Colin Evans

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Colin Evans,
a prisoner at HMP Full Sutton,
on 26 January 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, 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. 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 Colin Evans died in hospital of bronchopneumonia, with ischaemic heart
disease and chronic kidney disease contributory factors, on 26 January 2024,
while a prisoner at HMP Full Sutton. He was 84 years old. We offer our
condolences to Mr Evans’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Evans’ received at Full
Sutton was of a reasonable standard and equivalent to that which he could have
expected to receive in the community. The clinical reviewer made three
recommendations on advanced care planning, which the Head of Healthcare will
wish to address.
5. Restraints were disproportionately used during transfer and in hospital, without
due consideration for Mr Evans’ advanced age and long-term health conditions.
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The Investigation Process
6. We were informed of Mr Evans’ death on 26 January 2024.
7. NHS England commissioned an independent clinical reviewer to review Mr Evans’
clinical care at HMP Full Sutton.
8. The PPO investigator investigated the non-clinical issues relating to Mr Evans’
care.
9. The Ombudsman’s office contacted Mr Evans’ nephew to explain the investigation
and to ask if he had any matters he wanted us to consider. He did not respond.
10. The initial report was shared with HM Prison and Probation Service
(HMPPS). HMPPS found no factual inaccuracies in the report.
Previous deaths at HMP Full Sutton
11. Mr Evans was the seventh prisoner to die at HMP Full Sutton since January 2021.
Of the previous deaths, five were from natural causes and one was self-inflicted.
Our investigation into the death of a prisoner in December 2023 found that
restraints were unjustifiably used on hospital escort on an older man in poor
health.
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Key Events
12. On 17 December 1984, Mr Colin Evans was convicted of murder and sentenced to
life in prison with a minimum time to serve of 30 years. Mr Evans’ sentence was
reduced on appeal to 26 years and 4 months.
13. On 8 November 2006, Mr Evans was transferred to HMP Full Sutton.
14. In November 2010, Mr Evans was diagnosed with chronic kidney disease stage 3
(a long-term condition where the kidneys do not work effectively). He had a
number of other long-term health conditions including chronic lymphoid leukaemia
(cancer of the white blood cells), hypertension (high blood pressure), high
cholesterol, and first-degree atrioventricular block (where the heart beats
abnormally or slowly). Mr Evans was prescribed various medications to manage
these conditions and had annual reviews for hypertension and cardiovascular
disease.
15. On 25 August 2022, a consultant haematologist (specialist in blood diseases)
reviewed Mr Evans. The consultant found that Mr Evans did not require any
further reviews for chronic lymphoid leukaemia unless he became symptomatic
and discharged him from the hospital’s care.
16. On 2 March 2023, a consultant nephrologist (kidney specialist) reported that Mr
Evans’ kidney function was at 16% (normal kidney function is 90% or above). The
consultant noted that he would keep Mr Evans under review and consider
treatment were his kidney function to reduce to 7%.
17. In August, prison staff recorded that another prisoner now helped Mr Evans to
move around the prison by pushing him in a wheelchair.
18. On 21 September, the consultant nephrologist reviewed Mr Evans. He found that
Mr Evans’ kidney function had increased to 21%.
19. On 1 November 2023, Mr Evans was admitted to hospital overnight after reporting
feeling nauseous and experiencing abdominal pain. Before he was transferred to
hospital, a supervising officer completed the escort risk assessment and noted
that Mr Evans was a high risk to the public, a low risk to hospital staff and a low
risk of escape. They noted that Mr Evans was a Category A prisoner (the highest
security category). A nurse completed the medical section and had no medical
objections to the use of restraints. A duty manager concluded that Mr Evans
should be restrained by escort cable (a length of strong metal cable with a
handcuff at either end, one attached to the prisoner’s wrist and the other to an
officer), with two officers, based on his age and mobility.
20. On 22 November, Mr Evans was admitted to hospital. Before he was transferred
to hospital, a supervising officer completed the escort risk assessment and noted
that Mr Evans was a medium risk to the public, a low risk to hospital staff and a
low risk of escape. A doctor completed the medical section and had no medical
objections to the use of restraints. Mr Evans was restrained by escort cable with
two officers, based on his age and mobility.
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21. At the hospital, a consultant cardiologist diagnosed Mr Evans with heart failure
and atrial fibrillation (abnormal rhythm of the heart). He requested an
echocardiogram (ECG, a scan of the heart) to determine further management. The
consultant also noted that Mr Evans had cellulitis (a bacterial infection often
caused by poor circulation) in his leg. He prescribed antibiotics. Mr Evans returned
to Full Sutton that day.
22. In December, prison staff reported that Mr Evans struggled to move around the
unit, especially up the stairs. He was moved to another cell which had been
adapted to reduce the risk of falls, and to be opposite a prisoner who worked as
his carer.
23. On 14 December, a GP at Full Sutton recommended hospital admission as Mr
Evans’ swelling (a symptom of the cellulitis) had increased and was not
responding to the antibiotics. Mr Evans declined and said that he preferred to be
treated at Full Sutton.
