Dean Graham

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Dean Graham,
a prisoner at HMP Northumberland,
on 11 April 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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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.
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.
Mr Dean Graham died of acute cardiorespiratory failure (sudden failure of the heart and
lungs) on 11 April 2023 at HMP Northumberland. He was 42 years old. I offer my
condolences to Mr Graham’s family and friends.
Mr Graham, who had previously had throat cancer, underwent further surgery on his throat
on 30 March. He was discharged back to Northumberland on 7 April.
The clinical reviewer found that the care Mr Graham received in respect of his discharge
planning from hospital and subsequent care was not of the required standard. Mr Graham
was not appropriately reviewed by healthcare staff when he returned to Northumberland
and instructions in the hospital discharge summary were not followed.
The investigation found that there was a delay of over 15 minutes between Mr Graham
being found unresponsive and an ambulance being called. The prison carried out an
internal investigation and took disciplinary action against the member of staff concerned.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman May 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 30 June 2022, Mr Dean Graham was sentenced to six years and ten months
imprisonment for sexual offences. On 19 July, he was moved to HMP
Northumberland.
2. Mr Graham had previously had cancer of the larynx (part of the throat) and a partial
laryngectomy (removal of the larynx). He was obese and in December 2022, was
diagnosed with hypertension (high blood pressure).
3. On 30 March 2023, Mr Graham attended hospital for surgery to remove excess
tissue in his throat. Due to complications with his breathing, Mr Graham remained in
hospital as an inpatient for a week following his surgery. He was discharged back to
Northumberland unexpectedly on 7 April, after most prison healthcare staff had left
for the day. A nurse stayed late to see Mr Graham on his return and noted there
were no issues. There was subsequently no handover to day staff and despite the
hospital discharge summary saying that Mr Graham’s dressing should be changed
daily, this did not happen.
4. At 4.12am on 11 April, Mr Graham rang his cell bell. An operational support officer
(OSO) responded one minute later and found Mr Graham unresponsive on the floor
of his cell. The OSO called the senior prison custody officer (SPCO) for support,
who arrived at the cell between 10 and 15 minutes later with two prison officers. An
officer called a medical emergency code at 4.30am.
5. The SPCO and officers entered the cell and found that Mr Graham was cold to the
touch and showing clear signs of death. They did not start CPR. At 4.50am,
ambulance paramedics pronounced that Mr Graham had died.
6. The post-mortem report found that Mr Graham died from cardiorespiratory failure
caused by heart disease. Obesity was listed as a contributory factor.
Findings
7. The clinical reviewer found that while some aspects of Mr Graham’s care were of
the required standard, including the care he received for his laryngeal cancer and
his obesity, his discharge planning from hospital and subsequent care were not of
the required standard.
8. The clinical reviewer also found that staff had not put a care plan in place for Mr
Graham’s hypertension.
9. The OSO who responded to Mr Graham’s cell bell and found him unresponsive on
the floor, failed to call a medical emergency code as she should have done. This
resulted in a delay of over 15 minutes before an ambulance was called, during
which time Mr Graham died. The Director commissioned an internal investigation
and disciplinary action was taken against the OSO.
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Recommendations
• The Head of Healthcare should ensure that there are robust processes in place for
communicating with hospitals to ensure that information is appropriately shared and
discharge planning is completed.
• The Head of Healthcare should review the process of sharing information between
one shift and the next.
• The Head of Healthcare should ensure that care plans are initiated when clinically
indicated, including for hypertension.
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The Investigation Process
10. HMPPS notified us of Mr Graham’s death on 11 April 2023.
11. The investigator issued notices to staff and prisoners at HMP Northumberland
informing them of the investigation and asking anyone with relevant information to
contact her. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Graham’s prison and
medical records.
13. NHS England commissioned an independent clinical reviewer to review Mr
Graham’s clinical care at the prison. The investigator and clinical reviewer jointly
interviewed four members of staff.
14. Another investigator subsequently took over the investigation.
15. We informed HM Coroner for Newcastle of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
16. The Ombudsman’s family liaison officer contacted Mr Graham’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
had concerns about whether Mr Graham should have been discharged back to
Northumberland following his stay in hospital. This has been addressed in the
clinical review.
