Albany site) on 14 December 2021.
17. A nurse conducted an initial health screen. She recorded that Mr Reed had no
significant physical health conditions but was obese and his pulse rate and blood
pressure were both raised. There was no evidence of a second-stage health
assessment.
18. As a new prisoner, Mr Reed took lateral flow tests for COVID-19 on 14 and 20
December. Both were negative.
Deterioration in Mr Reed’s health
19. On 4 January 2022, Mr Reed took a lateral flow test, which was positive. A PCR
test was therefore taken and sent for analysis. The reason he was tested was not
recorded. Mr Reed was expected to self-isolate for ten days and advised to contact
healthcare if he felt unwell.
20. On 5 January, healthcare staff gave Mr Reed information about the monitoring
procedures, including daily welfare and symptom checks. During a check in the
afternoon, a healthcare assistant found that he had a slight cough (which Mr Reed
had attributed to vaping) but no temperature.
21. Later that afternoon, a nurse reviewed Mr Reed. She noted there was no cough or
shortness of breath and that his temperature and respiratory rate were normal.
However, he had a raised pulse rate, and his blood oxygen saturation level was
low, fluctuating between 88 - 91%. The nurse calculated an Early Warning Score 2
(NEWS2) of 4. (NEWS2 is a clinical assessment tool to determine the severity of a
patient’s illness and identify deterioration. A score of 4 indicates that increased
monitoring or escalation of treatment should be considered.)
22. Mr Reed was referred to the prison GP, who diagnosed pneumonia arising from
COVID-19 infection and Mr Reed was admitted to hospital overnight. When he
returned to the prison the following day, his clinical observations were within normal
range.
23. Just after 3.00pm on 7 January, Mr Reed had a welfare check. His temperature was
very high and some of his other vital signs were abnormal. His NEWS2 score was 9
(which suggests a high clinical risk and the need for urgent assessment by a team
with critical care skills). Staff requested an emergency ambulance, but despite the
risks to his health, Mr Reed refused to go to hospital and signed a disclaimer.
Healthcare staff had no concerns about his mental capacity to make the decision
and created a care plan to monitor his symptoms.
24. The prison assigned Mr Reed a family liaison officer (FLO). He informed Mr Reed’s
mother that her son was unwell. As she was concerned that he was refusing
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treatment, the FLO asked Mr Reed to call her. At around 7.30pm, after speaking to
his mother, he agreed to move to the healthcare centre’s inpatient unit, where he
was given continuous oxygen and closely monitored.
25. Nurses continued to encourage Mr Reed to go to hospital, explaining that his
condition could become life-threatening, but he persistently refused. A GP from the
NHS 111 service advised that if he lost capacity due to deterioration in his
condition, they should call an ambulance. Mr Reed remained alert, mobile and able
to perform personal care.
26. On 8 January, healthcare and wing staff shared information on Mr Reed’s situation.
A security risk assessment and escort documents were prepared in case Mr Reed
needed to leave the prison quickly.
27. Shortly after 4.00pm, healthcare and operational staff discussed the capacity to
continue treating Mr Reed at the prison, given the limited oxygen supplies. They
considered alternatives for obtaining additional oxygen tanks and how to fulfil their
duty of care. Healthcare staff felt that they were not best placed to manage his
deteriorating health.
28. After running out of oxygen, staff consulted the NHS 111 service. A GP said that he
could not prescribe oxygen out of hours and advised them to speak to healthcare
managers.
Admission to hospital
29. On 9 January, Mr Reed felt worse and agreed to go to hospital. He was escorted by
two officers, using an escort chain. A nurse informed his mother that he had been
admitted to hospital.
30. While waiting to be moved to a ward, Mr Reed’s condition deteriorated, and he was
moved to the critical care unit at 8.30pm. The restraints were removed and not
reapplied.
31. A nurse updated Mr Reed’s mother, gave her the contact details for the hospital and
told her to expect a call from the family liaison officer. Healthcare staff obtained
regular updates on Mr Reed’s condition.
32. On 14 January, Mr Reed’s mother left a message on the prison’s safer custody line,
asking where Mr Reed was. An operational manager tried to return her call, but
there was no response.
33. On 15 January, Mr Reed’s condition further declined, but he refused to move to the
intensive care unit. A prison nurse told his mother, who asked for a message to be
passed to him, encouraging him to agree. He was admitted to the unit just before
midnight, sedated and placed on a ventilator.
34. At around 10.30am on 16 January, Mr Reed’s mother left a message, again asking
for information on Mr Reed’s location. Another FLO contacted the intensive care
unit. She was told that Mr Reed was very poorly, and if he did not respond to
treatment within a few days, they would consider removing the ventilator. She
passed on the information, and also advised Mr Reed’s mother to contact hospital
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staff directly. On the same day, a prison nurse also contacted Mr Reed’s mother to
tell her that Mr Reed remained very poorly. Members of the family liaison team
noted that she was given further updates on 21 and 22 January.
35. On 23 January, a prison nurse told Mr Reed’s mother that due to his worsening
condition and not responding to treatment, the hospital would not attempt
resuscitation if Mr Reed’s heart or breathing stopped.
36. On 24 January, the hospital withdrew treatment and Mr Reed died at 11.59am. The
hospital informed his mother and the family liaison officer followed this up with a
call, at 2.52pm. She noted that Mr Reed’s mother did not want any help from the
prison or family liaison officer in the future.
37. On 25 January, Mr Reed’s mother telephoned the prison, asking to speak to
someone about her son’s death. The Head of Safer Custody returned her call, but
the details of their conversation were not documented.
