Harold Rushton

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Harold Rushton,
a prisoner at HMP Stafford, on
20 December 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
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. In March 2019, Mr Harold Rushton was sentenced to 16 years in prison for rape. He
died of cardiorespiratory failure on 20 December 2024, at HMP Stafford. He was 76
years old. We offer our condolences to Mr Rushton’s family and friends.
4. The Ombudsman’s office wrote to Mr Rushton’s next of kin to explain the
investigation and to ask if they had any matters, they wanted us to consider. Mr
Rushton’s next of kin did not ask any questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer, to review Mr
Rushton’s clinical care at Stafford.
6. The clinical reviewer concluded that the clinical care Mr Rushton received at
Stafford was of a good standard and equivalent to what he could have expected to
receive in the community. She found that the healthcare team supported and cared
for Mr Rushton very well. He was appropriately monitored and treated for his health
conditions as his health naturally declined over the years. The clinical reviewer
made recommendations not related to Mr Rushton’s death that the Head of
Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Rushton’s
care. We make no recommendations.
Governor and Head of Healthcare to note
8. Staff initiated CPR on Mr Rushton due to uncertainty about whether a DNACPR
order was in place for him. Once it was confirmed that he had an active DNACPR,
resuscitation efforts were ceased immediately. During the immediate debrief, the
Duty Governor suggested that DNACPR documentation should be more readily
accessible, proposing that a copy be kept in the prisoner’s cell.
9. The Safer Custody Manager reported that the DNACPR process was discussed in
detail at the Prevention of Future Deaths meeting. While the idea of storing a copy
of the DNACPR in the prisoner’s cell was considered, it was ultimately rejected.
Concerns were raised about confidentiality in shared cells and the impracticality of
accessing documents stored in locked cupboards in the cell during emergencies.
10. The Head of Healthcare at Stafford informed us that the communication process
around DNACPRs was also discussed. It was agreed that the prison would retain its
existing pathway and remind staff of the procedures. Following Mr Rushton’s death,
a notice was issued to staff, reminding them where to access the list of prisoners
with active DNACPR orders.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
11. Given that the existing process has been retained, despite its failure in Mr
Rushton’s case, the Governor may wish to assure himself that the current system is
fit for purpose. It is important that both prison and clinical staff are aware of which
prisoners have DNACPR orders and can access this information promptly in an
emergency.
12. Mr Rushton’s family received a copy of the initial report. They did not make any
comments.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
14. Practice Plus Group also pointed out some factual inaccuracies with the clinical
review. The investigator passed these onto the clinical reviewer who amended their
report.
Adrian Usher August 2025
Prison and Probation Ombudsman
Inquest
At the inquest held on the 11 December 2025, the coroner concluded Mr Rushton died of
natural causes.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE