Christopher Walton

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Independent investigation into the
death of Mr Christopher Walton,
a prisoner at HMP Ranby,
on 6 February 2025
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, 2026
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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 Walton died in hospital on 6 February 2025, following a heart attack
nine days earlier at HMP Ranby. He was 67 years old. We offer our condolences to
his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Walton received at Ranby
was not equivalent to that which he could have expected to receive in the
community. He found that there were multiple missed opportunities to respond to Mr
Walton’s deteriorating health and that symptoms consistent with serious
cardiovascular disease went unnoticed by healthcare staff. Despite clear signs of
decline, Mr Walton was not reviewed by qualified staff when concerns were raised,
and care plans were inadequate and not followed. After Mr Walton’s death, it
became apparent that he had not been taking his medication for at least three
weeks.
5. Mr Walton’s family told us that they raised concerns about Mr Walton’s health in five
voicemails left on the safer custody at-risk line (one on 18 January, two on 19
January and two on 26 January). All voicemails should be recorded in the at-risk
line log, along with the action taken, before being deleted. We know that staff
listened to the 18 and 19 January voicemails and a welfare check was carried out
on 19 January. However, the 18 January voicemail was not recorded in the at-risk
line log.
6. There are no voicemails about Mr Walton recorded in the at-risk line log on 26
January. Given we know that not all voicemail messages were being recorded in
the log, we consider that voicemails were left by the family on 26 January which
were not recorded or actioned by prison staff. We are not satisfied that the prison
has a robust process in place to ensure that voicemail messages are actioned
appropriately nor that there is an effective quality assurance process in place. We
also consider that the message provided to callers to the at-risk line needs to be
clearer about what they can expect.
Recommendations
• The Head of Healthcare should investigate why Mr Walton’s abnormal blood and
urine tests were not reviewed by a doctor and put systems in place to ensure that
this does not happen in the future.
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• The Head of Healthcare should rewrite the Medications in Possession document as
a Standard Operating Procedure (SOP), which should include:
• A system to monitor that a prisoner is taking medications as prescribed.
• A medical review to be triggered if a prisoner is not taking their medications to
investigate why this might be the case.
• The Head of Healthcare should rewrite the older person care plan to include:
• Regular reviews by healthcare to monitor for signs of physical and mental
deterioration, and.
• Reviews of mobility and monitoring for signs of weight loss.
• The Head of Healthcare should develop a workforce strategy to address chronic
understaffing as a matter of urgency.
• The Head of Healthcare should address the high number of “Code Calls” by:
• Introducing an “Urgent Assessment” system whereby a prison officer can
request a same day assessment to be undertaken by a Registered Nurse; and
• Implementing an audited log of calls to ensure the system is being used
appropriately.
• The Head of Healthcare should ensure that there is:
• Adequate training for nurses responsible for assessing the clinical condition and
appropriate treatment pathways for prisoners, and
• At least one nurse trained in advanced clinical assessment skills during all day
shifts within one year and that nurses should be trained to this level before
answering Urgent Assessment calls.
• The Governor should:
• Update the at-risk line message given to callers so that it tells them how often
messages are checked, whether they can expect a callback, details of the email
service and how to escalate immediate safeguarding concerns, and
.
• Implement a robust quality assurance process, including regular spot checks by
managers, to confirm calls are logged accurately and that entries are detailed
enough to support appropriate follow up.
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The Investigation Process
7. HMPPS notified us of Mr Walton’s death on 6 February 2025.
8. NHS England commissioned an independent clinical reviewer to review Mr Walton’s
clinical care at HMP Ranby.
9. The PPO investigator investigated the non-clinical issues relating to Mr Walton’s
care. She interviewed 11 members of staff from Ranby with the clinical reviewer on
15 April.
10. The Ombudsman’s office wrote to Mr Walton’s wife to explain the investigation and
to ask if she had any matters she wanted us to consider. Mr Walton’s family said
that Mr Walton was unwell during their visits on 18 January and 26 January, and
they had raised concerns with staff at Ranby and left voicemails on the at-risk line.
