Jamie Funnell

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Independent investigation into
the death of Mr Jamie Funnell,
a prisoner at HMP Lewes,
on 16 December 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, 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 Jamie Funnell died of a heart attack caused by left ventricular hypertrophy and dilation
(the left side of the heart becomes thicker and enlarged), coronary artery atherosclerosis
(a condition where arteries become clogged with fatty substances), electrolyte disturbance
(imbalances in body salts and minerals) owing to vomiting, and withdrawal from drugs and
alcohol. He died on 16 December 2023, at HMP Lewes. He was 44 years old. I offer my
condolences to his family and friends.
Mr Funnell died around 24 hours after arriving at Lewes. While his symptoms of alcohol
withdrawal were initially managed well, several opportunities were missed in the last hours
of his life to properly assess, monitor and treat what was a clear deterioration in his health.
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 ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On 15 December 2023, Mr Jamie Funnell was remanded to HMP Lewes for
assaulting an emergency worker. Mr Funnell had a history of substance misuse.
2. A nurse carried out Mr Funnell’s initial health screen and noted that his physical
observations were all within the normal range. Using recognised withdrawal
assessments (known as CIWA-B and CIWA-Ar), she assessed Mr Funnell as
having mild benzodiazepine withdrawal and minimal evidence of significant alcohol
withdrawal. The nurse referred Mr Funnell to the substance misuse team. A nurse
prescriber prescribed Mr Funnell diazepam as required and thiamine, both for
alcohol withdrawal, and methadone for opiate withdrawal.
3. At 5.00am on 16 December, Mr Funnell pressed his cell bell. A nurse assessed him
for alcohol withdrawal and found that his CIWA-Ar score now indicated moderate
alcohol withdrawal. The nurse gave Mr Funnell diazepam.
4. At 9.20am, a substance misuse nurse reviewed Mr Funnell, who had nausea and
was retching. The nurse did not record a CIWA-Ar score. He gave Mr Funnell anti-
sickness medication. Later in the morning, Mr Funnell told an officer that he had
vomited.
5. At about 2.00pm, the substance misuse nurse spoke to Mr Funnell through the cell
observation panel. Mr Funnell said that he felt rough. The nurse was unable to
complete a full clinical assessment because there was only one officer present on
the wing, so in line with local protocols the cell door could not be opened.
6. At 4.00pm, the officer unlocked Mr Funnell who walked down the landing to see the
substance misuse nurse and collapsed. The officer and a custodial manager (CM)
helped him back to his cell, where he collapsed again. Mr Funnell became
unresponsive and stopped breathing. The CM radioed a medical emergency code
blue (which indicates that a prisoner is unconscious or having difficulty breathing).
7. Healthcare staff started cardiopulmonary resuscitation (CPR), inserted an airway,
gave him oxygen and used a defibrillator. At 4.32pm, ambulance paramedics
arrived and took over emergency life support. At 5.16pm, they confirmed that Mr
Funnell had died.
Findings
8. The clinical reviewer concluded that the clinical care Mr Funnell received for alcohol
withdrawal was not equivalent to that which he would expect to receive in the
community.
9. No additional CIWA-Ar assessments were completed after Mr Funnell’s initial
development of alcohol withdrawal symptoms at 5.25am on 16 December. There
was no objective assessment of the severity of Mr Funnell’s clinical condition for
much of the day until his collapse. Diazepam was not continued in line with local
policy. On one occasion, a lack of staffing meant that a nurse could not conduct a
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full assessment of Mr Funnell’s symptoms. In combination, these factors meant that
opportunities to act on Mr Funnell’s potentially reversible clinical deterioration were
missed.
10. The attending ambulance service paramedics were concerned with aspects of the
CPR delivered by the healthcare staff.
Recommendations
• The Governor and Head of Healthcare should ensure that healthcare staff have
entry to prisoner’s cells on K Wing at the weekend, to allow face to face clinical
assessments when required.
• The Head of Healthcare should ensure that the Standard Operating Procedure for
Assessment and Management of Alcohol Dependence is revised, including that:
• Staff are given clear guidance about how to manage alcohol withdrawal within
48 hours of arrival in custody;
• Staff understand when and how to complete CIWA-Ar assessments and
prescribe and provide medications including diazepam in line with clinical
expectations.
• The Head of Healthcare should ensure that staff are competent to carry out
cardiopulmonary resuscitation in line with national guidance and arrange for
additional training when required.
