George Rose

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Independent investigation into
the death of Mr George Rose,
a prisoner at HMP Wymott, on
18 January 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 George Rose died of a ruptured abdominal aortic aneurysm (AAA) on 18 January 2024,
at HMP Wymott. He was 77 years old. I offer my condolences to Mr Rose’s family and
friends.
The clinical reviewer concluded that the clinical care Mr Rose received at HMP Wymott
was variable. The healthcare team at Wymott did not adhere to guidance in relation to the
secondary health screens, as a result a referral for AAA screening was not considered.
Mr Rose only missed one appointment due to lack of escort staff. He was taken to his
appointment on 25 August; however, the hospital had cancelled the clinic due to doctors
strikes and they failed to inform the prison.
These aspects of Mr Rose’s care were not equivalent to what he could have expected to
receive in the community.
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 September 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 8
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Summary
Events
1. On 20 May 2021, Mr George Rose was sentenced to 15 years in prison for sexual
offences. He was 75 years old. He was sent to HMP Wymott.
2. Mr Rose had several medical conditions, which included diabetes, transient
ischaemic attack (known as a mini stroke) and chronic obstructive pulmonary
disease (COPD). Healthcare staff monitored his diabetes and prescribed
medication for these conditions.
3. On 9 May 2023, a GP at the prison saw Mr Rose after he reported a lump in his
abdomen. The GP referred him for an urgent ultrasound, which was completed on
24 May. The results showed that Mr Rose had an 8.3cm abdominal aortic aneurysm
(AAA – this is a swelling in the aorta, the artery that carries blood from the heart to
the abdomen). The GP referred him to the vascular team at Royal Preston Hospital.
4. On 7 June, an appointment with the vascular team was booked for Mr Rose but the
prison was unable to take him to the appointment due to staffing issues. Another
appointment was arranged for 25 August, escort staff took Mr Rose to his
appointment, however the hospital had cancelled the clinic due to doctors strikes.
The hospital had failed to inform healthcare that his appointment was cancelled. A
consultant vascular surgeon saw Mr Rose on 29 November and explained the AAA
diagnosis and prognosis to him.
5. On 18 December, Mr Rose discussed a Do Not Attempt Resuscitation (DNACPR)
order (meaning in the event of a heart attack or if his breathing stopped, he would
not be resuscitated) with a GP which was agreed and signed.
6. On 18 January 2024, an officer found Mr Rose unresponsive in his cell. She radioed
a medical emergency code and healthcare staff attended. As Mr Rose had a
DNACPR in place, cardiopulmonary resuscitation (CPR) was not initiated.
Paramedics arrived and confirmed that Mr Rose had died.
Findings
7. The clinical reviewer concluded that the care Mr Rose received at Wymott was
variable. Although there were elements of care which were equivalent to what he
could have expected to receive in the community, there were some aspects of his
care that were not.
8. Mr Rose was not adequately assessed and screened during his first and secondary
health screens. As a result, he was not referred for AAA screening as he should
have been. Mr Rose had missed one hospital appointment due to the lack of
communication and partnership working between healthcare staff and prison staff
which had the potential to negatively impact on his health. These aspects of Mr
Rose’s care were not equivalent.
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The Investigation Process
9. HMPPS notified us of Mr Rose’s death on 18 January 2024.
10. The investigator issued notices to staff and prisoners at HMP Wymott informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Rose’s prison and
medical records.
12. NHS England commissioned a clinical reviewer to review Mr Rose’s clinical care at
the prison. She and the PPO investigator conducted joint interviews with healthcare
staff.
13. We informed HM Coroner for Lancashire of the investigation. The coroner gave us
the cause of death. We have sent the coroner a copy of this report.
14. The Ombudsman’s office contacted Mr Rose’s family to explain the investigation
and to ask if they had any matters, they wanted us to consider. The family raised
concerns about Mr Rose’s missed hospital appointments. These concerns have
been addressed in this report and the clinical review report.