They asked what medical assessments were carried out and what actions staff took
to address their concerns. They also asked how Mr Walton’s medication and diet
was monitored, and whether signs of a possible heart attack were missed. We have
addressed these concerns in our report and in a separate letter.
11. We shared our initial report with HMPPS and the prison’s healthcare provider,
Northamptonshire Healthcare NHS Foundation Trust. They found no factual
inaccuracies. HMPPS and Northamptonshire Healthcare NHS Foundation Trust
provided an action plan which is annexed to this report.
12. We sent a copy of our initial report to Mr Walton’s wife. She did not notify us of any
factual inaccuracies.
Previous deaths at HMP Ranby
13. Mr Walton was the fifth prisoner to die at Ranby since February 2022. Of the
previous deaths, two were self-inflicted, one was drug related, and one was from
unknown causes. There are no similarities between the findings in our investigation
into Mr Walton’s death and the findings from our investigations into the previous
deaths. Up to the end of September 2025, there have been four further deaths. Two
of these were from natural causes and two were drug related.
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Key Events
14. On 1 August 2024, Mr Christopher Walton was sentenced to five years in prison for
fraud. On 13 August, he was moved to HMP Ranby.
15. Before arriving in custody, Mr Walton had a history of stroke and high blood
pressure. While at Ranby, he took medication for both conditions, which he kept in
his cell.
16. On 18 January 2025, Mr Walton’s family visited him and told an officer at the visit
that he seemed unwell. At the end of the visit, the officer took Mr Walton back to the
wing and told the wing officer that they were concerned he may have had a stroke.
17. The officer radioed a code blue (a medical emergency code used when a prisoner
is unconscious or having breathing difficulties that alerts healthcare staff to attend
and the control room to call an ambulance). Two nurses arrived at Mr Walton’s cell
and found him sitting on his bed, talking in full sentences. They took his clinical
observations and calculated a NEWS2 score of zero. (The National Early Warning
Score (NEWS2) is a tool used to assess clinical deterioration. A score is calculated
from the clinical observations taken and the higher the score, the higher the risk. A
score of zero is low risk.) Mr Walton said he had felt tired over the past week but
otherwise felt well. The nurses checked for sings of a stroke by asking him to raise
his arms and grip with both hands but found no issues. They cancelled the
ambulance as they considered he did not need hospital treatment at the time. One
nurse noted that he had hypertension (high blood pressure) and blood tests were
booked for Monday (20 January).
18. Later that day, an officer recorded in Mr Walton’s prison record that a family
member had left a voicemail on the at-risk line (a phone number that members of
the public can leave a voicemail on to raise concerns about a prisoner) raising
concerns about his health. The officer noted that they phoned the family member
back, but they did not answer. They did not record the voicemail in the at-risk log.
There is no evidence that a welfare check was carried out for Mr Walton in
response to the voicemail, or that this concern was passed on to healthcare staff.
19. On 19 January, an officer listened to the at-risk line voicemail and logged that there
were two calls from Mr Walton’s family raising concerns about his health and that
he had not been in contact. The officer asked an officer on the wing to carry out a
welfare check on Mr Walton. The wing officer noted that he spoke to Mr Walton in
his cell and asked how he was feeling, Mr Walton said he was okay and that he
would contact his family to let them know.
20. On 20 January, Mr Walton’s cellmate told the wing officer that he was concerned
about Mr Walton as he was ‘hallucinating and a bit off his feet’. The officer called
the healthcare unit and asked for someone to see Mr Walton.
21. Later that day, a healthcare assistant saw Mr Walton in his cell and took his clinical
observations and recorded that these were within normal range. They requested a
urine sample and left the bottle with Mr Walton to collect a sample.
22. Later that evening, the evening wing officer contacted the healthcare unit as Mr
Walton was still unwell. The officer spoke with a nurse who asked for the urine
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sample to be brought up to the healthcare unit. The wing officer delivered the
sample. Mr Walton was not seen by healthcare staff that evening.
