Gavin Wheale

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Independent investigation into
the death of Mr Gavin Wheale,
a prisoner at HMP Birmingham,
on 8 August 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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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 Gavin Wheale died in his cell on 8 August 2024 at HMP Birmingham. He was 47 years
old. I offer my condolences to Mr Wheale’s family and friends. The pathologist gave the
cause of death as mixed drug interactions (morphine, cocaine and diazepam).
In my investigation into a death at Birmingham in May 2024, I identified a number of
weaknesses in reception procedures including the failure to examine all available
information about risk. These findings echoed some of the former Ombudsman’s findings
in a death there in February 2022. I am deeply concerned to find the same issues in this
case.
Mr Wheale arrived at Birmingham with a significant amount of evidence from the police
that he was concealing drugs on his person and had threatened to consume them. The
reception manager and the reception nurse did not examine all of the information about Mr
Wheale’s risk, and the nurse was unaware that Mr Wheale was concealing drugs. An
officer saw Mr Wheale conceal an item internally during a search and shortly afterwards
Mr Wheale self-reported that he had taken diazepam in a holding room. The officer did not
tell healthcare staff. Mr Wheale was taken to the care and separation unit (CSU –
segregation unit) in line with local policy. The CSU staff were unaware of the prison’s
secreted item policy and Mr Wheale was not made subject to extra monitoring. Neither the
nurse who assessed his fitness for segregation nor the one that checked him for a routine
night check considered the risks or potential consequences of Mr Wheale having
concealed drugs. He was found dead early the following afternoon.
The investigation identified a number of systemic and endemic failures by staff to follow
national and local guidance for the risk assessment of prisoners in reception and the
management of prisoners deemed to be concealing items. Overall, most seriously, there
was a complete and collective failure to recognise that prisoners concealing items are at
serious risk of harm. This meant that there was no effective oversight to prevent Mr
Wheale’s death.
At the time of writing in May 2025, two prison staff are facing disciplinary hearings into
their actions on 7 August 2024, as would a nurse had he not left employment there. The
prison has already put in place several measures as a result of learning from Mr Wheale’s
death and previous investigations. I welcome these and make fewer recommendations of
my own as a result.
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 July 2025
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Contents
Summary ........................................................................................................................ 1
The Investigation Process ................................................................................................4
Background Information ...................................................................................................5
Key Events .......................................................................................................................8
Findings ......................................................................................................................... 18
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Summary
Events
1. Mr Gavin Wheale had a significant history of poly-substance abuse and had served
several sentences for crimes relating to his addictions. He also had a history of
anxiety, depression, self-harm, concealing drugs, and accidental overdose.
2. On 12 December 2023, Mr Wheale was sentenced to 16 months imprisonment for
threatening a person with a bladed article in a public place. On 11 July 2024, he
was released on licence from HMP Doncaster. He was recalled to prison the
following day, but he remained unlawfully at large.
3. On 6 August 2024, West Midlands police arrested Mr Wheale for shoplifting. During
a strip search in police custody, officers noticed plastic packaging protruding from
his anus. They took him to hospital as they suspected he had drugs secreted in his
body. Mr Wheale was seen by a doctor but refused all other treatment. He was
returned to police custody, put under constant observation and kept handcuffed
overnight after he said he would retrieve the package as soon as he was able to.
4. On 7 August, Mr Wheale was taken to HMP Birmingham. In addition to risk
information contained in his escort records, a member of the escort service staff told
reception staff that Mr Wheale was concealing a package and required monitoring.
5. The custodial manager (CM) in charge of reception did not examine the escort
records and did not properly consider all of Mr Wheale’s risk factors as required by
local and national policy. Neither did he inform the reception nurse that Mr Wheale
was concealing a package. The reception nurse also did not read the escort
records. Mr Wheale gave a urine sample that tested positive for opiates,
benzodiazepines, cocaine and cannabinoids.
6. During a search, an officer saw a package fall out of Mr Wheale’s shoe. Mr Wheale
refused to give it to the officer and appeared to conceal it in his anus. A subsequent
X-ray body scan was inconclusive. Shortly afterwards, Mr Wheale showed the same
officer a plastic bag and told him that he had taken a single tablet of prescribed
diazepam. The officer told senior managers but did not tell healthcare staff.
7. Mr Wheale was segregated in line with local policy on secreted items. No one in the
CSU was aware of the prison’s secreted item policy and Mr Wheale was not risk
assessed or monitored more closely as he should have been. The nurse that
assessed whether Mr Wheale was physically and mentally fit enough to be
segregated did not consider the risks and potential consequences of Mr Wheale
concealing drugs.
8. Mr Wheale pressed his cell bell several times during the night and told the night
patrol officer that he was withdrawing from drugs. He also told the nurse that visited
him for a standard first night welfare check that he was in pain. She did not explore
why he was in pain or where his pain was and told him he was not allowed any type
of medication as he had a concealed item. She too did not consider the risks and
potential consequences of Mr Wheale concealing drugs.
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9. The next morning, several members of staff saw Mr Wheale and he came out of his
cell for a shower. Staff last saw him alive at about midday. At about 2.25pm, two
officers unlocked his cell to take him for another body scan and found him
unresponsive on his bed. Officers and nurses gave Mr Wheale cardiopulmonary
resuscitation (CPR) and naloxone (to reverse opiate overdose) but at 2.39pm the
prison GP pronounced life extinct.
Findings
10. There were a number of systemic and endemic failures by staff to follow national
and local guidance for the risk assessment of prisoners in reception and the
management of prisoners deemed to be concealing items.
• The reception CM did not consider all of the available information on Mr
Wheale’s risk in line with national guidance. He did not inform the reception
nurse that Mr Wheale was suspected of concealing an item as he should have
done.
• The reception nurse also did not look at the escort records in line with local
and national guidance and therefore failed to consider all of the available
information on Mr Wheale’s risk.
• The officer operating the body scanner did not tell healthcare staff that he had
seen Mr Wheale conceal a package internally and that he had reported taking
a tablet of diazepam. He made a serious error of judgement by not considering
this represented a significant increase in Mr Wheale’s risk.
• The officer operating the body scanner did not attempt to retrieve and secure
the bag Mr Wheale showed him as evidence for trace testing as he should
have done.
• The nurse that assessed Mr Wheale in the CSU and the nurse that completed
the night welfare check did not consider the risks and potential consequences
for Mr Wheale of concealing an item.
• The duty governor authorising segregation and none of the staff in the CSU
were aware of the prison’s secreted item policy and Mr Wheale was not
subject to extra monitoring as he should have been.
