Donald McKean

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Independent investigation into the
A report by the Prisons and Probation Ombudsman
death of Mr Donald McKean,
on 28 May 2023, following his
release from HMP Leeds
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, 2025
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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 detained people 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. Since 6 September 2021, the PPO has been investigating post-release deaths
that occur within 14 days of the person’s release from prison.
4. Mr Donald McKean died from pneumonia in hospital on 28 May 2023, following his
release from HMP Leeds. Mr McKean was 60 years old. We offer our condolences
to his family and friends.
5. Mr McKean had a difficult life, and his problems were exacerbated by learning
difficulties and alcohol. He returned to prison in March 2023, after a long period in
hospital where his behaviour became unmanageable and ultimately led to a new
sentence for the assault of hospital staff. Mr McKean’s family raised questions
about the suitability of imprisonment and the adequacy of societal support for him
over a long period of time. Unfortunately, these are not questions that the PPO
can answer as they are outside our remit. We found no issues of concern relating
to the input from Leeds and the Probation Service in the period leading up to his
death, and we make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr McKean’s death on 12 June 2023.
7. The PPO investigator obtained copies of relevant extracts from Mr McKean’s
prison and probation records.
8. We informed HM Coroner for West Yorkshire of the investigation. He gave us the
results of the non-invasive post-mortem examination. We have sent the Coroner a
copy of this report.
9. The Ombudsman’s family liaison officer contacted Mr McKean’s brother to explain
the investigation and to ask if he had any matters he wanted us to consider. He
raised issues relating to his brother’s brain damage in infancy and the subsequent
lack of adequate support for him during his life which are outside the remit of the
PPO’s investigation. He also said that he was concerned about Mr McKean’s care
at Leeds prior to his discharge and that his pneumonia was not diagnosed before
he went into a care home. This is discussed in this report. A further issue
regarding the prison’s contact with Mr McKean’s brother while he was in hospital
at the beginning of 2023 is addressed in separate correspondence.
10. The initial report was shared with Mr McKean’s brother. He did not reply to the
PPO, but his comments forwarded by the Coroner have been addressed in
separate correspondence.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found a factual inaccuracy regarding the attendees of a meeting, which
has been corrected in this report.
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Background Information
HMP Leeds
12. HMP Leeds is a local prison holding around 1,100 men with a high turnover. It has
a mix of remand and convicted prisoners, and a wide range of sentenced
prisoners. The prison serves the courts of West Yorkshire. Practice Plus Group
provides healthcare services, including mental health services, and there is 24-
hour coverage. Midlands Partnership Trust provides psychosocial substance
misuse services.
HM Inspectorate of Prisons
13. The most recent full inspection of HMP Leeds was in June 2022. HMIP inspectors
reported that the prison was well led and staffing levels were better than in many
other prisons. Inspectors said that there were clear governance structures for
healthcare leaders to review the quality of patient provision, and that there was
evidence of good partnership working between healthcare and prison staff.
Patients with long-term conditions and complex care needs were identified at
reception and reviewed. HMIP reported that there was good social care provision
for those prisoners who needed it and there was liaison with the local authority
and other agencies to plan for the release for these prisoners.
Probation Service
14. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people
for resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
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Key Events
15. Mr Donald McKean had an extensive offending history, frequently relating to his
behaviour in public and linked to his use of alcohol. This included numerous
breaches of the peace, assaults and threatening and disorderly behaviour. He also
had a long history of non-compliance with his licence conditions. A Probation
Service risk assessment for Mr McKean at the end of 2020, said that all his
offences reflected his difficulties relating to other people along with anti-social
attitudes, and that heavy alcohol use was a significant factor in his offending. The
risk assessment also noted that because of the extent of Mr McKean’s offending
behaviour, he had been barred from working with most organisations that might
help him to improve the quality of his life.
16. On 19 December 2022, Mr McKean was convicted of assaulting paramedics who
had gone to his aid on 16 November and was sentenced to a 12-month
community order. However, following the assault of another emergency worker, on
3 January 2023, he was remanded in custody and sent to HMP Leeds.
17. On arrival at Leeds, Mr McKean complained of an injury to his arm which he said
had happened in a fall the day before (but from ambulance and hospital records it
appears the injury was sustained on 1 January). Healthcare staff were concerned
that he may have fractured a bone and wanted him to be checked at hospital.
Because of Mr McKean’s behaviour difficulties, he needed three officers to escort
him to hospital and these were not initially available, and when they were, Mr
McKean refused to go. Eventually he agreed and he was taken to hospital on 8
January, where a fracture was confirmed. Mr McKean returned to the prison on
the same day, but before he did, he had had an epileptic seizure in hospital
(epilepsy was a pre-existing health condition). His clinical record noted that
following his hospital visit, Mr McKean was using a wheelchair.