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The Investigation Process
11. HMPPS notified us of Mr Funnell’s death on 16 December 2023.
12. The investigator issued notices to staff and prisoners at HMP Lewes informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
13. The investigator obtained copies of relevant extracts from Mr Funnell’s prison and
medical records.
14. NHS England commissioned a clinical reviewer to review Mr Funnell’s clinical care
at the prison. On 16 February, the investigator jointly interviewed six members of
staff at Lewes with the clinical reviewer and, on 23 February, they jointly interviewed
three members of staff by video link.
15. We informed HM Coroner for East Sussex of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
16. The Ombudsman’s office wrote to Mr Funnell’s mother to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Funnell’s mother
asked what medication Mr Funnell received at Lewes and when he received it. She
asked if he had vomited before he collapsed and whether he was being held on the
high dependency wing.
17. We shared the initial report with HM Prison and Probation Service. They identified
one factual inaccuracy, which we have corrected in this final report.
18. We also shared the initial report with Mr Funnell’s mother. She asked additional
questions that are outside the remit of our investigation.
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Background Information
HMP Lewes
19. HMP Lewes is a local prison serving the courts of East and West Sussex. Practice
Plus Group (PPG) provides primary care services and healthcare staff are on duty
24-hours a day.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Lewes was an independent review of progress
in February 2024. Inspectors reported that prison leaders had overhauled early
days processes to improve the experience of prisoners. They found that health
services had improved significantly. Clinical support for prisoners receiving opiate-
substitution therapy was very good, including regular reviews in line with evidence-
based practice.
Independent Monitoring Board
21. 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 January 2023, the IMB reported
that prisoners identified by the substance misuse service in Reception as needing
to detox should have been located on a dedicated substance misuse service wing.
However, a shortage of space meant that they were often located on the first night
centre. This resulted in delays to men getting their medication, which the IMB
identified as potentially life-threatening for men withdrawing from alcohol.
Previous deaths at HMP Lewes
22. Mr Funnell was the 15th prisoner at Lewes to die since December 2020. There have
not been any further deaths to the end of April 2024. Eight of the previous deaths
were due to natural causes, two were drug related and four were self-inflicted.
There are no significant similarities between our findings in this investigation and
those of the other deaths.
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Key Events
23. On 15 December 2023, Mr Jamie Funnell was remanded to HMP Lewes for
assaulting an emergency worker.
24. Mr Funnell had a complex medical history including a history of substance misuse
and paranoid schizophrenia (a severe, long-term mental health condition). He had
been to prison several times previously.
25. At around 6.00pm, Mr Funnell arrived at Lewes. The Person Escort Record (PER, a
document that accompanies prisoners on all journeys, including from court to
prison, and is used to highlight information including about medical risks) identified
the medication that Mr Funnell had received in police custody, including
prochlorperazine (used to treat nausea and vomiting). (The records available to us
do not explicitly say why this medication was given to Mr Funnell, but it is often
used to manage symptoms related to alcohol withdrawal.). It also noted that Mr
Funnell was “alcohol dependent”.
26. At around 8.20pm, a nurse carried out Mr Funnell’s initial health screen. She noted
that Mr Funnell engaged well and responded appropriately to questions. Mr
Funnell’s physical observations were all within the normal range. She noted that Mr
Funnell’s Clinical Institute Withdrawal Assessment Scale – Benzodiazepines
(CIWA-B, used to determine the extent to which an individual is withdrawing from
benzodiazepines) score was seven, (indicating mild withdrawal). She noted that Mr
Funnell’s CIWA-Ar (used to determine the extent of withdrawal from alcohol) score
was two (indicating mild alcohol withdrawal). Mr Funnell tested positive for
benzodiazepines and opiates. She referred Mr Funnell to the substance misuse
team.
27. A nurse prescriber then saw Mr Funnell. She noted that Mr Funnell had not taken
any illicit substances for around 48 to 72 hours because he had been in police
custody. She recorded that Mr Funnell told her that he used alcohol daily and had
spent around nine months in “rehab”, coming out around four months earlier. Mr
Funnell said that he drank three bottles of wine and two cans of very strong beer
each day and that he had last used alcohol three days earlier. He also said that he
used heroin every day.
28. The nurse said that she was mindful of the potential risk of substance withdrawal
and because of this she prescribed Mr Funnell 10mg diazepam for alcohol
withdrawal, which she noted should only be given if clear objective signs and
symptoms of alcohol withdrawal developed. She also prescribed 10ml methadone
for opiate withdrawal and 100mg thiamine (vitamin B1) for alcohol withdrawal. She
referred Mr Funnel for a review by the substance misuse team.