17. We shared our initial report with HMPPS and with the prison’s healthcare provider,
Spectrum Community Health CIC. They found no factual inaccuracies. Spectrum
Community Health CIC provided an action plan which is annexed to this report.
18. We sent a copy of our initial report to Mr Graham’s mother. She did not notify us of
any factual inaccuracies.
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Background Information
HMP Northumberland
19. HMP Northumberland is a large resettlement prison which holds up to 1,348 male
prisoners. The prison is managed privately by Sodexo. Healthcare is provided by
Spectrum. Nurses are on duty between 7.30am and 7.30pm from Monday to
Thursday; between 7.30am and 5.30pm on Fridays; and between 8.00am and
5.30pm on weekends.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Northumberland was December 2022.
Inspectors reported that overall Northumberland was a reasonably decent prison
with capable leadership. Positively, they saw that cell bells were answered promptly
more often than in other similar prisons.
21. However, they reported that a shortage of healthcare staff impacted on their
capacity to meet prisoner needs, and that the lack of 24-hour healthcare further
limited access. They noticed poor communication between healthcare workers and
prison officers, but overall found that prisoners were receiving acceptable care.
Independent Monitoring Board
22. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to 31 December 2022, the IMB
reported that the healthcare provision at Northumberland had been uneven due to
staffing issues. They noted that there had been some improvement with the
recruitment of more healthcare staff.
Previous deaths at HMP Northumberland
23. Mr Graham was the nineteenth prisoner at Northumberland to die since April 2020.
Of the previous deaths, 11 were from natural causes, six were self-inflicted, and
one was drug related.
24. We have previously made recommendations to Northumberland about care plans
and monitoring long-term conditions. We were told that two senior nurses had been
employed in January 2023 to manage long-term conditions and a clinical lead now
oversaw the process, including auditing referral times and quality of care plans.
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Key Events
25. On 5 May 2022, Mr Dean Graham was remanded in prison, charged with sexual
offences, and sent to HMP Durham.
26. On 30 June, Mr Graham was sentenced to six years and ten months imprisonment.
He was moved to HMP Northumberland on 19 July.
27. When Mr Graham arrived at Northumberland, he told healthcare staff that he had
previously had cancer in his larynx (part of the throat), which was diagnosed in the
community in 2018, and as a result, had had a partial laryngectomy (removal of the
larynx). He also had high blood pressure and obesity. Mr Graham was offered
advice on how to manage his obesity but was not agreeable to this.
28. On 4 October, a GP at Northumberland saw Mr Graham after he said he was
experiencing ‘noisy breathing’. The GP referred Mr Graham for an MRI scan on 11
October to investigate this issue further.
29. On 13 October, Mr Graham attended Freeman Hospital to discuss the MRI results
with an ear, nose, and throat (ENT) specialist. The ENT doctor told Mr Graham that
his noisy breathing was caused by excess tissue in his throat following his previous
surgery in 2018. Mr Graham was placed on a non-urgent waiting list to have a
micro-laryngoscopy (surgical removal of the excess tissue).
30. On 18 November, healthcare staff noted that Mr Graham’s blood pressure was
high. On 23 November, staff checked his blood pressure again and recorded that it
was above the normal range. An ECG (test to check the heart’s rhythm and
electrical activity) was done which returned normal results.
31. On 15 December, a nurse reviewed Mr Graham’s blood pressure and diagnosed
him with hypertension (high blood pressure). She offered him advice on how to
manage his weight and prescribed him medication to treat his hypertension. A
follow up appointment was arranged for 28 December however Mr Graham did not
attend. The appointment was then rescheduled for 6 January 2023.
32. Mr Graham attended his appointment on 6 January, and his blood pressure was still
high. Staff increased his medication dose and scheduled a further review for 27
January. Mr Graham attended appointments to monitor his blood pressure on 27
January, 1 March, and 10 March.
33. On 10 March, a GP reviewed Mr Graham’s medication because his blood pressure
remained high. The GP prescribed Mr Graham a different medication to try instead.
He scheduled a follow up appointment for 27 March.
