Eric Pyle

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Independent investigation into
the death of Mr Eric Pyle,
a prisoner at HMP Littlehey,
on 28 May 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, 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. 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 Eric Pyle died in hospital of necrotising pancreatis on 28 May 2024, while a
prisoner at HMP Littlehey. This happens when the inflammation from pancreatitis is
so severe that it causes tissue death. He was 68 years old. We offer our
condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Pyle received at HMP
Littlehey was not equivalent to that which he could have expected to receive in the
community. He found that Mr Pyle’s high cholesterol and chronic obstructive
pulmonary disease (COPD) was not managed in line with national guidelines.
5. The clinical reviewer made a recommendation about an issue not directly related to
Mr Pyle’s death but which the Head of Healthcare at HMP Littlehey will want to
address.
6. We found that the questions in the medical section of the escort risk assessment
had been misinterpreted and the responses contradicted the use of restraints.
Recommendations
• The Head of Healthcare at HMP Littlehey should ensure that all staff involved in the
escort decision-making process have received training on the policy framework and
legal position relating to hospital escorts, taking a prisoner’s current medical
condition and how this impacts their ability to escape into consideration.
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The Investigation Process
7. HMPPS notified us of Mr Pyle’s death on 28 May 2024.
8. NHS England commissioned an independent clinical reviewer to review Mr Pyle’s
clinical care at HMP Littlehey.
9. The PPO investigator investigated the non-clinical issues relating to Mr Pyle’s care.
She interviewed one member of staff from HMP Littlehey on 24 July 2024.
10. The Ombudsman’s office wrote to Mr Pyle’s next of kin, his wife, to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond to our letter.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
Previous deaths at HMP Littlehey
12. Mr Pyle was the thirty seventh prisoner to die at HMP Littlehey since 28 May 2021.
Of the previous deaths, 32 were from natural causes and four were self-inflicted.
There are no similarities between the findings in our investigation into Mr Pyle’s
death and the findings from our investigations into the previous deaths.
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Key Events
13. On 2 June 2017, Mr Eric Pyle was sentenced to nearly seven and a half years in
prison for sexual offences and was sent to HMP Bullingdon.
14. On 1 August, Mr Pyle was transferred to HMP Rye Hill.
15. On 22 April 2021, a GP operating at Rye Hill saw Mr Pyle after he reported
abdominal pain and vomiting. He diagnosed him with acute cholecystitis
(inflammation of the gallbladder) and referred him to the hospital to consider if he
needed gallbladder removal surgery.
16. On 28 April, Mr Pyle was transferred to HMP Littlehey. During his reception screen,
he reported that he had had problems with his gallbladder, and he was referred to a
prison GP for assessment.
17. On 30 April, a GP operating at Littlehey reviewed Mr Pyle and referred him to a
gastroenterologist.
18. On 23 September, Mr Pyle attended a hospital appointment. Hospital staff agreed
that Mr Pyle should be considered for gallbladder removal surgery. Although Mr
Pyle had already had an ultrasound scan, the scan results had not been included in
the referral. They therefore asked for another ultrasound scan to be completed.
19. On 15 October, Mr Pyle declined to attend hospital for his further ultrasound scan.
He signed a hospital attendance refusal form which stated that he would be
discharged from the hospital waiting list.
20. On 8 November, a GP at Littlehey saw Mr Pyle, who told her that he had had
problems with his gallbladder for 20 years. Mr Pyle said that he had not attended
his recent hospital appointment because he was worried about fat digestion and
absorption (which makes it harder to get enough vitamins) after the operation, and
he preferred to have treatment when he was not in prison. She reassured him and
told him to consider whether he wanted to be re-referred. We saw no evidence to
say whether Mr Pyle supported a re-referral.
21. On 14 December, Mr Pyle attended an appointment with a GP at Littlehey and was
diagnosed with chronic obstructive pulmonary disease (COPD) for which he was
prescribed an inhaler.
22. On 23 December, a nurse saw Mr Pyle to assess his COPD. This was to be
reviewed annually. The medical records state that she was unable to complete a
lung function test (known as spirometry) due to COVID-19 restrictions.
23. On 27 April 2022, the nurse saw Mr Pyle for his COPD. The medical records
indicate that she was still unable to complete the spirometry due to the COVID-19
restrictions.
24. On 27 July 2023, the nurse reviewed Mr Pyle for his COPD.
25. On 18 January 2024, a GP at Littlehey referred Mr Pyle to the colorectal surgery
department at hospital as he had had recent right-sided upper abdominal pain. The
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medical records contained no information about whether surgery had been
scheduled or took place.
26. On 13 February, a GP operating at Littlehey saw Mr Pyle. He said he had had right-
sided upper abdominal pain for two years. The GP prescribed pain relief medication
and arranged for Mr Pyle to have an ultrasound scan.
27. On 6 March, a nurse told Mr Pyle that his ultrasound results identified a strong
likelihood of gallstones.
28. On 19 March, a GP at Littlehey told Mr Pyle that his ultrasound scan showed
multiple gallstones. He referred him urgently to the gastrointestinal surgery
department.
29. On 1 May, a code blue was called as Mr Pyle was in pain. Healthcare staff attended
and assessed that an ambulance was not needed but instead, they asked for Mr
Pyle to be taken to hospital by prison transport. The medical records indicate that
healthcare staff suspected an acute worsening of cholecystitis.
30. An escort risk assessment was completed. A nurse completed the medical section
which stated that Mr Pyle may need a wheelchair. It also said that his
health/mobility affected his ability to escape, and the use of restraints could cause
him injury/pain. Despite this, the assessment stated that Mr Pyle should be
restrained with a single cuff. The Head of Operations approved the use of restraints.