24. On 28 December, a GP at Full Sutton reviewed Mr Evans, who continued to
experience shortness of breath and swelling to his legs. Mr Evans agreed to a
transfer to hospital for treatment. An emergency ambulance was requested and
arrived to transfer Mr Evans to York District Hospital.
25. Before he was transferred to hospital, a supervising officer completed the escort
risk assessment and noted that Mr Evans was a high risk to the public, a low risk
to hospital staff and a low risk of escape. The GP completed the medical section
and had no medical objections to the use of restraints. He recorded that Mr Evans’
medical condition restricted his ability to escape, but that he did not have impaired
mobility. A duty manager concluded that Mr Evans should be restrained by escort
cable, with two escorting officers.
26. The prison nursing team ensured daily liaison with the hospital following Mr Evans’
transfer.
27. On 13 January, Mr Evans’ health deteriorated. The attending doctor indicated that
treatment was required, and the escort cable restraint was immediately removed
by staff when asked to do so. Prison staff did not restrain Mr Evans again as
instructed by a security manager. Mr Evans remained on oxygen and various
intravenous treatments. Two days later, hospital staff completed a do not attempt
to resuscitate order (a document to provide guidance on best action to take should
a person experience cardiac arrest or die suddenly).
28. On 24 January, the hospital commenced end of life care as Mr Evans had stopped
eating and drinking and had not recovered from his heart failure.
29. On 26 January, Mr Evans died in hospital.
Liaison with Mr Evans’ family
30. On 15 January, a prison family liaison officer contacted Mr Evans’ nephew and
told him about Mr Evans’ medical condition. The family liaison officer agreed to
keep Mr Evans’ nephew updated about his health. They also agreed how the
news of Mr Evans’ death would be delivered.
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31. On 26 January, in line with their agreement, the family liaison officer telephoned
Mr Evans’ nephew, to inform him of the death.
Cause of Death
32. The post-mortem report concluded that Mr Evans’ died from pneumonia.
Ischaemic heart disease and chronic kidney disease were also listed as
contributory factors.
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Findings
Restraints, security and escorts
33. 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.
34. Mr Evans was 84 years old and had a significant medical history of poor health,
including pneumonia and heart and kidney disease. In the last few months of his
life, cellulitis restricted his mobility.
35. On two occasions in November 2023, Mr Evans went to hospital for unplanned
admissions or outpatient appointments. He was restrained on both occasions. On
1 November, the medical section of the escort risk assessment was not fully
completed, and therefore no evidence that his condition, including struggling to
breathe, was considered when judging whether to use restraints. On 22
November, a doctor at the prison completed the medical section but did not object
to the use of restraints. On each occasion, Mr Evans was assessed as a low risk
of escape.
36. On his final admission, from 28 December, restraints were used for two weeks
before being removed when Mr Evans’ health deteriorated further. Despite his
age, health and poor mobility, a GP at Full Sutton recorded in the escort risk
assessment that Mr Evans did not have impaired mobility.
37. Prison staff told us that the starting point for restraints applied to a Category A
prisoners during external escorts is ordinarily the application of double cuffs.
(Double cuffs means that two pairs of handcuffs are used. One pair is used to
handcuff the prisoners’ wrists together, and the other handcuffs one wrist to that of
an officer.) They said they always consider if this is proportionate based on age,
mobility and medical presentation. They said the reduction in restraints from
double cuff to escort cable only was proportionate based on Mr Evans being a
Category A prisoner.
38. While Mr Evans’ might have been a Category A prisoner, his symptoms and
medical history on each of these occasions, in line with the High Court judgement,
meant that his risk could have been effectively managed by the officers
accompanying him without the use of restraints. It is not evident that his medical
condition was properly reported or considered in the escort risk assessment, or
that prison staff demonstrated that any risk factors he might have had outweighed
his medical condition.
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39. We frequently raise concerns about how well healthcare staff understand, or feel
empowered, to make a meaningful contribution to the risk assessment process,
such as in this case. In March 2024, we recommended that NHS England develop
national guidance for establishments to develop local standard operating
procedures for healthcare input into restraints risk assessments. This
recommendation was accepted, and NHS England told us that they are working
with HMPPS to review the Prevention of Escapes – External Escorts Policy
Framework, with particular focus on the escort risk assessment. This work is
planned for completion by October 2024.
40. In the meantime, it is important that Full Sutton properly considers the prisoner’s
age, health and mobility when determining the appropriate level of restraints.
Following the death of a prisoner in December 2023, we recommended that the
Governor ensure that all staff undertaking risk assessments for prisoners taken to
hospital understand the legal position on the use of restraints, and that authorising
managers show that they have taken this information into account when assessing
a prisoner’s current level of risk. The response to this recommendation is currently
outstanding, and we do not therefore repeat it.
Inquest
41. The inquest into Mr Evans’ death concluded on the 30 August 2024. The coroner
confirmed that Mr Evans died from natural causes.
Adrian Usher
Prisons and Probation Ombudsman September 2024
Prisons and Probation Ombudsman 7
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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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