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Background Information
15. HMP Wymott is a category C prison holding male prisoners. It is managed by
HMPPS. Greater Manchester Mental Health NHS Foundation Trust provides
healthcare services.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Wymott was in December 2023. Inspectors
noted that levels of staff sickness were far too high leading to the cancellation or
curtailment of activities, including health care appointments. Specialised officers,
most of them with additional psychological training or prison offender managers,
were frequently redeployed to do operational tasks.
Independent Monitoring Board
17. 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 May 2023, the IMB reported that
there was a shortage of staff and increase in inexperienced staff that had put a
strain on the prison’s ability to maintain a safe and secure environment for all.
Previous deaths at HMP Wymott
18. Mr Rose was the 29th prisoner to die at Wymott since 1 January 2021. Of the
previous deaths, 25 were from natural causes. There were no similarities between
our findings in this investigation into Mr Rose’s death and the investigation findings
for the other deaths.
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Key Events
19. On 20 May 2021, Mr Rose was convicted of sexual offences and sentenced to 15
years imprisonment. He was sent to HMP Wymott.
20. Mr Rose had several pre-existing health conditions, including pre-diabetes,
transient ischaemic attack, and chronic obstructive pulmonary disease (COPD).
Healthcare staff monitored and prescribed medication to help control his conditions.
21. On 18 June, a nurse carried out the first and second health screens. There is no
record that he asked Mr Rose if he had been involved in NHS checks and screening
programmes relevant to his age as he should have done. As a result, the nurse did
not check whether Mr Rose had engaged in the NHS abdominal aortic aneurysm
(AAA) screening programme, so no referral was made.
22. On 9 May 2023, a GP at the prison saw Mr Rose after he had found a lump in his
abdomen. He referred Mr Rose for an ultrasound of his abdomen and pelvis.
23. On 24 May, Mr Rose was taken to hospital by prison escort for the urgent
ultrasound. The results showed that Mr Rose had an 8.3cm abdominal aortic
aneurysm (AAA) in his abdomen. A prison GP referred Mr Rose to the vascular
team at Royal Preston Hospital.
24. On 31 May, Mr Rose had an appointment with the vascular team, however the
hospital cancelled the appointment and rescheduled it for 7 June.
25. The prison was not able to escort Mr Rose to his appointment on 7 June due to
staffing issues, but the prison did not inform healthcare staff of this, so they did not
tell the hospital that Mr Rose was not able to attend.
26. On 19 June, healthcare staff received a letter from the vascular team saying Mr
Rose had failed to attend his appointment on 7 June and another appointment was
arranged for 25 August.
27. On 25 August, Mr Rose was taken to his appointment, however when he arrived the
hospital had cancelled the clinic due to doctors strikes. The hospital had failed to
inform healthcare staff that Mr Rose’s appointment had been cancelled.
28. On 29 November, a consultant vascular surgeon saw Mr Rose and explained the
AAA diagnosis and the prognosis if it ruptured.
29. On 30 November, a nurse saw Mr Rose. He told her he had an aneurysm that could
burst at any time, and he did not want staff to start CPR if that happened. Mr Rose
requested to have a DNACPR (Do not attempt cardiopulmonary resuscitation) order
put in place. She made an appointment for Mr Rose to discuss this with the GP.
30. On 18 December, a GP in the prison saw Mr Rose. Mr Rose was made aware of
the implications of a DNACPR, and he confirmed that he understood. A DNACPR
was put in place and the decision was recorded in Mr Rose’s medical records. A
copy of the DNACPR paperwork was taken to his wing and wing staff were made
aware of this.
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Events of 18 January 2024
31. At approximately 4.45pm on 18 January, wing staff realised that Mr Rose had not
collected his evening meal. An officer went to Mr Rose’s cell, opened the
observation panel of Mr Rose’s door, and found that he was unresponsive on the
floor. She opened the door and tried to get a verbal response from Mr Rose, but he
did not respond. She was unable to find a pulse and radioed a code blue (indicating
a prisoner is unconscious or is having breathing difficulties).