11. There was a complete and collective failure among all staff to recognise that
prisoners concealing items are at serious risk of harm. This resulted in a lack of
clinical assessment and monitoring and meant that there was no effective oversight
to prevent Mr Wheale’s death.
12. The clinical reviewer concluded that the clinical care offered to Mr Wheale was not
of the required standard and therefore not equivalent to that which would have been
received in the wider community.
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Recommendations
• The Governor and Head of Healthcare should deliver training to staff
emphasising the potential risk of harm to a prisoner suspected of secreting
items and introduce a robust assurance process to satisfy themselves that this
learning has been embedded.
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The Investigation Process
13. HMPPS notified us of Mr Wheale’s death on 8 August 2024.
14. The investigator issued notices to staff and prisoners at HMP Birmingham informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Wheale’s prison and
medical records, CCTV, body worn video camera (BWVC) footage and staff radio
communications. Despite several requests, including to senior prison managers, we
were not provided with the cell bell records from the CSU. Further information was
provided by West Midlands police and West Midlands Ambulance Service. West
Midlands police investigated Mr Wheale’s death for the Coroner but did not consider
any criminal charges. The prison provided the investigator with a copy of their local
investigation into the actions of two members of staff on 7 August 2024.
16. The investigator interviewed 15 members of staff at Birmingham in November 2024.
Two members of staff were absent on sick leave and did not wish to be interviewed.
17. NHS England commissioned a clinical reviewer to review Mr Wheale’s clinical care
at the prison. The clinical reviewer interviewed seven healthcare staff together with
the investigator.
18. We informed HM Coroner for Birmingham of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
19. The Ombudsman’s office contacted Mr Wheale’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Wheale’s mother
had no specific questions but asked for a copy of our report, which we have sent to
her.
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Background Information
HMP Birmingham
20. HMP Birmingham is a category B reception prison. Birmingham and Solihull Mental
Health Foundation Trust provides 24-hour healthcare services at the prison and
sub-contracts Birmingham Community Healthcare NHS Trust to provide primary
care services. Substance misuse services are delivered by an integrated service
known as the Birmingham Recovery Team (BRT).
HM Inspectorate of Prisons
21. The most recent inspection of HMP Birmingham was in January and February
2023. Inspectors noted significant improvements at the prison since the previous
inspection. They found that the leadership team, which was well motivated and
supportive of the Governor’s priorities, had helped to improve stability. Healthcare
services were well led by knowledgeable managers with a clear vision for providing
better outcomes for prisoners.
22. Inspectors found reception and induction arrangements were appropriate. The
segregation unit was in a temporary location due to the refurbishment project which
meant that three wings were out of use. Cells were clean and adequately equipped
but the regime was limited and there was little to stimulate or motivate prisoners.
23. There had been significant investment in physical and procedural security
arrangements to prevent the ingress of drugs. This included the body scanner,
enhanced gate security and better netting. Far fewer prisoners than at the previous
inspection said it was very or quite easy to get hold of drugs.
Independent Monitoring Board
24. 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 June 2023, the IMB reported that
the prison had continued to build on the earlier successes and improvements.
25. The Board’s main concerns were centred on the recruitment and retention of
suitable staff and the negative impact of staffing issues on the regime and
availability of support for prisoners. The body scanner had proved effective in
detecting and deterring the ingress of drugs. The number of prisoners placed in
segregation following a positive scanner reading had steadily reduced between
2021 and 2023.
Previous deaths at HMP Birmingham
26. Mr Wheale was the thirteenth prisoner to die at Birmingham since August 2021. Of
the 12 previous deaths, seven were from natural causes, three were self-inflicted,
one was drug related and one was a homicide.
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27. In a self-inflicted death in 2022, we recommended that the Governor should review
the Person Escort Record (PER) system to ensure that reception staff had access
to all relevant information. The two deaths immediately before Mr Wheale’s in May
and June 2024 were both of prisoners in their early days in custody. In the first of
these, we recommended that the Governor and Head of Healthcare should review
the training for reception and induction staff to ensure they examine and share all
relevant information about risk including information in the PER. We also
recommended that the Head of Healthcare review the quality and compliance with
policy of reception health screens.
Segregation
28. Segregation units are used to keep prisoners apart from other prisoners.
Segregation is authorised by an operational manager at the prison who must be
satisfied that the prisoner is fit for segregation after an assessment by a member of
healthcare staff. The unit at HMP Birmingham is known as the care and separation
unit (CSU) and comprises 15 cells.
29. Regimes are usually restricted and prisoners are permitted to leave their cells only
to collect meals, shower, make phone calls and have a daily period in the open air.
A doctor should visit at least every three days and a registered nurse on the other
days to assess the physical, emotional and mental wellbeing of the prisoners and
whether there are any apparent clinical reasons to advise against continuing
segregation.
30. Segregation policy is contained in Prison Service Order (PSO) 1700.
X-ray body scanner
31. An X-ray body scanner uses ionising radiation to provide high resolution and real
time body view images. Guidance on operating the body scanner is contained in the
Use of X-Ray Body Scanners (adult male prisons) Policy Framework. Scans should
only be undertaken when deemed necessary and proportionate in order to prevent,
detect or investigate crime, to maintain prison security, good order and discipline
and there is intelligence or reasonable suspicion that the person is internally
concealing an item.
32. If an X-ray body scan of a prisoner shows a negative scan image but the prisoner
has been seen by staff or another person to internally conceal an item, the prison
may manage the prisoner as if they do have an internally concealed item on
grounds of reasonable suspicion. If the image indicates that the prisoner is
internally concealing an item, healthcare must be told as soon as possible in case
there is a risk to the prisoner. Positive detection of an illicit or unauthorised item
must also be recorded on the Incident Reporting System (IRS).
33. In all cases the prison must consider the location and observation requirements of
the prisoner. This could include use of segregation and/or suicide and self-harm
monitoring procedures, if applicable, locating the prisoner in healthcare, or sending
the prisoner for outside medical intervention. This decision should be made in
conjunction with the advice from healthcare.
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34. If the prisoner has an unknown internally concealed item, an operational manager
must ensure that a defensible decision is made on any actions taken or not taken
and recorded on the prisoner’s record.
Digital Person Escort Record (DPER)
35. A person escort record (PER) must be completed every time a person in custody is
escorted between police stations, courts and prisons. It provides relevant
information on a prisoner and highlights risks they may pose to themselves and to
others during and after the movement. A paper PER is used for all escorts
undertaken by HMPPS. All escorts undertaken by private escort companies
(GEOAmey and Serco) are booked via the Book a Secure Move (BaSM) system.
PERs for moves booked on this system are referred to as digital PERs or DPERs
because the record is online. BaSM is a web-based platform that can be accessed
by all prison staff. Healthcare staff are also able to access the system if they have
been provided with a Prison Service (NOMIS) user account.
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Key Events
36. Mr Gavin Wheale had a significant history of poly-substance abuse and had served
several sentences for crimes relating to his addictions. He also had a history of
anxiety, depression, self-harm, concealing drugs, and accidental overdose.
37. On 12 December 2023, Mr Wheale was sentenced to 16 months imprisonment for
threatening a person with a bladed article in a public place. In February 2024, he
was supported by Prison Service suicide and self-harm monitoring procedures
(known as ACCT) after he overdosed on illicit drugs. He told staff that it was not a
deliberate overdose.
38. On 11 July 2024, Mr Wheale was released on licence from HMP Doncaster. His
licence was revoked the next day after he failed to go to the accommodation
arranged for him and to attend a pre-arranged appointment with the Probation
Service. He was recalled to prison for a fixed term of 28 days.
39. Mr Wheale remained unlawfully at large until 6 August when West Midlands police
arrested him for shoplifting. During the arrest, a member of the public told officers
that Mr Wheale had concealed an item in his mouth. At the police station, Mr
Wheale said the item he had concealed was ibuprofen. A strip search was
authorised to confirm Mr Wheale did not have a quantity of drugs with which he
could harm himself. During the search officers noticed plastic packaging protruding
from his anus. They took Mr Wheale to Sandwell Hospital as they suspected he had
drugs secreted inside his body.
40. Mr Wheale was seen by a doctor and given an electrocardiogram (ECG - a scan of
the heart) but refused all other treatment and was returned to police custody. He
was put under constant observation and kept handcuffed overnight due to telling
officers that he had concealed drugs to retrieve in prison.
7 August 2024
Escort to and reception at HMP Birmingham
41. Mr Wheale arrived at HMP Birmingham at 12.20pm. The investigator asked for
CCTV of the reception area for this period but was told it was not working. A
custodial manager (CM) was in charge of Birmingham reception that day and an
officer was responsible for operating the X-ray body scanner. Both the CM and
officer were on sick leave during the investigation and did not wish to be
interviewed. However, both made written statements immediately after Mr Wheale’s
death which the prison provided to us. We were also provided with evidence from a
subsequent prison investigation into the events of 7 August. The following account
has been taken from these sources, prison documents and from police custody
records and police statements from GEO Amey staff provided to us by West
Midlands police.
42. The police completed a digital person escort record (DPER) on the web-based
Book a Secure Move (BaSM) system. The DPER showed Mr Wheale:
• Had a history of overdose and concealing class A drugs internally (‘plugging’).
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• Had currently got something concealed in his anus.
• Had said he would remove the item as soon as he was able to and take it.
• Had refused hospital treatment.
• Was under constant observation and required constant observation.
• Was detoxifying.
43. The paper PER completed by the police for Mr Wheale’s escort from police custody
to Sandwell Hospital the previous night also arrived with him. The front of the PER
was blank. The risk indicator page showed Mr Wheale:
• Had a history of self-harm and had previously attempted to hang himself.
• Had overdosed in 2017.
• Had a history of concealing drugs.
• Had been strip-searched and a package was seen in his anus on 6 August.
The medical information section also showed Mr Wheale was suspected of having a
package in his anus.
44. A prisoner custody officer (PCO) from GEO Amey escorted Mr Wheale to the
prison. She said it was hot in the van and they wanted to move Mr Wheale into the
prison as soon as possible to avoid distressing him (we understand there was a
queue to enter the prison because some prisoners had arrived from another prison
after an incident). She telephoned reception to try and expedite the move. She said
she told an officer that Mr Wheale was handcuffed and suspected of concealing
something, possibly drugs.
45. The PCO said she saw the “duty governor” in reception when they brought Mr
Wheale in and told him that the police believed Mr Wheale was concealing drugs.
The duty governor that day said he was in reception along with two other senior
managers dealing with the arrival of the prisoners from another prison and did not
speak to anyone from the escort service. He said nobody in reception said anything
to him about Mr Wheale. Escort records showed Mr Wheale was transferred to
prison custody at 12.45pm. The PCO said she also handed over the paper PER
that had been started when Mr Wheale was taken to Sandwell Hospital and Mr
Wheale’s hospital discharge letter.
46. An officer said the GEO Amey escort telephoned before they brought Mr Wheale in
and told her that he was being constantly supervised as he had concealed
something and would need to be monitored. She said she read the DPER when Mr
Wheale arrived and was aware that Mr Wheale had been under constant
observation in police custody and had been handcuffed to prevent him retrieving the
item. She said she told the CM before he started the reception process with Mr
Wheale that he was potentially concealing drugs and had previously refused
treatment. She also said she told the officer who was operating the body scanner
that Mr Wheale might have been concealing drugs.
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47. The CM said he attended a meeting at about 1.30pm. He returned to reception at
about 3.00pm and Mr Wheale and several other prisoners were waiting to be
processed. The CM said reception staff informed him that Mr Wheale had
concealed something while in police custody and had arrived in handcuffs to
prevent him from retrieving the item. He said the staff told him that the duty
governor had advised them to process Mr Wheale in the normal way and the
handcuffs had been removed. The CM said he was aware that the prison had a
secreted items policy but he was unaware whose responsibility it was to initiate the
process and had never read it.
48. The CM said Mr Wheale showed signs of withdrawing from drugs and asked to be
‘rushed through’. The CM said this was usually a sign that the person was
concealing something. He explained to Mr Wheale that he would follow the normal
process, which was an interview with the reception CM, an initial health assessment
with a nurse, an X-ray body scan and then a search.
49. The CM said he looked at the front of the DPER and could see there were alerts but
he did not read the detail because he had known Mr Wheale for years, he knew that
Mr Wheale might have something concealed, he knew his self-harm history and he
had not arrived with a suicide and self-harm (SASH) warning form. He completed
the initial interview with Mr Wheale and the first section of the cell sharing risk
assessment (CSRA). Mr Wheale denied that he had concealed something. The CM
informed Mr Wheale that he would be scanned and that any secreted items would
show up. He said Mr Wheale did not reply but walked away from the desk.
50. A healthcare assistant saw Mr Wheale next and completed a set of physical
observations. Mr Wheale’s blood pressure was significantly elevated. The
healthcare assistant asked for a urine sample and Mr Wheale told them he was
unable to pass urine at that time.
51. A nurse then completed an initial health assessment. The nurse said he was given
Mr Wheale’s file containing the first part of his CSRA and his custodial document
file. He said the DPER was online and he did not have access to it from his
computer terminal. There was no PER or extra information about risk in Mr
Wheale’s paper file and he did not see the hospital discharge letter. He said no one
told him that Mr Wheale was suspected of concealing an item or gave him any other
information about Mr Wheale before he saw him.