Before Mr Pyle left Littlehey, his restraints were changed to an escort cable due to
his medical condition and mobility. The escorting officer told us that as Mr Pyle was
able to walk short distances, he walked to the prison van and then used a
wheelchair when he arrived at hospital.
31. On 2 May, a member of the healthcare team contacted the hospital, who told them
that Mr Pyle’s abdominal pain was controlled. Escort officers on bedwatch at the
hospital submitted a request for Mr Pyle’s restraints to be removed due to his
condition. This request was approved, and Mr Pyle’s restraints were removed at
7:05pm. Mr Pyle was assigned a family liaison officer, who contacted his wife and
told her that Mr Pyle was very unwell in hospital.
32. On 3 May, healthcare staff phoned the hospital for an update. They said that Mr
Pyle had been moved to the critical care unit and was being treated for pancreatitis.
Healthcare remained in contact with hospital staff daily.
33. On 4 May, Mr Pyle’s wife and daughter visited him in hospital. Mr Pyle’s wife told
the family liaison officer that she was happy to be contacted by phone call if Mr
Pyle’s health deteriorated.
34. On 15 May, healthcare staff contacted the hospital who told them that Mr Pyle had
returned to a hospital ward. He continued to deteriorate and needed intravenous
fluids, intravenous antibiotics, a nasogastric tube and strong pain relief medication.
35. On 26 May, healthcare staff phoned the hospital who said that Mr Pyle needed
high-flow oxygen and had been moved back to the critical care unit. Mr Pyle’s wife
visited him in hospital.
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36. On 27 May, healthcare staff contacted the hospital who gave a poor prognosis for
Mr Pyle and his condition had deteriorated.
37. At 9.30am on 28 May, Mr Pyle died in hospital.
38. At 9.50am, Mr Pyle’s family liaison officer contacted his wife and told her he had
died.
Post-mortem report
39. A hospital doctor gave Mr Pyle’s cause of death as necrotising pancreatitis. Mr Pyle
also had COPD and gallstones which contributed to but did not cause his death.
The Coroner accepted this cause of death, and no post-mortem examination was
carried out.
Inquest
40. At an inquest held on 3 March 2025, the Coroner concluded that Mr Pyle died of
natural causes.
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Findings
Clinical findings
41. The clinical reviewer concluded that the clinical care Mr Pyle received in prison was
not of a good standard and not equivalent to that which he could have expected to
receive in the community. They found that Littlehey did not complete annual
assessments for Mr Pyle’s COPD or high cholesterol, as recommended by national
guidance.
42. The clinical reviewer found that Mr Pyle experienced a delay in receiving his
spirometry test at Littlehey, and his medical records incorrectly stated that this could
not be completed due to COVID restrictions. The clinical reviewer was unable to
explain why this was recorded as a reason because guidance published on 28 April
2021 recommended that spirometry testing should restart with appropriate risk
assessments in place.
43. The clinical reviewer made one recommendation about matters not directly affecting
Mr Pyle’s death, which the Head of Healthcare at HMP Littlehey will want to
address.
Restraints, security and escorts
44. 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. The Graham 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. 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.
45. When Mr Pyle went to hospital on 1 May, a nurse completed a medical risk
assessment, and ticked a box to indicate that she had no medical objections to the
use of restraints. She told us that as Mr Pyle had previously been fit, mobile and
was not usually a wheelchair user, she recommended that restraints should be
used.
46. Mr Pyle’s risk of escape was not considered in line with the Graham Judgment. The
medical risk assessment stated that Mr Pyle was usually independent but may need
a wheelchair due to his current presentation. The nurse told us that as far as she
was aware, a prisoner would still be restrained even if they were in a wheelchair.
However, if Mr Pyle needed a wheelchair, his ability to escape would have been
significantly reduced.
47. The nurse told us that if a prisoner was not suitable for restraints, this would be
documented in their medical notes and, if it was not, she would generally
recommend a single cuff. However, decisions about restraints should be made on a
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case-by-case basis and based on a prisoner’s health and mobility at the time of the
escort.
48. The nurse ticked the box in the medical section of the risk assessment to confirm
that Mr Pyle’s current health and mobility affected his ability to escape. She told us
that this was an oversight, and she inserted the wrong answer. As Mr Pyle was
assessed as potentially needing a wheelchair, she correctly ticked the box to say
that his mobility affected his ability to escape.
49. The nurse also indicated in the medical section that the use of restraints could
cause injury or pain to the prisoner. She said she had historically ticked yes for
every prisoner as the risk of injury to a prisoner from restraints was always a
possibility. She said that in future, she would base her response on whether a
prisoner had current injuries.
50. The nurse also stated that she was not familiar with the Graham Judgment and had
not had any training on it.
51. The Head of Operations told us that he approved the use of restraints based on the
healthcare team’s assessment that there were no medical objections. There was no
recent intelligence that there were security or behavioural concerns about Mr Pyle.
52. While we appreciate that Mr Pyle ended up walking to the prison van, we are
concerned about the decision-making and interpretation of the questions in the risk
assessment. The completed medical risk assessment suggested that restraints
should not have been used but the nurse concluded that she had no medical
objections to the use of restraints. We therefore make the following
recommendation:
The Head of Healthcare at HMP Littlehey should ensure that all staff involved
in the escort decision-making process have received training on the policy
framework and legal position relating to hospital escorts, taking a prisoner’s
current medical condition and how this impacts their ability to escape into
consideration.
Adrian Usher
Prisons and Probation Ombudsman January 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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