32. At approximately 4.50pm, healthcare staff attended but no CPR was started
because Mr Rose had an active DNACPR in place.
33. At approximately 5.10pm, the ambulance paramedics arrived at the prison and
confirmed that Mr Rose had died.
Contact with Mr Rose’s family
34. Following Mr Rose’s death, the prison appointed a family liaison officer (FLO). Mr
Rose told staff that he had no next of kin. The FLO contacted Mr Rose’s solicitor
and the coroner to see if they had any record of Mr Rose’s next of kin. The coroner
provided the contact details for members of Mr Rose’s family. The FLO contacted
the family, but they did not wish to be involved.
35. On 1 February, the FLO established contact with one of Mr Rose’s sons. She
offered her condolences and on-going support.
36. The prison contributed towards Mr Rose’s funeral in line with prison policy.
Support for prisoners and staff
37. After Mr Rose’s death, a prison manager debriefed the staff who were involved to
ensure they had the opportunity to discuss any issues arising, and to offer support.
The staff care team also offered support.
38. The prison posted notices informing other staff and prisoners of Mr Rose’s death
and offering support.
Cause of death
39. The coroner accepted the cause of death provided by the lead GP at HMP Wymott
and no post-mortem examination was carried out. The GP gave Mr Rose’s cause of
death as ruptured abdominal aortic aneurysm.
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Findings
Clinical care
40. The clinical reviewer concluded that the clinical care Mr Rose received at Wymott
was variable, and there were elements which were not equivalent to what he could
have expected to receive in the community.
41. They found that the healthcare team at Wymott did not adhere to NICE guidance in
relation to the secondary health screen. Mr Rose was not asked whether he had
been engaged with the NHS for health checks and screening programmes.
Therefore, a referral for an AAA screening was not considered.
42. A healthcare administration manager at Wymott confirmed that there is now a
process in place which ensures that prisoners at Wymott are offered AAA screening
when they turn 65 years old, in line with the national guidance. A list of all eligible
prisoners is provided quarterly to the NHS AAA screening team who arrange clinics
at the prison.
43. Prison Service Order (PSO) 3050, states prisons must ensure continuity of
healthcare for prisoners during their time in prison. However, the prison was unable
to provide staff to escort Mr Rose for one of his hospital appointments on 7 June.
The clinical reviewer said that if Mr Rose had been assessed by the vascular team
in June 2023, it may have resulted in him being properly diagnosed with quicker
intervention. She found that there was a lack of communication and partnership
working between healthcare staff and custodial staff and information was not
shared in a timely manner.
44. Since Mr Rose’s death the prison has begun work to explore the issues around
providing escorts for external hospital appointments which includes:
• an operational procedure for healthcare, administration and prison staff
about the escort process,
• ensuring that all healthcare, administration and prison staff are aware of their
roles and responsibilities in relation to the escort process and the escalation
process,
• an urgent review of the escort profile (the number of staff allocated to escort
duties at any given time); this will determine if the current escort profile is
sufficient to meet the needs of the population at HMP Wymott,
• completion of an audit within three months of the implementation of the local
operational procedure to ensure that the escort process has measurably
improved.
45. In light of the prison’s efforts to improve partnership working between healthcare
and prison staff and to make improvements to the prison escorts provision for
hospital appointments, we make no recommendation.
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46. The clinical reviewer made some recommendations not directly linked to Mr Rose’s
death which we do not repeat here but which the Head of Healthcare will wish to
address.
47. The initial report was shared with HM Prison and Probation Service (HMPPS),
Greater Manchester Mental Health NHS Foundation Trust pointed out some factual
inaccuracies in the clinical reviewer’s report and the initial report, and these have
been amended accordingly.
48. Mr Rose‘s family received a copy of the initial report. They did not make any
comments.
49. At the inquest held on 30 April 2025, the coroner concluded that Mr Alexander
George Rose died of 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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