52. The nurse said Mr Wheale told him that he had a bad back because the police had
hit him but did not want to show him his injuries. Mr Wheale denied any current
thoughts of suicide or self-harm but said he had last self-harmed and had attempted
suicide in June 2024. He gave a history of poly-drug misuse and post-traumatic
stress disorder (PTSD – symptoms can include flashbacks and changes in mood).
53. The nurse said he did not make a plan to review Mr Wheale’s blood pressure
because he had no history of high blood pressure. He said he told Mr Wheale that
he needed to give a urine sample so that the correct medication could be
prescribed to manage his withdrawal symptoms.
54. Mr Wheale was given some water and about 45 minutes after the initial health
assessment he provided a urine sample that tested positive for opiates,
benzodiazepines (sedatives), cocaine and cannabinoids. A GP subsequently
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reviewed Mr Wheale’s clinical record and prescribed methadone for opiate
withdrawal. However, his first dose due that evening was withheld in the light of the
urine screen results to avoid risk of opiate overdose. The only other medications he
had been prescribed in the community were for asthma and acid reflux.
55. After he completed the health assessment the nurse handed Mr Wheale’s file to an
officer so that he could scan him. The officer said he did not get a handover from
the nurse, and he did not read Mr Wheale’s file.
56. The officer said he asked Mr Wheale to remove his shoes and a small bag fell out
of one of them. He asked Mr Wheale to give him the bag but Mr Wheale refused
and then concealed the package in his anus. He scanned Mr Wheale and the
results of the scan were inconclusive. The officer put Mr Wheale into one of the
holding rooms pending a second scan in line with local policy. A short while
afterwards, he said Mr Wheale held up a small plastic bag at the window of the
room. The officer opened the door asked him what it was. Mr Wheale said, “it was a
tablet”. The officer said he asked Mr Wheale what sort of tablet it was, and Mr
Wheale replied, “It’s diazepam, it’s my medication and I took it”. (Diazepam is used
to treat anxiety and has sedative effects. Mr Wheale was not prescribed it.) The
officer said he did not see Mr Wheale swallow anything.
57. The officer said he told the reception CM and another CM (who was in reception to
take over). Both CMs denied this when interviewed for the prison’s internal
investigation.
58. The officer said he did not consider initiating Prison Service suicide and self-harm
monitoring procedures (known as ACCT) because Mr Wheale told him he had only
taken one tablet and that it was medication and he did not appear to be suicidal. He
did not inform healthcare staff that Mr Wheale had said he had taken a tablet
because he did not consider one tablet to be an overdose. The officer said he was
not aware of the prison’s secreted items policy.
59. Mr Wheale refused to take a second scan and the CM asked staff to take him to the
care and separation unit (CSU – segregation unit) in line with the prison’s local
policy for managing prisoners suspected of concealing items.
60. The officer subsequently submitted a security information report (IR), made an entry
on Mr Wheale’s prison record (NOMIS) and informed the orderly officer (the most
senior uniformed grade responsible for ensuring the running of the regime and
managing incidents) that Mr Wheale had allegedly taken a tablet. The officer did not
secure the bag as evidence and we do not know what happened to it. Mr Wheale
was escorted to the CSU.
Care and separation unit (CSU)
61. The investigator watched CCTV of Mr Wheale’s journey to the CSU and for the
duration of Mr Wheale’s stay there. Based on other documentary evidence, later
body worn video camera (BWVC) footage and staff radio communications, the
CCTV clock is about 23 minutes behind the correct time. We have adjusted the
times accordingly in the account of events below.
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62. Mr Wheale arrived at the CSU at about 4.13pm. An officer said he remembered Mr
Wheale arriving from reception and being told that he had given a positive indication
on the body scanner and was suspected of secreting an item. He said he was not
made aware that Mr Wheale might have taken a substance in reception. Mr Wheale
was given a full search (a strip search) and then given a clean set of prison clothes.
The officer said that Mr Wheale was held in the CSU for reasons of good order and
discipline (GOOD). This meant that, during the day, he would be checked during the
daily routine roll counts but would not be checked more often.
63. The officer recorded the reason for segregation as “body scan protocol”. He said he
was not aware at the time of any requirement to check prisoners suspected of
concealing items internally any more frequently than any other prisoner and he had
never been made aware that such prisoners might be at increased risk of harm. He
was not aware of the prison’s secreted items policy. The officer had worked in the
CSU for four years.
64. At about 5.35pm, a nurse assessed whether Mr Wheale was medically fit to be
segregated. She said she looked at Mr Wheale’s clinical record before going to the
CSU but did not notice the results of his urine screen. The nurse said Mr Wheale
looked physically well. She understood that as long as the prisoner was not suicidal,
appeared fine and was talking, it was safe to segregate them. She was unable to
complete a set of physical observations because there was no medical equipment
in the CSU.
65. The nurse said Mr Wheale denied any suicidal thoughts, asked her for methadone
and walked off when she told him he could not have any. She completed the
segregation safety algorithm and answered no to the question of whether Mr
Wheale was within four weeks of detoxification or stabilisation from opiates, which
was incorrect. She said she would have been unable to complete a clinical opiate
withdrawal screen (COWS) assessment as she was not trained to do so.
66. The duty governor signed the Authority for Initial Segregation at 5.49pm. He did not
complete the form as he should have done and was unable to say why he had not
done so when interviewed during the prison’s investigation. In his PPO interview,
the duty governor said that he would not normally go and speak to the person being
segregated because they would be spoken to the next day. He said he signed the
paperwork once he was satisfied that a nurse had confirmed that Mr Wheale was fit
to be segregated. He said no one told him that Mr Wheale was suspected of
concealing an item or that he might have taken an unknown substance in reception.
Overnight checks 7 – 8 August 2024
67. The night duty officer in the CSU that night said she was told in the handover at the
beginning of her shift that Mr Wheale had arrived in the CSU that day because he
had ‘failed’ the body scanner and was suspected of concealing a package. She said
that all prisoners in the CSU are checked hourly overnight. The checks are not
recorded but night staff are required to write a summary of the night on each
prisoner’s record before they go off duty at the end of their shift. The officer said she
was not aware of the prison’s secreted items policy.
68. She said Mr Wheale pressed his cell bell several times during the night and told her
he was “rattling” (withdrawing from drugs) and asked for paracetamol. She said she
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explained that the night nurse would not be able to give him any medication until
they were satisfied that he did not have any drugs concealed on him. She said Mr
Wheale appeared to accept this and went to sleep.
