Edward McCulloch

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Independent investigation into the
death of Mr Edward McCulloch,
a prisoner at HMP Isle of Wight,
on 25 June 2021
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 detainees in immigration centres.
2. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Edward McCulloch died on 25 June 2021 of lung cancer at HMP Isle of Wight.
He was 83 years old. We offer our condolences to Mr McCulloch’s family and
friends.
4. The clinical reviewer concluded that the clinical care Mr McCulloch received at HMP
Isle of Wight was equivalent to that he could have expected to receive in the
community. He made one recommendation.
5. We found that the decision to restrain Mr McCulloch when he was taken to hospital
in May was not justified given his advanced age and poor mobility.
6. We also found that there was a delay in assigning a family liaison officer (FLO),
which was not done until after Mr McCulloch died.
Recommendations
• The Head of Healthcare should ensure that staff use a coordinated care plan
approach to manage long-term conditions, and accurately record care plans and the
outcomes in the medical records.
• The Governor should ensure that a family liaison officer is appointed for prisoners
who are seriously or terminally ill and that the next of kin is kept informed of the
prisoner’s condition, in line with PSI 64/2011.
• The Governor 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 and that assessments fully take into account the health of a
prisoner and are based on the actual risk the prisoner presents at the time.
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The Investigation Process
7. NHS England commissioned an independent clinical reviewer to review Mr
McCulloch’s clinical care at HMP Isle of Wight.
8. The PPO investigator has investigated non-clinical issues, including Mr McCulloch’s
location, the security arrangements for his hospital escorts, liaison with his family
and whether compassionate release was considered.
9. The PPO family liaison officer wrote to Mr McCulloch’s next of kin, his son, to
explain the investigation. He did not respond to our letter.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Isle of Wight
11. Mr McCulloch was the 16th prisoner to die at HMP Isle of Wight since June 2019.
Of the previous deaths, ten were from natural causes and five were self-inflicted.
12. We have previously made a recommendation to Isle of Wight about ensuring the
use of restraints on sick and elderly prisoners is justified. We were told that the
Governor would remind staff of their responsibilities by January 2022.
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Key Events
13. In December 2014, Mr Edward McCulloch was sentenced to 18 years in prison for
sexual offences. In May 2015, he was moved to HMP Isle of Wight.
14. Mr McCulloch had several serious health conditions including heart disease,
hypertension (high blood pressure), chronic obstructive pulmonary disease (COPD
– the term for a group of serious lung diseases), osteoarthritis (a condition which
causes joints to become stiff and painful), an amputated lower right leg, and
dementia. Healthcare staff saw him frequently to monitor these conditions.
15. On 23 March 2021, a multi-disciplinary meeting was held to discuss Mr McCulloch's
frailty and need for increased social care.
16. Between 8 April and 20 May, Mr McCulloch was admitted to the prison’s Inpatient
Healthcare Unit (IHU) four times and declined to be admitted to the IHU once
despite a prison GP’s advice.
17. On 20 May, a GP admitted Mr McCulloch to the IHU after diagnosing him with a
chest infection. Another multi-disciplinary meeting was held, where it was decided
to begin end of life management for Mr McCulloch.
18. On 28 May, a GP noted Mr McCulloch’s condition was appearing to become
terminal and prescribed anticipatory medications (medicines that are prescribed for
symptoms that might develop in the future) delivered by syringe driver (a small
battery powered pump which delivers medication through a tube into the skin).
19. On 3 June, a GP noted that despite some initial improvement, Mr McCulloch was
continuing to deteriorate and appeared to be approaching the end of his life.
20. On 17 June, a meeting was held where assigning a family liaison officer (FLO) and
enquiring about any next of kin (NOK) were discussed. The next day, the prison
chaplain visited Mr McCulloch.
21. On 23 June, a GP reviewed Mr McCulloch and noted he was weaker and struggling
to swallow pills. Mr McCulloch declined any treatment, and all his unnecessary
medication was stopped. He continued receiving painkillers.
22. Mr McCulloch died on 25 June in the IHU.
Post-mortem report
23. The post-mortem report concluded that Mr McCulloch died of carcinoma of the lung
(lung cancer) as a result of cigarette smoking. The post-mortem also showed that
cerebrovascular disease, ischaemic heart disease, hypertension, and old age were
contributory factors.
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Non-Clinical Findings
Liaison with Mr McCulloch’s family
24. Prison Service Instruction (PSI) 64/2011, about safer custody, says that prisons
must ensure that arrangements are in place for an appropriate member of staff to
engage with the next of kin or a nominated person of prisoners who are either
terminally or seriously ill.
25. On 3 June, the prison GP noted that Mr McCulloch was nearing the end of his life.
On 17 June, a meeting was held where assigning a FLO and enquiring about any
NOK were discussed. The next day, Mr McCulloch was visited by the prison
chaplain. However, a FLO was not appointed until 25 June, after Mr McCulloch
died. We recommend:
The Governor should ensure that a family liaison officer is appointed for
prisoners who are seriously or terminally ill and that the next of kin is kept
informed of the prisoner’s condition, in line with PSI 64/2011.
Restraints, security and escorts
26. 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. The judgment indicated 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.
27. The investigator reviewed Mr McCulloch’s escort risk assessment from 9 May 2021,
for one of his hospital appointments. The risk assessment noted that Mr McCulloch
was experiencing declining physical and mental health and was becoming
increasingly frail and confused. It also said that Mr McCulloch was only partially
mobile, requiring use of a wheelchair, and that his medical condition (below knee
amputation) would restrict his ability to escape unassisted. Despite this, staff
assessed Mr McCulloch’s escape potential as ‘normal’ and his risk to staff and the
general public as ‘high’, and a manager authorised the use of 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).
28. We are not satisfied that the use of restraints on Mr McCulloch was proportionate to
the risks he posed. Mr McCulloch was an elderly prisoner with reduced mobility
who had a very low risk of escape and who was accompanied by two prison
officers. We are not satisfied that the authorising manager took this into account
when authorising restraints. We do not consider that the use of restraints was
justified. We also note that two months before, in March, no restraints were used
on Mr McCulloch when he was taken to hospital. We do not understand therefore
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why restraints were used in May, when his condition had deteriorated, and he was
even less of an escape risk. We recommend:
The Governor should ensure that authorising mangers take account of all the
information in escort risk assessments and that all decisions to use restraints
on prisoners taken to hospital are proportionate to their risk.
Louise Richards May 2022
Assistant Ombudsman
Inquest
At the inquest, held on 6 August 2025, the Coroner concluded that Mr McCulloch 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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