23. On 24 January, Mr Walton’s urine sample result showed elevated creatinine and
albumin levels (possible sign of poor kidney function). A review of this by a doctor
was advised. The test results were not reviewed by a doctor until after Mr Walton’s
death.
24. On 26 January, Mr Walton’s family visited him again. They told the investigator that
they again raised concerns about Mr Walton’s health with prison staff at the visit
and later left voicemails on the at-risk line saying Mr Walton had been experiencing
chest pain. The custodial manager who oversees visits at Ranby told us that it was
rare for families to raise health concerns during a visit and if they did, staff would
advise the prisoner to make an application to see healthcare staff. Ranby has no
record of any voicemails from Mr Walton’s family on the at-risk line log for 26
January. The voicemails are not stored.
25. Mr Walton was not seen again by healthcare staff until 28 January.
Events on 28 January
26. On 28 January, at around 3.00pm, Mr Walton’s cellmate told the wing officer that Mr
Walton was looking very unwell. The officer phoned the healthcare unit and spoke
to a nurse and asked for him to be assessed as soon as possible. The nurse
advised that an appointment would be made for Mr Walton to be seen the following
day. The officer told the investigator that he was concerned about Mr Walton and
was considering calling a code blue, even if not required, as he wanted healthcare
staff to see Mr Walton.
27. After the phone call ended, the officer returned to Mr Walton’s cell and found him
lying on his back and struggling to breathe. The officer radioed a code blue and put
Mr Walton in the recovery position.
28. When healthcare staff arrived, they confirmed cardiac arrest and started CPR. They
attached a defibrillator, which delivered a shock, and resuscitation efforts continued
until Mr Walton began to show signs of Return of Spontaneous Circulation (ROSC).
29. Mr Walton was taken to hospital where he underwent treatment for a heart attack
and was admitted to the intensive care unit. However, Mr Walton’s condition
deteriorated and he died in hospital nine days later, on 6 February.
30. After Mr Walton’s death, staff at Ranby found medication in his room which
suggested he had not been taking his medication as prescribed.
Post-mortem report
31. The post-mortem report concluded that Mr Walton died of acute cardiac failure
(heart failure) caused by myocardial infarction (heart attack) and aortic stenosis
(narrowing of the arteries).
32. At the inquest, held on 7 May 2025, the Coroner concluded that Mr Walton died of
natural causes.
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Findings
Clinical findings
33. The clinical reviewer concluded that the care Mr Walton received at Ranby was not
of the required standard and therefore not equivalent to that which he could have
expected to receive in the community.
34. The clinical reviewer found that the clinical assessment of Mr Walton on 18 January
was not consistent with his condition as described by prison staff, prisoners, and
family members. Despite officers contacting healthcare staff twice on 20 January,
Mr Walton was not assessed by a qualified member of staff.
35. The clinical reviewer also found that the in-possession medication process and
older persons care plan were not sufficient. Mr Walton was in possession of his
medication for high blood pressure and to reduce the risk of heart attack and stroke.
After Mr Walton’s death, a week’s worth of medication was found in his cell. Mr
Walton had not collected his medication from the pharmacy since the end of
November, which meant he had not taken at least three weeks’ worth of his
medication.
36. We recommend:
The Head of Healthcare should investigate why Mr Walton’s abnormal blood
and urine tests were not reviewed by a doctor and put systems in place to
ensure that this does not happen in the future.
The Head of Healthcare should rewrite the Medications in Possession
document as a Standard Operating Procedure (SOP), which should include:
• A system to monitor that a prisoner is taking medications as
prescribed.
• A medical review to be triggered if a prisoner is not taking their
medications to investigate why this might be the case.
The Head of Healthcare should rewrite the older person care plan to include:
• Regular reviews by healthcare staff to monitor for signs of physical and
mental deterioration.
• Reviews of mobility and monitoring for signs of weight loss.
37. The clinical reviewer found that the healthcare service at Ranby was impacted by
staff shortages and an over reliance on agency staff, along with a high volume of
‘code blue’ calls. Although Ranby operates a nurse-led healthcare service, none of
the nurses had training in advanced clinical assessment skills. We recommend:
The Head of Healthcare should develop a workforce strategy to address
chronic understaffing as a matter of urgency.
