Clive Manning

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Clive Manning,
a prisoner at HMP Swaleside,
on 31 December 2023
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© 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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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. On 16 January 2019, Mr Clive Manning was sentenced to 15 years in prison for
sexual offences.
4. He died from disseminated cancer (cancer that has spread throughout the body)
with pneumonia on 31 December 2023, while a prisoner at HMP Swaleside. He was
59 years old. We offer our condolences to Mr Manning’s family and friends.
5. The Ombudsman’s office wrote to Mr Manning’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
6. NHS England commissioned an independent clinical reviewer to review Mr
Manning’s clinical care at HMP Swaleside.
7. The clinical reviewer concluded that the clinical care Mr Manning received at HMP
Swaleside was of a good standard and at least equivalent to that which he could
have expected to receive in the community. She found that Mr Manning’s end-of-life
care was significantly above the expected standard and an example of good
practice. The clinical reviewer made recommendations not related to Mr Manning’s
death which the Head of Healthcare will want to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Manning’s
care.
9. We did not find any non-clinical issues of concern. We make no recommendations.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. At an inquest held on 12 January 2024, the Coroner concluded that Mr Manning
died of natural causes.
Head of Healthcare to note
Delayed certification of death
12. Although Mr Manning died at approximately 7.30am on 31 December 2023, his
death was not certified until 5.00pm by paramedics attending another incident. As a
result, Mr Manning’s body was left in his cell for nearly twelve hours. While it did not
make a difference to the outcome, this was not dignified for the deceased, it
delayed the police notifying the Coroner and it might have caused distress to
prisoners and staff to know that Mr Manning’s body remained in his cell for so long.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
13. We recognise the resourcing difficulties the prison faced as Mr Manning died on
New Year’s Eve when there were no suitable healthcare staff on shift to certify his
death. We also appreciate that the prison called an ambulance, but this was
appropriately given low priority as Mr Manning had already died. However,
healthcare staff should have contacted Medway On-Call Care (MedOCC), a local
medical service providing on-call care, to request a clinician to certify Mr Manning’s
death. This would likely have prevented the delay in his body leaving the prison.
Adrian Usher July 2024
Prisons and Probation Ombudsman
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE