Darren Barker

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Darren Barker, a
prisoner at HMP Peterborough,
on 12 September 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
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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 HM Prison and Probation Service (HMPPS) in ensuring
the standard of care received by those within service remit is appropriate then our
recommendations should be focused, evidenced and viable. This is especially the
case if there is evidence of systemic failure.
3. Mr Darren Barker died in hospital on 12 September 2023, of pancreatic cancer
which had spread to other parts of his body, while a prisoner at HMP Peterborough.
He was 46 years old. I offer my condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Barker received at
Peterborough was of a good standard and was equivalent to that which he could
have expected to receive in the community.
5. In July 2022, Mr Barker’s blood was tested. The liver function tests and C-reactive
protein (CRP) that detects infection was not repeated as the sample was lost. The
clinical reviewer was unable to comment on whether these blood tests would have
provided any indication that Mr Barker had cancer at that time.
6. The clinical reviewer made a recommendation not related to Mr Barker’s death that
the Head of Healthcare will wish to address.
7. It was not until two days before he died that a prison manager authorised the
removal of Mr Barker’s restraints in hospital.
Recommendations
 The Head of Healthcare should ensure that there is a robust blood test monitoring
system in place so that samples that are lost, insufficient or mislabelled are
reviewed and, if necessary, repeated.
 The Director and Head of Healthcare should ensure that all staff undertaking risk
assessments for prisoners taken to hospital understand the legal position on the
use of restraints, that healthcare staff complete the medical information section of
the escort risk assessment in full, and that assessments fully take into account the
health of a prisoner and are based on the actual risk he presents at the time.
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The Investigation Process
8. We were notified of Mr Barker’s death on 13 September 2023. NHS England
commissioned an independent clinical reviewer, to review Mr Barker’s clinical care
at Peterborough.
9. The PPO investigator investigated the non-clinical issues relating to Mr Barker’s
care.
10. The investigator issued notices to staff and prisoners at HMP Peterborough
informing them of the investigation and asking anyone with relevant information to
contact him. Two prisoners responded: one subsequently refused to be interviewed
and the other had been released and could not be contacted.
11. The PPO family liaison officer wrote to Mr Barker’s daughter to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
12. We shared the initial report with the Prison Service. There were no factual
inaccuracies.
Previous deaths at HMP Peterborough
13. In the three years before Mr Barker’s death eleven prisoners died from natural
causes at Peterborough, one of which was as a result of COVID-19. There have
also been two drug related deaths and a self-inflicted death in the same period. Our
investigations into the deaths of men in October 2022 and November 2022 found
that restraints had been inappropriately used on older, terminally ill prisoners.
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Key Events
14. On 4 July 2022, Mr Darren Barker was remanded to HMP Peterborough.
15. On 25 July, Mr Barker saw a nurse because he had a lump under his right armpit.
The nurse planned for him to see a GP at Peterborough. In the meantime, blood
tests were taken.
16. On 1 August, a GP at Peterborough saw Mr Barker. The GP reviewed some of the
blood results, which were normal. He noted that the plan was to await all blood test
results, as some were still outstanding. If these results were abnormal then the plan
was for further GP review. However, the sample for the liver function tests and C-
reactive protein (CRP, that detects infection) was lost, and the tests were not
repeated. There are no further entries relating to the lump under his armpit in Mr
Barker’s medical records until July 2023.
17. On 31 January 2023, Mr Barker was sentenced to two years and seven months in
prison for breaching a non-molestation order and for criminal damage.
18. On 22 May, Mr Barker was released on licence. His licence was revoked on 15
June, and he was sent back to Peterborough.
19. On 15 July, a nurse saw Mr Barker in his cell. He told her that he could feel a lump
in his right armpit/chest area which he had had for a long time. She booked a GP
appointment for Mr Barker.
20. On 18 July, a GP at Peterborough saw Mr Barker and noted that he had a large
lump with extensive bruising over the right breast and armpit area. The GP referred
Mr Barker to a hospital specialist under the NHS suspected cancer pathway, which
requires patients with suspected cancer to be seen by a specialist within two weeks.
21. On 20 July, a prison GP saw Mr Barker because the pain under his armpit was
getting worse. He noted that Mr Barker had a large cystic swelling (a lump under
the skin caused by a build-up of fluid) measuring fifteen centimetres by seven
centimetres which extended to the nipple and chest area. He noted that there were
no signs that the area was infected. He sent Mr Barker to hospital. When Mr Barker
went to hospital, prison staff restrained him with a single cuff. Hospital staff said that
Mr Barker had a chest wall haematoma (a collection of blood in the chest wall area)
and planned for him to have an ultrasound scan to assess the nature of the lump.
Hospital staff sent Mr Barker back to Peterborough.
22. On 10 August, healthcare staff sent Mr Barker to hospital because the lump under
his right armpit was severely swollen. When he went to hospital prison staff
restrained him with a single cuff, which in hospital they replaced with an escort
chain (a long chain with a handcuff at each end, one of which is attached to the
prisoner and the other to an officer). The following day, Mr Barker had a
Computerised Tomography (CT) scan which showed that he had a large mass in
the right armpit. Hospital staff planned for him to have an MRI scan. Mr Barker
returned to Peterborough that day.
23. On 21 August, Mr Barker went to hospital, where he was admitted as an inpatient.
He remained in hospital for the rest of his life. When he went to hospital, prison staff
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restrained Mr Barker with a single cuff. Mr Barker had an ultrasound guided biopsy
(a scan of the body and a sample of tissue taken for analysis), a CT scan and an
MRI. The CT scan, carried out on 24 August, showed that Mr Barker had a large
mass (cancer) in the head of his pancreas which had spread to other parts of his
body.
24. On 29 August, an operational manager reviewed the level of restraint and
authorised that Mr Barker be restrained with an escort chain. At 10.30am on 10
September, she again reviewed the level of restraint and authorised that the escort
chain be removed.
25. The operational manager said that, on 29 August, she was the duty manager that
went to hospital to carry out the manager’s bedwatch check and as part of the
check reviewed the handcuff arrangements. She said that Mr Barker had been in
hospital and was still on a single standard handcuff which made it difficult for
movement in bed and to receive treatment. She said that she also took into account
the risk that Mr Barker could escape and signed the risk assessment that she was
happy for an escort chain to be applied. She said that, on 10 September, the
documentation showed that Mr Barker’s circumstances had changed, and the
hospital were now treating him as end-of-life care. She said that she therefore
authorised that the restraint should be removed.
26. On 12 September, Mr Barker died in hospital.
Post-mortem report
27. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Barker’s cause of death
as pancreatic cancer which had spread to other parts of his body.
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Clinical findings
28. The clinical reviewer concluded that the clinical care Mr Barker received at
Peterborough was of a good standard and was equivalent to that which he could
expect to have received in the community.
29. In July 2022, a GP at Peterborough saw Mr Barker because he had a lump under
his right armpit and had blood taken for testing. These were reported as acceptable.
However, the liver function tests and C-reactive protein (CRP) that detects infection
was not repeated as the sample was lost. The clinical reviewer was unable to
comment on whether these blood tests would have provided any indication that Mr
Barker had cancer at that time. We make the following recommendation:
The Head of Healthcare should ensure that there is a robust blood test
monitoring system in place so that samples that are lost, insufficient or
mislabelled are reviewed and, if necessary, repeated.
30. The clinical reviewer said that the investigations into the lump under Mr Barker’s
armpit and referral in July 2023, was in accordance with National Institute for Health
and Care Excellence (NICE) Guidelines for suspected cancer: recognition and
referral which requires patients with suspected cancer to be seen by a specialist
within two weeks.
Non-Clinical Findings
Restraints, security and escorts
31. 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.
32. Mr Barker was sent to hospital on three occasions shortly before his final admission
on 21 August. On only one of these occasions is there evidence that the medical
section was completed on the escort risk assessment, and there is no evidence that
a medical assessment was completed at any time during his final admission.
33. This meant that Mr Barker’s medical condition and its effect on his ability to escape
was not properly considered when determining the level of restraints. While he was
a relatively young man with little evidence of restricted mobility at the earlier hospital
appointments, Mr Barker’s health rapidly deteriorated during his final admission and
it is probable that proper, proactive consideration of his medical condition would
have resulted in restraints being removed earlier.
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34. Following the deaths of prisoners in 2022, we twice made recommendations about
the inappropriate use of restraints on terminally ill prisoners at Peterborough. The
Head of Safety told us that the prison is in the process of implementing a review of
the medical sections in escort records with the intention of adding a quality
assurance procedure to this. It is important that this is completed quickly to ensure
that, in future, terminally ill prisoners are no longer unnecessarily handcuffed.
The Director and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners taken to hospital understand the legal
position on the use of restraints, that healthcare staff complete the medical
information section of the escort risk assessment in full, and that
assessments fully take into account the health of a prisoner and are based on
the actual risk he presents at the time.
Inquest
35. The inquest into Mr Barker’s death concluded on 21 August 2024, and returned a
verdict of natural causes.
Adrian Usher
Prisons and Probation Ombudsman March 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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