69. He woke again later and pressed his cell bell. This time she said he asked her if he
could go on the body scanner again and what would happen the next day. The
officer said she explained that he would be scanned the following day and told him
what regime he could expect on the CSU. She said she had seen prisoners in
withdrawal from drugs and Mr Wheale did not appear to have any of those
symptoms and neither did he appear to be under the influence of drugs.
70. At about 11.10pm, a nurse spoke to Mr Wheale through the observation panel in his
cell door for the overnight welfare check on prisoners with substance misuse
issues. She said the purpose of the visit was to check Mr Wheale for symptoms of
withdrawal although she was not required to use the COWS tool as part of this. She
was aware that Mr Wheale was in the CSU because he had not given a clear body
scan in reception. She said she was not made aware that Mr Wheale might have
taken a substance in reception.
71. The nurse said Mr Wheale sat up in bed, told her he was in pain and asked for
paracetamol. She told him that he was not allowed any medication at all because
he was suspected of concealing a package. She said she did not question Mr
Wheale about where his pain was because she knew she could not give him any
medication.
8 August 2024
72. Between 8.36am and 9.11am, a nurse, Imam, and duty governor checked Mr
Wheale for the required daily check of every prisoner in the CSU. No one raised
any concerns about Mr Wheale.
73. An officer unlocked Mr Wheale at 9.28am. She said she knew Mr Wheale as a
familiar face and knew from the CSU whiteboard that he was in the CSU because
he had not given a clear body scan in reception the day before. She said in her
experience such prisoners were treated the same as every prisoner segregated for
GOOD and were not subject to additional checks. She was not aware of the
prison’s secreted items policy. The officer said Mr Wheale asked for a shower and
to use the phone and kiosk (a terminal that prisoners can use to order items from
the prison shop and submit applications).
74. At 9.45am, a psychosocial worker from the substance misuse recovery team
completed Mr Wheale’s initial assessment at his cell door. She said she looked at
Mr Wheale’s clinical record to check what medication he was on before she visited
him and remembered seeing that he had not given a clear body scan and would
therefore not be given any medication until he did so. Mr Wheale answered her
questions and then asked when he could have some medication. The psychosocial
worker said she explained that he would not have any until he could provide a clear
scan. She said Mr Wheale looked a bit dishevelled but appeared to walk steadily
and his speech was not slurred. Nothing in his appearance gave her any cause for
concern.
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75. At 9.59am, a probation service officer completed Mr Wheale’s basic custody
screening (a routine assessment to identify the prisoner’s key needs). He said the
CSU staff were unwilling to open the cell as they did not have time so he spoke to
Mr Wheale through his observation panel. He said Mr Wheale sat on the edge of his
bed and did not respond to any of his questions. He did not look ill or in pain, but
the probation service officer assumed he was withdrawing from drugs. As it became
apparent that Mr Wheale was not going to respond to him, he told him he would
come back and speak to him another time.
76. An officer said Mr Wheale pressed his cell bell more than once that morning to ask
when he would be let out for his shower and she explained that they had to do each
prisoner in turn. She said Mr Wheale appeared fine.
77. At 11.40am, Mr Wheale left his cell to use the shower. He returned to his cell at
11.53am and staff gave him his lunch. There was no indication that Mr Wheale was
in any physical difficulty at this point. An officer said Mr Wheale was sitting up
smiling on his bed when he gave him his lunch and caught an orange he threw to
him.
78. At 12.01pm, a Reverend looked through Mr Wheale’s observation panel and put
something under his door. The Reverend provided information about his visit to the
investigator by email. He said he was visiting all new prisoners registered as
Church of England to give them a welcome booklet and Christian Diary. When he
looked through the observation panel, Mr Wheale was lying on his bed apparently
asleep. He decided not to try to wake him as he knew Mr Wheale had already been
visited by the duty chaplain on the CSU round. He pushed the welcome booklet and
diary under Mr Wheale’s door and left.
79. According to CCTV, Mr Wheale did not press his cell bell after this point.
Emergency response
80. As well as CCTV footage, the investigator watched body worn video camera
(BWVC) footage and listened to staff radio communications from 8 August. She
also obtained information from the West Midlands Ambulance Service. The
following account has been taken from these sources and staff interviews and
statements.
81. At about 2.25pm, two officers went to Mr Wheale’s cell to collect him for a second
body scan in reception. One officer said he tried to wake Mr Wheale, but when he
looked more closely, he realised he was not breathing and started chest
compressions immediately while he remained on the bed.
82. An officer radioed a code blue emergency (indicating that a prisoner had either
stopped or was having difficulty breathing). Her initial radio transmissions were
indistinct (possibly due to her location in the cell) and there was a delay of about a
minute and a half before the control room officer was able to understand what she
was saying. The control room officer asked the orderly officer and the emergency
response nurse to acknowledge and made all staff aware there was a code blue.
Another officer in the control room called an ambulance within a minute. Once
control room staff told the call handler that there was a code blue emergency, they
did not ask for any further details. The handler dispatched an ambulance as a
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category two but did not tell prison staff this (meaning the situation was serious but
not immediately life threatening) with an estimated response time of 17 minutes.
83. The emergency response nurse arrived at Mr Wheale’s cell at 2.32pm, followed
shortly by other healthcare staff. At 2.33pm, the control room officer rang the
ambulance service back to tell them Mr Wheale was not breathing and the
ambulance response was upgraded to a category one (a life threatening
emergency).
84. The nurse asked the officers to bring Mr Wheale out on to the landing to allow more
space to perform CPR which they did. The nurse said Mr Wheale was cold and his
pupils were fixed and dilated but rigor mortis had not set in and his limbs were still
flexible. He was able to insert an i-gel airway to give Mr Wheale oxygen without
difficulty. The nurse said that as soon as the defibrillator was attached it advised it
was going to deliver an electric shock to Mr Wheale which was unusual because it
had not gone through the analysis process first.
85. The defibrillator continued to analyse Mr Wheale’s cardiac output but did not advise
any further shocks. Healthcare staff administered naloxone (to reverse opiate
overdose) but it had no effect. The dose they gave him was not recorded.
86. A GP said he arrived after the initial shock from the defibrillator and after staff had
administered naloxone. He said he was surprised that the defibrillator had advised a
shock as soon as it was attached to Mr Wheale because there were signs that he
had died, including fixed dilated pupils and absence of respiratory and cardiac
output. He thought the defibrillator had likely malfunctioned. The GP said he
discussed the situation with the emergency response nurse and the other
healthcare staff present and they agreed to stop CPR. He pronounced life extinct at
2.39pm. The first ambulance arrived at the prison at about 2.40pm.