The Head of Healthcare should address the high number of “Code Calls” by:
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• introducing an “Urgent Assessment” system whereby a prison officer
can request a same day assessment to be undertaken by a registered
nurse; and
• implementing an audited log of calls to ensure the system is being
used appropriately.
The Head of Healthcare should ensure that there is:
• Adequate training for nurses responsible for assessing the clinical
condition and appropriate treatment pathways for prisoners.
• At least one nurse trained in advanced clinical assessment skills
during all day shifts within one year and that nurses should be trained
to this level before answering Urgent Assessment calls.
Good practice
38. The clinical reviewer noted that the immediate use of CPR and the use of a
defibrillator were likely to have been key factors in managing to achieve a return of
spontaneous circulation (ROSC – resumption of a sustained heart rhythm) following
Mr Walton’s cardiac arrest. He commended the swift actions of prison officers and
healthcare staff.
At-risk line
39. The at-risk line is a dedicated phone number that members of the public can use to
leave a voicemail when concerned about a prisoner at Ranby. The line is checked
four times in a 24-hour period (once in the morning, afternoon, evening and night)
by the orderly officer (the senior officer in charge) and all voicemails should be
logged on the at-risk line log. Once the voicemails have been listened to, they are
deleted.
40. On 18 January, Mr Walton’s family left a voicemail on the at-risk line expressing
concerns about Mr Walton’s health. We know that the prison listened to this
voicemail as an officer noted on Mr Walton’s electronic prison record that he had
tried to call the family back but got no answer. However, there was no record of this
voicemail on the at-risk line log. Also, there is no evidence that the officer carried
out any further action in response to the voicemail, such as a welfare check or
forwarding the concerns to healthcare staff.
41. Mr Walton’s family told the investigator that they left another two voicemails on 26
January, after Mr Walton had complained of pain in his arms and chest at a visit
that morning.
42. There is no record on the at-risk line log of any voicemails regarding Mr Walton on
26 January. We know that not all voicemails are recorded in the at-risk line log as
evidenced above. Based on the evidence we have, we consider that Mr Walton’s
family left voicemails on 26 January which the prison failed to record or action.
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43. The investigator interviewed the Head of Safety at Ranby who said the at-risk line
system relies on orderly officers listening to messages, logging them accurately and
taking the appropriate action. As the orderly officer deletes the voicemail once they
have actioned it, there is no way to verify whether a message was received or acted
upon, unless it was logged. The Head of Safety said that it was not usual practice
for the orderly officer to return a call and so families would not receive an
acknowledgement that their voicemail had been heard. He acknowledged that a 24-
hour live service would be the ideal but resources did not permit. He said there was
also an email service that people could use to raise concerns, details of which were
on the prison portal, which provided a clearer audit trail.
44. When asked if there was a quality assurance process in place to check that
voicemails were being logged and handled correctly, the Head of Safety said that
there were quarterly test calls from regional staff. The regional staff member would
leave a message requesting a callback and when the orderly officer returned the
call, the response time was recorded.
45. The investigator made a test call to Ranby’s at-risk line. The recorded message
does not tell the caller how often messages are checked, and it does not tell them
that they will not receive a call back. There is no mention of the email service and
no alternative contact method or signposting should the caller have an urgent
safeguarding concern.
46. Our investigation has shown that not all calls made to the at-risk line are being
logged. The current quality assurance process is ineffective in establishing whether
orderly officers are listening to, logging and actioning voicemails. All it establishes is
that orderly officers will return a call made by regional prison staff. This requires
urgent review. We recommend:
The Governor should:
• Update the at-risk line message given to callers so that it tells them
how often messages are checked, whether they can expect a callback,
details of the email service and how to escalate immediate
safeguarding concerns.
• Implement a robust quality assurance process, including regular spot
checks by managers, to confirm calls are logged accurately and that
entries are detailed enough to support appropriate follow up.
Adrian Usher
Prisons and Probation Ombudsman December 2025
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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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