18. On 10 January, Mr McKean moved to the prison’s dedicated social care unit,
where more support was available to him. When Mr McKean arrived at Leeds, he
was incontinent and had slurred speech and right sided weakness. On 13
January, a GP at Leeds thought that Mr McKean may have had a stroke and
asked for his hospital scan results from 8 January. When healthcare staff received
the scan results, they did not give any indication that Mr McKean had recently had
a significant stroke.
19. On 19 January, Mr McKean became very unwell and was taken back to hospital.
Due to his behaviour towards staff, they called the police. The next day, Mr
McKean was diagnosed with aspiration pneumonia and admitted to hospital. A
scan on 25 January also showed he had suffered a stroke. Leeds did not have the
capacity to do stroke rehabilitation and Mr McKean remained in hospital.
20. On 22 February, the Crown Prosecution Service (CPS) decided to discontinue the
case against Mr McKean because of his health issues, and he was released from
prison. He remained in hospital as an ordinary patient. However, his continual
difficult behaviour with hospital staff escalated to assault and, on 14 March, staff
called police. Mr McKean returned to Leeds on remand on 16 March. On 17 April,
Mr McKean was sentenced to 20 weeks imprisonment for assault and
harassment.
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21. Following Mr McKean’s return to Leeds, he was again accommodated in the social
care unit, where he received daily input from healthcare staff for his continence,
showering and other needs. Mr McKean was frequently abusive to staff and
although this caused considerable issues at times, his difficulties were well known
to staff at Leeds, who often made great efforts to accommodate his requirements.
Pre-release planning
22. On 25 April, a multi-agency meeting considered plans to manage Mr McKean’s
risks in the community and support needs, including accommodation on his
release from prison. The planning for Mr McKean’s discharge was led by his social
care worker with input from many others, including probation and prison staff.
23. On 17 May, Mr McKean’s social care worker visited the prison and held a meeting
with his prison offender manager (POM) and healthcare staff. They engaged Mr
McKean in the discussions and told him that it was likely that he would go to a
care home on release. Leeds said that he could continue to use his prison
wheelchair and they would arrange transport on discharge. The meeting also
agreed the support of a substance misuse worker for Mr McKean when he was
released.
24. Following the meeting, on 19 May, Mr McKean’s community offender manager
(COM) confirmed that his assessed needs were too great for alternative
accommodation such as an approved premises (AP). Mr McKean’s POM was
concerned about release without suitable accommodation. Following her
enquiries, she confirmed that it was not legally possible for him to stay in prison
past his release date. Healthcare staff wrote a report outlining Mr McKean’s needs
and behaviours so that an accommodation provider would have advance
knowledge of his requirements.
25. On 20 May, Mr McKean’s social care worker confirmed that there was a care
home place available for him and that he would be provided with 24-hour one to
one support. He also said that a place in a care home closer to one of his brothers
might become available in a few weeks.
26. Mr McKean was released from prison on 24 May, and he was met at his care
home by his COM, his social care worker, and his substance misuse support
worker.
Circumstances of Mr McKean’s death
27. On 27 May, Mr McKean became ill at his care home and was taken to hospital,
where he died the following day.
Post-mortem report
28. A non-invasive post-mortem report concluded that Mr McKean died from
pneumonia. A cerebrovascular accident (commonly known as a stroke, which is
serious condition where the blood supply to part of the brain is cut off) was given
as a factor which contributed to, but which did not cause the death.
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Findings
29. Mr McKean’s brother was concerned that Mr McKean may have been released to
a care home with established pneumonia that had not been diagnosed. He was
seen on a daily basis by prison and healthcare staff, by a doctor at the prison two
days before his release, and by a nurse at reception on the day of his release.
They had no concerns and there is nothing in his prison or clinical notes leading
up to his release that would give any indication that Mr McKean had become
unwell or that there was a suspicion of pneumonia. We did not find any
shortcomings in his care and make no recommendations.
Good practice
30. Mr McKean often required a lot of staff attention and was frequently angry and
abusive to both prison and healthcare staff at Leeds. He was assessed by
probation staff as being a high risk of serious harm to the general public and very
high risk of serious harm to staff when in custody. However, despite being very
challenging, staff at Leeds treated Mr McKean with understanding in the period
leading to his discharge from prison in May. Mr McKean’s social care worker had a
very good appreciation of Mr McKean’s difficulties and included him in the decision
making about his future, and worked closely with the prison staff and his COM in
the lead up to his release from prison to ensure that he had appropriate
accommodation with sufficient support.
Adrian Usher
Prisons and Probation Ombudsman December 2023
Inquest
31. The inquest into Mr McKean’s death concluded in October 2024 and found that he
died of natural causes.
6 Prisons and Probation Ombudsman
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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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