Francis Graham

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Francis Graham,
a prisoner at HMP Dovegate,
on 4 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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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 Francis Graham died in hospital from lung cancer on 4 April 2023, while a
prisoner at HMP Dovegate. He was 43 years old. We offer our condolences to Mr
Graham’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Graham received at
Dovegate was equivalent to that which he could have expected to receive in the
community.
5. We found no issues of concern and make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Graham’s death on 4 April 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
Graham’s clinical care at HMP Dovegate.
8. The PPO investigator investigated the non-clinical issues relating to Mr Graham’s
care.
9. The PPO family liaison officer wrote to Mr Graham’s next of kin, his brother, to
explain the investigation and to ask if he had any matters he wanted us to consider.
He did not respond to our letter.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies.
Previous deaths at HMP Dovegate
11. Mr Graham was the 11th prisoner to die at Dovegate since April 2020. Of the
previous deaths, seven were from natural causes, two were self-inflicted and one
was drug related.
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Key Events
12. On 1 February 2023, Mr Francis Graham was remanded to HMP Dovegate,
charged with shoplifting and threats to shop staff. He was subsequently convicted
and sentenced for these offences and a previously suspended sentence for assault
and theft was activated, giving him a total of 24 weeks imprisonment.
13. Mr Graham had a long history of offending linked to drug addiction and
homelessness. When he arrived at Dovegate, he said that he was spending £50 a
day on heroin and was drinking alcohol daily. He tested positive for several illicit
drugs. Staff put Mr Graham on an alcohol detoxification programme and a
methadone programme to treat his opiate addiction.
14. As well as his substance misuse issues, Mr Graham had a number of long-term
health conditions, including atrial fibrillation (a condition that causes the heart to
beat irregularly), regular issues with deep vein thromboses (DVTs, blood clots in the
deep veins of the body, a common condition in intravenous drug users, which can
lead to dangerous lung problems) and hepatitis C (a viral infection that can cause
serious liver disease). Mr Graham also had burns to his face and body from a
house fire in November 2019.
15. On 3 February, Mr Graham told staff he thought he had a chest infection.
Healthcare staff took samples for testing and a GP at Dovegate prescribed
antibiotics. The tests came back negative for an infection. Blood tests results in mid-
February were slightly abnormal and so further blood samples were scheduled.
However, Mr Graham refused his blood test on 23 March, and signed a disclaimer,
but it is not clear why.
16. On 20 March Mr Graham said he had a sore and swollen throat, and on 24 March,
he saw a GP complaining of a cough again. He did not have any breathlessness or
problems with walking up the stairs. The GP prescribed antibiotics and steroids and
scheduled to review Mr Graham in a month’s time.
17. A week later, Mr Graham said that he had been struggling to breathe and was seen
by a nurse in the morning and then by a GP later the same day. The GP noted that
although there was no immediate cause for concern, healthcare staff should visit Mr
Graham daily to check his clinical observations.
18. Following difficulty breathing on 1 April, and a deterioration in his observations,
healthcare staff requested an ambulance to take Mr Graham to hospital. He left the
prison early in the afternoon.
19. The hospital initially indicated that Mr Graham would return to prison on the same
day but delayed sending him back until X-rays had been examined. Following this,
the hospital said it was not happy for Mr Graham to return to prison, as it appeared
that he had possible lung cancer.
20. The following day, Mr Graham became critically unwell and was transferred to the
hospital’s intensive care unit. He remained there until his death on 4 April.
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Post-mortem report
21. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Graham’s cause of
death as respiratory failure (the lungs stopped working), caused by metastatic lung
cancer (advanced lung cancer which has begun to spread). They gave intravenous
drug use (injection of illicit drugs) and atrial fibrillation as factors which contributed
to the death but did not cause it.
Findings
22. Mr Graham had poor health as a result of his lifestyle and drug use and from the
effects of serious burns sustained in a house fire. He was an ex-smoker. Although
he had a cough at Dovegate, there were no signs of significant deterioration in his
health prior to his transfer to hospital on 1 April, and the subsequent discovery of
lung cancer. The clinical reviewer concluded that Mr Graham’s healthcare at
Dovegate was equivalent to that which he could have expected to receive in the
community.
23. We make no recommendations.
Adrian Usher
Prisons and Probation Ombudsman September 2023
Inquest
The inquest, held on 30 November 2023, 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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