Contact with Mr Wheale’s family
87. The prison appointed two family liaison officers. They drove to Mr Wheale’s
mother’s home and broke the news of his death and offered their condolences that
afternoon. The prison offered a financial contribution to Mr Wheale’s funeral in line
with national policy.
Support for prisoners and staff
88. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
89. After Mr Wheale’s death, a senior prison manager, debriefed the staff involved in
the emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
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90. The prison posted notices informing other prisoners of Mr Wheale’s death and
offering support. The prison delivered postvention support to the other prisoners on
the CSU that afternoon. Staff reviewed all prisoners assessed as being at risk of
suicide or self-harm in case they had been adversely affected by Mr Wheale’s
death.
Actions taken by the prison following Mr Wheale’s death
91. New assessment and monitoring procedures were immediately brought in for all
prisoners moved to the CSU after a positive body scan. The Head of Security re-
wrote and re-issued the prison’s secreted items policy. The prison subsequently ‘dip
tested’ compliance with the document and amended it to ensure that new prisoners
managed under the policy also received a first night interview in the same way as
every other prisoner.
92. On 9 August, the Head of Healthcare issued a notice to all healthcare staff
reminding them of the requirement to read the DPER before beginning the initial
reception health assessment and reiterating that if they had issues accessing the
DPER they must ask officers to show them the document. He said that if staff were
not working that way, they would be liable to disciplinary investigation.
93. On 28 August, the Head of Healthcare wrote to the reception nurse under the
disciplinary policy requiring him not to return to work after the end of his leave until
the Trust had completed a fact-finding investigation into his actions on 7 August. On
6 September, he wrote to the nurse again advising him that it might be necessary
for the Trust to conduct an investigation. In December, the Head of Healthcare told
the clinical reviewer that the Trust had discussed the nurse in a Decision Making
Group (DMG) meeting and decided not to pursue further investigation as he had left
their employment and no longer worked in prisons. They passed on their concerns
to his new employers.
94. The Deputy Governor issued terms of reference for a local investigation to
determine the actions taken by the reception CM and officer responsible for
operating the x-ray body scanner on 7 August. Both men were suspended from duty
pending the outcome. The local investigation was also asked to consider Mr
Wheale’s care in the CSU. The investigation was undertaken by the Head of
Security and his final report was submitted on 17 March 2025 with a
recommendation that the CM and officer should face disciplinary hearings.
95. The Head of Security also made a number of other recommendations which
resulted in the following actions:
• A quality assurance check was introduced to ensure that the ‘record handover’
button in the DPER is completed. (Which by our understanding means that in
completing it, staff are confirming that they have read the contents of the PER.
This does not mean, of course, that anyone can be sure that they have.)
• A list of all staff drawing BWVC are reported to the Governor’s briefing each
morning and any staff not drawing a camera are challenged. (This was
because Officer Webster was not wearing one when he did Mr Wheale’s body
scan.)
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• Training on handling evidence was included in security awareness days in
January and March and guidance has been provided to staff.
• Staff have been briefed on ensuring that all incidents that may impact on a
prisoner’s risk are communicated appropriately. Further measures and testing
of this are planned.
• The Senior Leadership Team have received a verbal briefing on completing
the authority to segregate including making defensible decisions.
• The fault with the CCTV in reception has been reported but had not been
resolved at the time of writing in April 2025.
Post-mortem report
96. The pathologist gave the cause of death as mixed drug interactions (morphine,
cocaine and diazepam).
97. No drugs were found concealed inside Mr Wheale’s body.
Coroner’s inquest
98. The Coroner’s inquest held between 30 June and 9 July 2025 gave the medical
cause of death as: mixed drug interactions (morphine, cocaine and diazepam).
99. The jury concluded that Mr Wheale’s death was drug related and identified
shortcomings in the following areas at the time of Mr Wheale’s death:
• The training of custodial and medical staff at HMP Birmingham in he
implementation of policies and procedures designed to facilitate the arrival,
processing and housing of prisoners considered ‘at risk’ or vulnerable.
• The lines of communication across custodial staff at HMP Birmingham
concerning the effective transfer of information pertinent to the health and
wellbeing of incoming prisoners.
• The lines of communication between medical and custodial staff at HMP
Birmingham concerning the effective transfer of information pertinent to the
health and wellbeing of incoming prisoners.
• The facilities and resources in the reception area at HMP Birmingham
pertaining to custodial staff’s ability to monitor and supervise incoming
prisoners, particularly those considered ‘at risk’ or vulnerable.
The jury did not find that these shortcomings impacted on Mr Wheale’s death.
100. The Coroner issued a Prevention of Future Deaths (regulation 28) report at the
conclusion of the inquest outlining his concerns, including that Birmingham’s
secreted items policy did not provide clear guidance to staff on how to manage
prisoners entering the prison with concealed items who then claim to have removed
or ingested the item.
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Findings
Assessment of Mr Wheale’s risk
Risk assessment in reception
The reception CM’s assessment
101. Prison Service Instruction (PSI) 7/2015 Early Days in Custody requires reception
staff to examine the PER and any other available documentation to identify
immediate needs and risks already recorded. Staff are required to be aware that
particular groups are at a higher risk of suicide/self-harm. Annex D of PSI 07/2015
lists the categories of prisoners who may be especially vulnerable to suicide or self-
harm.
102. Mr Wheale arrived at Birmingham with a significant amount of information about his
risk factors in his PER and his DPER. In addition, GEO Amey escort staff provided
a verbal handover to reception staff by telephone and in person. When he arrived at
Birmingham, Mr Wheale had a number of risk factors that indicated a risk of serious
harm: he had a history of self-harm and attempted suicide, he was on licence recall,
he had a history of concealing class A drugs and overdose, he was detoxifying from
drugs and he had concealed a package internally and stated his intention was to
take the contents as soon as he could.
103. The reception CM acknowledged that he did not read all of the information in the
PER and DPER because he was familiar with Mr Wheale from previous sentences.
In his statement, and from what we know of his interview for the prison’s
investigation, the CM said he considered Mr Wheale’s risk of suicide and self-harm
based on his knowledge of Mr Wheale’s history, the fact that Mr Wheale was
adamant he was not suicidal, and that Mr Wheale had always been honest with
him.
104. Staff judgement is important and there is a place for using experience and skills in
determining risk. However, knowledge and past experience of a person should not
replace the consideration of all available risk information. Risk fluctuates according
to a combination of factors including current circumstances. The CM does not
appear to have considered that Mr Wheale was at risk of harm due to having an
item concealed or the potential consequences should he retrieve and consume the
contents or if it leaked internally. Neither does he seem to have considered the
importance of making sure that the reception nurse was aware of the information
that Mr Wheale had drugs concealed on him.
