David Algie

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Independent investigation into
the death of Mr David Algie,
a prisoner at HMP Wymott,
on 11 July 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, 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 David Algie died on 11 July, while a prisoner at HMP Wymott. He was 38 years
old. The cause of Mr Algie’s death was a brain haemorrhage. We offer our
condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Algie received at Wymott
was of a reasonable standard, equivalent to that which he could have expected to
receive in the community. He made recommendations about record keeping,
access to Person Escort Records and debriefing staff. These issues did not impact
on the cause of Mr Algie’s death, but the Head of Healthcare will wish to consider
them.
5. We found that the prison used restraints while Mr Algie was in a coma during his
journey and initial admission to hospital. We have raised the issue of inappropriate
use of restraints with Wymott before and consider that more needs to be done to
ensure staff make better judgements.
Recommendations
• The Governor and Head of Healthcare should implement further measures to
ensure that staff are appropriately skilled to complete and authorise escort risk
assessments; decisions are based on a prisoner’s medical condition and the actual
risk they present at the time; restraints are not used during serious or invasive
treatment, unless there are exceptional reasons for doing so; and quality assurance
processes are introduced/strengthened to ensure that staff routinely comply with the
Graham Judgement.
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The Investigation Process
6. HMPPS notified us of Mr Algie’s death on 11 July.
7. NHS England commissioned an independent clinical reviewer to review Mr Algie’s
clinical care at HMP Wymott.
8. The PPO investigator investigated the non-clinical issues relating to Mr Algie’s care.
The investigator and the clinical reviewer jointly interviewed three members of staff
from Wymott on 2 and 19 September.
9. The Ombudsman’s office wrote to Mr Algie’s aunt, his next of kin, to explain the
investigation. Mr Algie’s aunt did not have any specific questions for the
investigation to consider.
10. We sent a copy of our initial report to Mr Algie’s next of kin. She did not notify any
factual inaccuracies.
11. The initial report was shared with HM Prison and Probation Service (HMPPS) who
reported a typographical error, which we have amended. HMPPS accepted our
recommendation.
Previous deaths at HMP Wymott
12. Mr Algie was the 30th prisoner to die at Wymott since July 2021. Of the previous
deaths, three were self-inflicted and the remainder were due to natural causes. We
have previously raised concerns about the completion of security risk assessments
and the use of restraints, and the prison provided guidance to staff.
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Key Events
13. Mr David Algie was remanded to prison on 26 January 2006. He was convicted of
murder on 14 December and sentenced to life imprisonment, with a minimum
period to serve of 15 years.
14. On 20 March 2023, Mr Algie was released, but he breached the conditions of his
licence and returned to prison on 13 April. He transferred from HMP Forest Bank to
HMP Wymott on 10 May.
15. Mr Algie’s reception and second-stage health screens were completed on 10 and
13 May, respectively. No significant physical health conditions or concerns were
identified. However, he was referred to the mental health team, as he had been
diagnosed with paranoid schizophrenia in 2020, and a care plan was put in place.
16. Mr Algie had a history of substance misuse in the community and in prison. He was
promptly assessed by the drug and alcohol recovery service, a recovery plan was
created, and he received continuing support during his sentence. In spite of this, he
continued to use illicit drugs in prison. (On 21 June 2024, he was found under the
influence and on 1 July, he refused to take a mandatory drug test.)
17. In 2023 and 2024, Mr Algie had annual health checks. Blood tests in April and June
2024, were mainly within normal range but indicated some abnormalities. (An
appointment was made for a GP review on 23 July, but Mr Algie died before this
took place.)
Events of 6 July 2024
18. At 2.50pm on 6 July 2024, a prisoner told an officer that Mr Algie was unwell. The
officer went to Mr Algie’s cell and found that he was vomiting, with a headache and
dizziness. The officer radioed a code blue medical emergency (which indicates that
a prisoner is either unresponsive or has difficulty breathing) and an ambulance was
requested. A nurse assessed Mr Algie. As she did not consider him to be acutely
unwell, she asked for the ambulance to be stood down.
19. At around 4.20pm, the officer went to check Mr Algie and saw him lying on the floor
of his cell. He was responsive but incoherent. The officer again called a code blue
and placed Mr Algie in the recovery position while waiting for a nurse.
20. A nurse helped Mr Algie to his bed and took clinical observations. He recorded that
Mr Algie’s speech was slurred, his pupils were dilated, and he became ‘slightly
unresponsive’. The nurse suspected he was under the influence of drugs and
administered naloxone (a medication to reverse the effects of an opioid overdose).
He noted that after five minutes, Mr Algie became ‘slightly responsive’.
21. An ambulance arrived at the prison at 4.40pm and the paramedics reached the cell
at 4.55pm. They noted that Mr Algie scored 13/15 on the Glasgow Coma Scale
(GCS - a tool to assess a patient’s level of consciousness), which suggested a
moderate traumatic brain injury. He was unable to move independently, and the
paramedics suspected an opiate overdose or stroke. At 5.15pm, a GCS score of 8
indicated that he was in a coma. The paramedics took Mr Algie to the Royal
Preston Hospital. He was escorted by two prison officers, who were instructed to
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use an escort chain in the ambulance and single handcuffs at other times. (An
escort chain is a long chain with a handcuff at each end, one of which is attached to
the prisoner, the other to an officer.) They left the prison at 5.29pm and when they
arrived at the hospital at 6.02pm, the GCS score was 5/15, meaning a severe head
injury (the lowest possible score is 3/15).