38. There was no further recorded contact until six months later. On 20 July, the Head
of Safer Custody wrote to Mr Reed’s mother to explain that prison staff were under
the impression that she had intended to arrange Mr Reed’s funeral, but they had
been informed that his body was still in the morgue.
39. A representative from the Salvation Army responded on behalf of Mr Reed’s
mother. She thought the funeral had already taken place and that the prison had
arranged it. She mentioned that Mr Reed’s mother was not in good health and that
the prison had not responded to her requests for information while Mr Reed was in
hospital. The family representative attributed the lack of information to Mr Reed’s
mother’s struggle to accept his death.
40. After further correspondence with the Salvation Army representative, the prison
arranged and paid for Mr Reed’s funeral. This took place on 30 August and prison
staff later delivered the ashes to his mother.
Post-mortem report
41. The post-mortem report concluded that Mr Reed died of respiratory failure caused
by COVID-19 pneumonia and chronic obstructive pulmonary disease.
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Findings
Clinical Findings
42. The clinical reviewers were satisfied that Mr Reed’s care at Isle of Wight was
equivalent to that which he could have expected to receive in the community.
Notably, his management and care in the inpatient unit was of a high standard,
exceeding the level he could have expected in the community. However, they found
areas of weakness, which we reflect below.
Management of Mr Reed’s risk of infection from COVID-19
43. When Mr Reed returned to Isle of Wight in December 2021, he was promptly
identified as at moderate risk of complications from COVID-19, and it was noted
that he had previously declined the vaccine. The clinical reviewers were concerned
that staff at Isle of Wight had not discussed the reasons for his decision with him or
given him a further opportunity to receive the vaccine. This was pertinent as there
had been an outbreak of COVID-19 just before his return. Mr Reed appears to have
contracted COVID-19 at Isle of Wight, as two lateral flow tests in December 2021
were negative.
44. Mr Reed had also refused investigations to identify possible health conditions linked
to past habits, such as smoking and substance misuse. As some of those
conditions can increase a person’s risk from COVID-19, the clinical reviewers
considered that healthcare staff should have further explored his concerns, as well
as the support available. We recommend:
The Head of Healthcare should ensure that prisoners who decline COVID-19
vaccinations are given the opportunity to reconsider their decision, and that
healthcare staff discuss and record the reasons for the refusal.
The Head of Healthcare should ensure that if a patient refuses investigation of
potential medical conditions, healthcare staff fully explore and document the
reasons and consider whether they need information or support to address
any concerns.
Monitoring Mr Reed after he contracted COVID-19
45. The healthcare department has a local protocol for monitoring patients who test
positive for COVID-19. Those at moderate risk of complications are reviewed daily,
observations taken and NEWS2 scores calculated.
46. The investigation found that Mr Reed was appropriately managed after he tested
positive and healthcare staff were responsive to signs of deterioration. They
respected his initial wish not to go to hospital and monitored him closely in the
inpatient unit. Any concerns were escalated to the prison GP, and they also sought
advice from the NHS 111 service. However, when the prison ran out of oxygen, the
on-call GP was unable to prescribe replacement tanks.
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47. The clinical reviewers considered that it might be beneficial to review the use of the
NHS 111 service to assess whether out-of-hours GP provision is adequate. We
recommend:
The Head of Healthcare should review the use of the NHS 111 service to
determine whether there is a need to extend the provision of prison GPs.
Contact with Mr Reed’s next of kin
48. Prison Service Instruction 64/2011, Safer Custody, states that a prisoner’s next of
kin should be informed immediately if they become seriously ill or if there is
unpredicted or rapid deterioration in their physical health. Following the death of a
prisoner, a family liaison officer must be appointed, and a log of contacts, actions
and discussions should be kept. The guidance also states that the wishes of the
prisoner’s family should be respected if they do not want contact with the prison and
gives advice on ending contact at an appropriate time.
49. Isle of Wight adopted best practice by quickly assigning a family liaison officer to
share information with Mr Reed’s mother. Healthcare staff also contacted Mr Reed’s
mother at key points where there were changes or concerns. We cannot account for
her view that she was not given information as the family liaison log and healthcare
staff contact were well-documented while he was an inpatient. However, as some of
her requests for information were shortly after such contact, it is conceivable that
she did not understand what was said, particularly given her poor health.
50. The quality of contact after Mr Reed’s death is less clear. The prison contacted her
within three hours and a brief entry noted, “Contact made with NOK. Has declined
any help from prison or FLO in the future.” The next day, Mr Reed’s mother
telephoned to ask for information, but the details of the conversation were not
documented. We acknowledge that the prison intended to respect the wishes for no
contact. However, given she was elderly and likely to have been shocked and
distressed at such an early stage, it would have been prudent to send written
information after the telephone call, detailing the processes and avenues of support,
as well as confirming their understanding of her wish for no contact.
51. Six months passed before it came to light that there had been a misunderstanding
about arranging Mr Reed’s funeral and he had yet to be buried. His mother was
understandably distressed by this disclosure. Without a proper record, we cannot
determine how this mistake happened. The prison should review their
communication process for bereaved families to prevent a similar error in the future.
We recommend:
The Governor should ensure that the method of communication with
bereaved families is appropriate to their needs and that all contact is fully
documented.
Kimberley Bingham
Acting Prisons and Probation Ombudsman March 2025
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Inquest
At the inquest, held on 13 August 2025, the Coroner concluded that Mr Reed died from
natural causes.
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