105. The prison’s secreted item policy in operation at the time of Mr Wheale’s death
required all staff who suspected a prisoner of having secreted items to inform the
duty governor or orderly officer, CSU, security department, safer custody and
healthcare. In common with every other member of staff involved in this
investigation, the CM was unaware of the requirements of this policy.
106. We raised similar concerns about risk assessment in Birmingham reception in our
investigation into a self-inflicted death there in May 2024. We recommended that
the Governor and Head of Healthcare should review the training for reception and
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induction staff to ensure they understand how to identify prisoners at risk of suicide
and self-harm, including that all relevant risk information, including the PER, is
properly shared and examined as part of the reception/first night process.
107. In January 2025, the prison responded that they had:
“Reviewed and amended the training provided to reception and induction staff.
Guidance detailing how to identify risk of self-harm and suicide, particularly in
reception, has been distributed to all custodial managers and has been relayed to
all reception and induction staff. All reception staff have now received
demonstrations from the reception custodial managers on how to check and record
information on the digital PER. These demonstrations are also delivered to all
custodial managers during morning briefings.”
108. In the light of this we make no further recommendation. However, experience tells
us that proper risk assessment in reception requires maintained focus if genuine
cultural change is to happen, and so we urge the Governor to continue to focus on
this vital area.
109. We are satisfied that the prison has appropriately investigated the actions of the CM
on 7 August and that the Governor will be holding a disciplinary hearing in due
course.
Reception health assessment
110. Although reception staff should have informed the reception nurse that Mr Wheale
was concealing an item, it was his also responsibility to examine the PER and
DPER. He failed to do this and claimed to the investigator that he did not have
access to the DPER. After the interview, the investigator queried this with the Head
of Healthcare, who confirmed that all healthcare staff had access to the BaSM
system for use during the initial health assessment in reception. The Head of
Healthcare said that, as access issues were common, staff had been instructed to
ask officers to show them the DPER if they could not see it. The Head of Healthcare
added that after Mr Wheale died, he had asked the nurse why he did not look at the
DPER and the nurse had said that he had been too busy and had not had time.
111. This was a serious omission. The nurse was aware from the results of his urine
sample that Mr Wheale had a number of other drugs in his system and this was a
significant opportunity to consider necessary measures to mitigate his risk of
overdose.
112. In response to the recommendation referenced above from our investigation into
the death in May 2024, The Head of Healthcare responded in January 2025 that
healthcare staff now had more robust training before being allowed to complete
reception health assessments and were supervised for an initial period. He had also
updated the reception operating procedures for healthcare staff.
113. In the same investigation, we also recommended that the Head of Healthcare
should review the quality and compliance with policy of reception and secondary
health screens in the previous 12 months, ensure that prisoners are referred to the
mental health team when appropriate, and identify any improvements required. In
January 2025, the Head of Healthcare responded:
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“Dip-testing was completed and those that had not referred correctly were taken off
screening. Retraining and competency skills were re-assessed until fully competent
and able to carry out screenings correctly.”
114. We note this and the reminder the Head of Healthcare sent to staff on 9 August in
response to Mr Wheale’s death and make no further recommendation, although we
repeat our advice that he maintains appropriate focus on driving sustained
improvement.
115. Had he remained employed by Birmingham and Solihull Mental Health Foundation,
the nurse would have faced investigation under the Trust’s disciplinary policy. We
believe this would have been appropriate and we would have recommended that it
did. It is not within our remit to make recommendations to Trusts not providing
healthcare services in prisons.
Reception searching and X-ray body scan
116. Guidance to prison staff on searching is contained in the Searching Policy
Framework. This says:
If a member of staff concludes either by visual observations or via a body scan that
the prisoner is internally concealing an item(s), this information must be relayed to
healthcare as soon as possible in case the internally concealed item may cause a
risk to the prisoner. Information must include what the item could be (for example,
drugs / mobile phone / weapon), enabling healthcare to manage the health risks to
the prisoner. And:
If the prisoner refuses or is unable to safely remove or pass a suspected item the
prison must consider the risks presented by that prisoner to themselves and/or
others. In all cases the prison must consider the location and observation
requirements of the prisoner. This could include use of segregation and/or ACCT, if
applicable, locating the prisoner in healthcare, or sending the prisoner for outside
medical intervention. This decision should be made in conjunction with the advice
from healthcare.
117. The same guidance is echoed in the Use of X-Ray Body Scanners (adult male
prisons) Policy Framework which says that prisoners seen by staff to internally
conceal an item may be managed as if they have provided a positive scan, which
requires healthcare to be informed immediately. Birmingham’s secreted item policy
required all staff who suspect or discover a prisoner of having secreted items to
inform the duty governor, the CSU, the security department, safer custody and
healthcare.
118. If there had been any doubt that Mr Wheale was concealing a package it was
removed during the search process when the reception officer saw Mr Wheale
retrieve an item from his shoe and conceal it internally. At this point, the officer
should have informed the list of people above. Mr Wheale’s assertion shortly
afterwards that he had consumed a substance which he said was a single tablet of
diazepam should have made it imperative that the officer informed the necessary
people immediately.
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119. The officer did inform the orderly officer and security department and told the prison
investigator that he told two CMs, but they both denied this. Crucially he did not
inform healthcare staff and failed to recognise a clear increase in risk to Mr
Wheale’s health.
120. We understand from the prison’s investigation that the officer did not consider
informing healthcare staff or that Mr Wheale’s risk of harm had increased because
Mr Wheale said he had taken a single tablet and that it was his medication. We
consider that this was a serious error of judgement and a significant missed
opportunity to ensure Mr Wheale received proper medical assessment, care and
transfer to hospital. The officer did not know the quantity or identity of the substance
Mr Wheale might have consumed. Neither did he retrieve the bag Mr Wheale
showed him for evidence and testing using the prison’s drug trace testing
equipment.
121. We are satisfied that the prison has appropriately investigated the actions of the
officer on 7 August and that the Governor will be holding a disciplinary hearing in
due course.
Risk assessment in the CSU
Segregation health screen
122. Birmingham’s secreted item policy required healthcare staff to assess the prisoner’s
health, offer advice on the most appropriate location and complete the Initial
Segregation Health Screen. As part of this process the policy required them to
explain that holding items internally is extremely dangerous and take the prisoner’s
blood pressure.
123. In common with other members of staff, the nurse in the CSU was unaware of this
policy and completed a standard segregation health screen. She was aware that Mr
Wheale was suspected of concealing an item. She said she had looked at his
medical record but was unable to account for why she was not aware of the results
of his urine test.