22. At 6.05pm, while Mr Algie was in the Major Trauma Unit, the escort officers
recorded, “…advised by doctors that he should be kept on the escort chain as he is
unresponsive.” At 6.10pm, they contacted the Custodial Manager responsible for
the operational management of the prison, who said the escort chain should remain
on Mr Algie until he regained consciousness and could respond. At 6.23pm, a scan
confirmed a bleed on the brain and the Custodial Manager authorised removal of
the restraints at 6.26pm.
23. On 10 July, the prison began an application for early release on compassionate
grounds. The hospital removed the ventilator that day and Mr Algie died at 2.20am
on 11 July.
Post-mortem report
24. The report of the post-mortem examination concluded that the cause of Mr Algie’s
death was a spontaneous intracerebral haemorrhage due to cerebral arteriovenous
malformation.
25. It was noted that, depending on Mr Algie’s symptoms, it was probably reasonable
for healthcare staff to have initially suspected a benign headache.
26. The toxicology report noted Mr Algie’s history of using synthetic cannabinoids.
However, there was no evidence of this, or any other illicit substances in the blood
samples screened. The pathologist said that due to the interval between Mr Algie’s
hospital admission and death, it was highly unlikely that the toxicological tests
reflected the compounds in his blood when he was first admitted to hospital.
Although in rare cases, intracranial haemorrhages have occurred after the use of
synthetic cannabinoids, the pathologist considered it unlikely that illicit substances
made more than a minimal contribution to Mr Algie’s death.
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Findings
Clinical findings
27. The clinical reviewer concluded that Mr Algie’s physical and mental healthcare were
of a reasonable standard and at least equivalent to that which he could have
expected to receive in the community. He noted that Mr Algie did not have any long-
term health conditions and received adequate treatment for minor ailments.
28. The clinical reviewer noted the need for improvements in aspects of care not related
to the cause of Mr Algie’s death including record keeping; ensuring reception
healthcare staff have access to Person Escort Records; and debriefing staff after an
emergency incident. He made recommendations which are not repeated in this
report, but the Head of Healthcare will wish to consider.
Non-clinical findings
Use of restraints
29. 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.
30. A judgment in the High Court in 2007 (known as the Graham Judgement) 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.
31. The paramedics recorded that Mr Algie was, “unable to mobilise or coordinate his
own movements” and they suspected his condition had been caused by a stroke or
an opiate overdose. The clinical entry on Mr Algie’s security risk assessment was
ticked to indicate his medical condition was life threatening; it did not restrict his
ability to escape; there were no objections to the use of restraints; and the restraints
did not need to be removed for treatment.
32. Mr Algie’s risk was assessed as ‘normal’ on the individual elements of the risk
assessment (on a scale of low/normal/high). It was noted that he had absconded in
2003 and was a risk to staff and adults, but no supporting detail was given. Despite
Mr Algie’s poor condition and an escort of two officers, the prison concluded that he
should be handcuffed with single handcuffs, reduced to an escort chain in the
ambulance, with no justification as to why this was considered necessary. After his
admission to hospital, the restraints remained in place for around 25 minutes,
although prison staff knew that he was unconscious.
33. The Head of Healthcare told the investigator that the entry in the medical records
was ambiguous, and a different nurse had completed the risk assessment. The
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entry stated that Mr Algie was able to sit on the bed with assistance and was
'slightly unresponsive' then 'slightly responsive' but there was no mention that his
condition was life-threatening. The Head of Security could not account for the
decision on the use of restraints but said that the prison had previously tried to
improve the risk assessment process, in collaboration with the healthcare
department.
34. The judgements by healthcare and operational staff suggest some staff do not
understand the policy and the factors to be considered when taking decisions on
restraints. This is an issue we have raised with Wymott before. In 2023, the prison
produced an action plan listing measures to raise the awareness of all custodial
managers on completing risk assessments, as well as the importance of assessing
an individual’s risk against their health condition. Guidance was also sent to all
operational and healthcare staff about the Graham Judgement and ensuring risk
assessments are fully completed.
35. We consider that the use of restraints, particularly when Mr Algie was in a coma,
was unacceptable and inhumane. It casts doubt on whether the steps already taken
have been effective and shows that more work needs to be done to improve staff
understanding of the process, as well as judgements in individual cases. We
recommend:
The Governor and Head of Healthcare should implement further measures to
ensure that staff are appropriately skilled to complete and authorise escort
risk assessments; decisions are based on a prisoner’s medical condition and
the actual risk they present at the time; restraints are not used during serious
or invasive treatment, unless there are exceptional reasons for doing so; and
quality assurance processes are introduced/strengthened to ensure that staff
routinely comply with the Graham Judgement.
Governor to note
Delays in access for ambulances
36. The paramedics noted delays entering and leaving the prison. It took some time to
get to the wing and there was a further delay while the prison arranged for staff to
escort Mr Algie to hospital. The Head of Security explained that there are two
external vehicle gates and four additional vehicle gates to get to the wing. In spite of
this, a delay of 15 minutes in a medical emergency seems excessive, with no
particular mitigating reasons. We are aware of work conducted by HMPPS to speed
the entry and egress of emergency services in prison. The Governor will wish to
consider the learning from this investigation.
Inquest
37. At an inquest held on 16 April 2026, the coroner concluded that Mr Algie died of
natural causes.
Adrian Usher
Prisons and Probation Ombudsman March 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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