34. On 27 March, Mr Graham did not attend his appointment for reasons unknown.
35. On 30 March, Mr Graham attended Freeman Hospital for his micro-laryngoscopy.
Mr Graham was expected to return to Northumberland after his procedure that day,
however following the operation there were complications with his breathing. As a
result, Mr Graham was admitted to the Intensive Care Unit (ICU) and given a
tracheostomy (a tracheostomy is an opening made in the throat through which a
tube is fitted to assist with breathing)
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36. On 3 April, Mr Graham was discharged from ICU and placed on an ENT ward to
recover from his operation. On 6 April, his tracheostomy tube was removed.
37. While Mr Graham was in hospital, Northumberland healthcare staff held multi-
disciplinary team (MDT) meetings to plan for Mr Graham’s return to prison. They
first met on 5 April but did not yet have an expected discharge date. They met again
on 7 April to discuss Mr Graham’s discharge, which they expected to take place the
next day. They noted that a member of the healthcare team would contact the
hospital to discuss the discharge details but there is no evidence that this was done.
38. During the late afternoon of Friday 7 April, which was a bank holiday, Mr Graham
was discharged back to Northumberland. Healthcare staff at the prison were not
expecting his discharge until the next day, and healthcare services had already
closed for the day. A nurse volunteered to stay on past her shift and saw Mr
Graham in reception at approximately 5.50pm. She looked over his hospital
discharge letter, which stated that Mr Graham needed the dressing on his
tracheostomy wound to be changed daily, and that Mr Graham would be reviewed
in hospital in two to three months’ time. She did not complete any physical
observations as Mr Graham appeared medically fit.
39. On 8 April, Mr Graham attended the medication hatch in the morning to request his
prescribed pain relief medication. The nurse at the medication hatch told him that
his medication was not available, which agitated Mr Graham. The nurse then
arranged for his medication to be prescribed and Mr Graham received it at 2.20pm
that day.
Events of 10 to 11 April 2023
40. At around 8.30pm on 10 April, an Operational Support Officer (OSO) conducted a
roll check (a check that each prisoner was in their cell). The OSO stated in interview
that she checked Mr Graham’s cell at approximately 9.00pm and had no concerns.
No information had been handed over to the OSO about Mr Graham’s recent
discharge from hospital, so she was not aware of his health issues.
41. At 4.12am on 11 April, Mr Graham pressed his cell bell to alert staff that he needed
assistance. Cell bell records indicate that the OSO responded to the bell by
attending Mr Graham’s cell at 4.13am. The OSO said that on arrival, she looked
into Mr Graham’s cell through the observation panel and saw him lying on the
ground with his upper body under his bed and his legs sticking out. She knocked on
the door and called out to him repeatedly, but he did not respond. The OSO said
that she saw Mr Graham moving his legs while she was knocking.
42. At approximately 4.14am, the OSO called the Senior Prison Custody Officer
(SPCO) who was in charge that night. She told him that Mr Graham was lying on
the floor, that his legs were moving, but that he was not responding to her. The
SPCO told the OSO that he would attend Mr Graham’s cell and asked her to go and
wait in the main office. He then called two prison officers and asked them to meet
him at Mr Graham’s cell, while he made his way there from the reception unit in a
prison van.
43. Between 4.25 and 4.30am, the SPCO and the two officers arrived at Mr Graham’s
cell. They found him lying on the floor, unresponsive. They felt that he was cold to
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the touch, and they could not feel a pulse or see any breathing. They also saw post-
mortem staining (purple coloration of the skin which becomes visible from
approximately 30 minutes following death).
44. At 4.30am, one of the officers called a code blue (a medical emergency code used
when a prisoner is unconscious or having breathing difficulties).
45. While waiting for the ambulance to arrive, the prison officers did not attempt to
resuscitate Mr Graham due to clear signs that he was already dead. The
ambulance arrived at Northumberland at 4.38am. The paramedics logged the post-
mortem staining visible on Mr Graham’s body and pronounced Mr Graham
deceased at 4.50am.
Contact with Mr Graham’s family
46. On the morning of 11 April, the prison appointed a SPCO as the family liaison
officer (FLO) and a PCO as his deputy. They attended the home of Mr Graham’s
mother to inform her of his death. They offered their condolences and support, and
explained what would happen next. Following the visit, the FLO remained in contact
with Mr Graham’s mother to support with funeral arrangements.
