Dean Gathercole

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Dean
Gathercole, a prisoner at HMP
Littlehey, on 8 February 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
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. In 2018, Mr Dean Gathercole was sentenced to 17 years imprisonment for sexual
offences. He died of ischaemic heart disease (with underlying diabetes,
hypertension and hypercholesterolaemia) on 8 February 2024, at HMP Littlehey. He
was 59 years old. We offer our condolences to Mr Gathercole’s family and friends.
4. The Ombudsman’s office wrote to Mr Gathercole’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not reply.
5. NHS England commissioned an independent clinical reviewer to review Mr Dean’s
clinical care at Littlehey.
6. The clinical reviewer concluded that the clinical care Mr Gathercole received at
Littlehey was of a good standard and equivalent to that which he could have
expected to receive in the community. She noted that he had an extensive and
complex medical history, care plans were in place for all his healthcare needs and
regular blood tests were completed, in line with the guidelines for each of his
conditions. She made no recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr
Gathercole’s care.
8. We did not find any non-clinical issues of concern and make no recommendations.
9. The initial report was shared with HMPPS. They found no factual inaccuracies.
10. An inquest, held on 14 October 2024, concluded that Mr Gathercole died from
natural causes.
Good practice
11. In August 2021, Mr Gathercole began to ignore medical advice and took actions
which could have been severely detrimental to his health. The prison assigned a
family liaison officer, who encouraged him to cooperate with his treatment and
engaged the support of his family. Over the following two and a half years, the
family liaison officer consistently maintained clear and comprehensive records of
actions and contact. We are pleased to note the timely appointment of a family
liaison officer and the considerable support provided.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Governor to note
Emergency response
12. There appears to have been a significant delay in requesting an ambulance when
Mr Gathercole reported chest pains at 3.30am on 8 February 2024. Although the
time of the initial telephone call was recorded as 3.32am on the incident log, the
ambulance service records show it was 3.40am. In addition, the paramedics noted
a delay when they arrived at the prison gate and were waiting to be taken to the
houseblock. The delays did not affect the outcome for Mr Gathercole, but prison
managers will wish to ensure there are no performance issues in this area.
Security risk assessments and the use of restraints
13. The investigation found inconsistencies in the use of restraints on Mr Gathercole for
hospital visits between November 2023 and January 2024, with him sometimes
attending hospital appointments unrestrained and other times restrained, with little
evidence for the different assessments of risk.
14. In response to the findings in another recent investigation at Littlehey, HMPPS’
Operational Security Group Director implemented several measures to monitor
compliance with the policy on the use of restraints and so I make no further
comment.
Adrian Usher
Prisons and Probation Ombudsman September 2024
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