124. The clinical reviewer was concerned that the nurse did not discuss or consider the
risks and potential consequences of having a secreted package with either Mr
Wheale or prison staff. Leaving aside the fact that she was not aware of the
secreted item policy, this should have formed a fundamental part of any healthcare
risk assessment. The clinical reviewer was also concerned that the nurse focused
solely on Mr Wheale’s mental health and said she would not have performed any
physical observations in any case. We consider that the nurse’s understanding that,
as long as the prisoner was not suicidal, appeared fine and was talking it was safe
to segregate them, demonstrated an inadequate understanding of the risks of
segregating prisoners.
125. The Head of Healthcare told the clinical reviewer in November 2024 that work was
ongoing to “upskill” mental health nurses to complete physical assessments and
clinical observations if appropriate during segregation health screens. The nurse
who completed the segregation health screen is no longer employed at the prison
so we make no recommendation regarding her.
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Authority to segregate
126. The Use of X-Ray Body Scanners (adult male prisons) Policy Framework requires
an operational manager to record a defensible decision on any actions taken or not
taken when considering the location of a prisoner deemed to be internally
concealing an item. This could include their location and requirements for frequency
of observations. Birmingham’s secreted item policy also required the duty governor
to consider the nature of the item, the risks to the individual and the risk to security
when locating the prisoner.
127. The Head of Security told the investigator that his understanding was that prisoners
concealing items were taken to the CSU and processed in the normal way. He said
it was not his practice to speak to prisoners when signing the authority to segregate
and he usually just signed once the nurse had agreed it was safe to segregate. We
consider that he too demonstrated insufficient understanding of the risks and
potential consequences for prisoners concealing items.
First night welfare check by the nurse
128. The nurse did not ask Mr Wheale about the nature or location of his pain because
she thought he was not allowed to receive any pain relief due to concealing an item.
The clinical reviewer noted that under Birmingham’s Standard Operating Policy
(SOP) for ‘The assessment and provision of Clinical Substance misuse services’,
no opiate substitution therapy (OST) can be prescribed in these circumstances due
to the possibility of overdose, but paracetamol is low risk and can be given if
clinically indicated. The fact that she thought she was unable to give Mr Wheale any
medication should not have precluded the nurse from exploring why Mr Wheale was
in pain and where the site of his pain was. She knew he was suspected of
concealing an item and this should have prompted greater clinical curiosity.
Secreted item policy
129. The prison’s secreted item policy listed a number of actions for the CSU CM and for
regular searching of the prisoner and his cell. CSU staff were required to complete
a secreted item log and a secreted item observation sheet with the level of
observations set after discussion with healthcare staff.
130. None of the CSU staff spoken to for this investigation, including two officers who
had worked in the CSU for over four years each, said they were aware of the
secreted item policy, and no one could recall any instances of prisoners suspected
of concealing items being monitored more closely. None of the secreted item policy
documents were completed and no one knew where to find the policy.
Risk assessment conclusion
131. There were a number of failures by operational and healthcare staff to follow
national and local guidance for the risk assessment of prisoners in reception and
the assessment and management of prisoners deemed to be concealing items.
These failures were evidently systemic and endemic. This is the third investigation
at Birmingham to identify weaknesses in reception risk assessment. Nobody was
aware of the requirements of the prison’s secreted item policy and most had never
heard of it and did not know where to find it.
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132. Overall, there was a complete and collective failure among all staff to recognise that
prisoners concealing items are at serious risk of harm. This resulted in a lack of
clinical assessment and monitoring and meant that there was no effective oversight
to prevent Mr Wheale’s death.
133. In September 2024, the Head of Security re-wrote and re-issued the secreted item
policy and brought in random checks to test compliance. We welcome this but we
do not think that it gets to the heart of the main issue in this case - the fundamental
cross-prison lack of awareness of the risks to prisoners from concealed items. As a
result, no one considered measures to mitigate those risks, including whether Mr
Wheale should have gone to hospital for testing and monitoring in an acute
environment or whether he could be safely managed by increased observation and
clinical monitoring in the prison environment. The difference in how Mr Wheale was
treated by the police is stark. We make the following recommendation:
The Governor and Head of Healthcare should deliver training to staff
emphasising the potential risk of harm to a prisoner suspected of secreting
items and introduce a robust assurance process to satisfy themselves that
this learning has been embedded.
134. We suspect that staff at Birmingham are not alone in focusing on the security risk
posed by secreted items rather than on the potential risk of harm to the prisoner.
HMPPS colleagues responsible for the relevant policy areas should consider
whether wider awareness training is necessary.
Clinical care
135. The clinical reviewer concluded that the clinical care offered to Mr Wheale was not
of the required standard and therefore not equivalent to that which would have been
received in the wider community. The clinical reviewer was concerned that, as well
as not following or not being aware of guidance, nursing staff showed a lack of
professional curiosity, a lack of empathy and a lack of motivation to attempt to
develop a therapeutic relationship with Mr Wheale.
136. We have covered the majority of her concerns in the sections above. In addition to
these the clinical reviewer noted that the reception nurse did not plan to review Mr
Wheale’s blood pressure which was not in the normal range during the reception
health screen and the dose of naloxone given during the emergency response was
not recorded.
137. The clinical reviewer questioned whether the GP’s decision to stop CPR was in line
with resuscitation guidance given the defibrillator administered an electric shock
when first attached to Mr Wheale. We are satisfied that a guideline is not a
substitute for an informed clinical decision and that the GP explained his decision at
interview.
Prisons and Probation Ombudsman 23
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Governor to note
Emergency call
138. Although radio traffic showed that the initial transmissions from staff in the CSU
were inaudible, the control room officer called the ambulance service immediately
she was aware they were radioing a code blue. The emergency services call
handler asked whether the patient was breathing and arranged an ambulance as
soon as the control room officer told him there was a code blue emergency. He did
not ask what that meant or for any other details and did not say what level of priority
he had assigned to the call. We therefore consider that it was reasonable for the
control room officer to have assumed that the call handler understood the nature of
the emergency and had sent an ambulance with the top priority of category one.
139. In fact he had assigned the call category two and the call was only correctly
prioritised in the control room officer’s second call when she was able to confirm
that Mr Wheale was not breathing. This did not make a difference to the outcome in
Mr Wheale’s case and we are aware that HMPPS and NHSE are currently
developing further national guidance in relation to medical emergencies. We make
no recommendation. However, the Governor should note that staff should not
assume that the ambulance service will know what a code blue emergency means
and that the only way to ensure an ambulance is dispatched with the highest priority
is if they tell them that the patient is not breathing or conscious.
24 Prisons and Probation Ombudsman
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