47. Mr Graham’s funeral took place on 4 May and the prison contributed to the cost, in
line with national policy.
Support for prisoners and staff
48. Despite several requests for Northumberland to share evidence that they debriefed
staff who were involved in the emergency response, to ensure that they had the
opportunity to discuss any issues arising and to offer support, no evidence was
provided.
Post-mortem report
49. The post-mortem report concluded that Mr Graham died of acute cardiorespiratory
failure (sudden failure of the heart and lungs) caused by left ventricular hypertrophy
(thickening of the wall within the heart). Raised body mass index (obesity) was
listed as a contributing factor.
50. The pathologist noted that there was no evidence to suggest that the cancer Mr
Graham had received treatment for some years before had reoccurred, nor was
there anything to suggest that the recent procedures he had undergone in hospital
were connected to his death.
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Findings
Clinical care
51. The clinical reviewer found that some of the care Mr Graham received was of the
required standard, in particular his ongoing care for laryngeal cancer, multi-agency
working and care received for his obesity. However, the care Mr Graham received
regarding his discharge planning from hospital and subsequent care was not of the
required standard and was only partially equivalent to the care he could have
expected to receive in the community.
52. The Head of Healthcare confirmed during interview that healthcare staff were
responsible for contacting the hospital and coordinating a discharge plan. This did
not happen. Mr Graham arrived back at the prison unexpectedly in the late
afternoon of 7 April. He was seen in reception by a nurse who volunteered to stay
on past her shift, but the nurse did not draw up a formal plan in relation to Mr
Graham’s ongoing care or provide any handover to day staff who would arrive the
following morning. Mr Graham’s discharge letter stated that he would need to have
the dressing on his tracheostomy wound changed daily, however no appointments
were arranged to do this so his dressing remained unchanged. We recommend:
The Head of Healthcare should ensure that there are robust processes in
place for communicating with hospitals to ensure that information is
appropriately shared and discharge planning is completed.
The Head of Healthcare should review the process of sharing information
between one shift and the next.
53. The clinical reviewer found that Mr Graham did not have a care plan for his
hypertension and his QRisk2 score (calculation of risk of heart attack/stroke) was
not updated after his diagnosis of hypertension. The Head of Healthcare said that
this was due to not having a permanent member of the healthcare team to complete
long term conditions care. He said that a long-term conditions nurse had recently
been employed and they would review implementation of care plans. We
recommend:
The Head of Healthcare should ensure that care plans are initiated when
clinically indicated, including for hypertension.
Emergency response
54. The OSO responded quickly to Mr Graham’s cell bell but when she got to the cell
and saw Mr Graham unresponsive on the floor, she called for assistance from the
night SPCO rather than calling a medical emergency code. The code was not called
until the SPCO and two officers arrived around 15 minutes later.
55. The OSO said in interview that she did not immediately call a code blue because
she saw Mr Graham’s legs moving and took this as a sign that he was not
unconscious. She also said that she had experienced a similar situation with a
different prisoner two weeks earlier, where the prisoner had been faking an
emergency as he was under the influence of illicit substances.
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56. We acknowledge that the OSO had not been told that Mr Graham had recently
been discharged from hospital following an operation and a period of treatment on
the ICU. During her interview, the OSO said that had she known about Mr
Graham’s medical condition, she probably would have called a code blue herself.
57. In response to this incident, the Director promptly launched an internal investigation
into staff actions during the emergency response. The investigation found that the
OSO’s delay in calling an emergency code amounted to misconduct, and she was
subject to disciplinary proceedings. In light of Northumberland’s swift action on this
matter, we make no recommendation.
Good practice
58. Since Mr Graham’s death, the Director of Northumberland has reviewed the
processes at Northumberland for when a prisoner is discharged from hospital. They
have since introduced a requirement for staff to note any recent hospital discharges
in the observation book. This allows all staff, including night prison staff, to identify
any prisoners who may be vulnerable as a result of recent medical treatment. We
consider this to be a positive change in response to learning from this incident.
Inquest
59. At the inquest, held on 14 October 2024, the jury concluded that Mr Graham died
from natural causes.
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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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