29. Mr Funnell was allocated a cell on K Wing, the detoxification stabilisation unit.
Events of 16 December 2023
30. At 5.00am on 16 December, Mr Funnell pressed his cell bell. An officer responded
and Mr Funnell told him that he could “feel a seizure coming on”. The officer radioed
for healthcare staff to attend. Nurse A saw Mr Funnell and assessed him for alcohol
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withdrawal. The nurse noted that during the assessment Mr Funnell was visibly
shaking and vomited clear liquid. He noted that Mr Funnell’s respiratory rate was 18
breaths per minute, that his blood oxygen saturation was 97% (normal) and that his
pulse rate had increased to 107 beats per minute (raised). The nurse recorded a
CIWA-Ar score of 18. (This indicated that Mr Funnell had moderate alcohol
withdrawal. A score of more than 20 would indicate severe withdrawal.) The nurse
gave Mr Funnell 10mg diazepam, two paracetamol tablets and gave him a drink.
31. At 9.20am, Nurse B, a substance misuse nurse, reviewed Mr Funnell, who told him
that he had nausea and retching. The nurse told us that Mr Funnell appeared
clinically stable, alert and fully orientated and that he did not observe any shaking,
excessive sweating or hallucinations. The nurse did not record a CIWA-Ar score, a
Clinical Opiate Withdrawal Scale score (COWS, to determine the extent of opiate
withdrawal) or a National Early Warning Score (NEWS, a tool to detect and respond
to clinical deterioration). The nurse gave Mr Funnell 10mg metoclopramide (anti-
sickness medication), 10ml methadone and 100mg thiamine.
32. Officer A was working on K Wing and said that Mr Funnell had vomited and been
retching that morning, and that he had the appearance of “someone who was
detoxing”.
33. At around 10.30am, Officer A unlocked Mr Funnell so that he could shower or
exercise, which he declined. Mr Funnell told him that he wanted to stay in bed.
34. At around 12.00pm, Officer A unlocked Mr Funnell for his lunch. He said that Mr
Funnell was still in bed, so he took him some food to his cell. He said that Mr
Funnell looked generally unwell.
35. At about 2.00pm, Officer A went back to Mr Funnell’s cell after he pressed his cell
bell. He spoke to Mr Funnell through the observation panel. Nurse B also spoke to
Mr Funnell, who said that he was feeling “rough” and asked for diazepam and
methadone. The nurse was unable to complete a full clinical assessment because
there was only one officer present on K Wing and security procedures therefore
meant that he was unable to open the cell door. The nurse did not give Mr Funnell
any medication.
36. Officer a said that, at 3.00pm, Mr Funnell rang his cell bell and asked for pain relief.
He told Mr Funnell that he would be unlocked for his clinic and medication at
4.00pm. He did not tell Nurse B of this conversation.
37. At around 4.00pm, Officer A unlocked Mr Funnell for his medication. Mr Funnell
walked down the landing towards the clinic and collapsed. He went to help him, with
a Custodial Manager (CM), and called Nurse B to help them. The officers walked Mr
Funnell back to his cell where, outside, he collapsed again. Officer A said that as he
fell, they caught him and walked him into his cell.
38. Nurse B placed Mr Funnell in the recovery position because his breathing was
shallow. The CM radioed for healthcare assistance. The nurse then identified that
Mr Funnell was unresponsive and not breathing and the CM radioed a medical
emergency code blue (which indicates that a prisoner is unconscious or having
difficulty breathing).
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39. The staff pulled Mr Funnell onto the landing and Nurse B started cardiopulmonary
resuscitation (CPR). Another nurse and an Emergency Care Technician (ECT)
arrived and supported Nurse B. The ECT left the scene to collect the emergency
bag and defibrillator, returned and inserted an airway and gave Mr Funnell oxygen
through a bag-valve-mask. The healthcare staff used a defibrillator, which indicated
no shockable rhythm. A nurse carried out chest compressions.
40. Prison staff in the control room telephoned the ambulance service and, after they
had given details of the medical emergency, transferred the call to the wing office
where the officers with Mr Funnell gave up-to-date information.
41. At 4.32pm, ambulance paramedics arrived and took over emergency life support. At
5.16pm, they said that Mr Funnell had died.
42. The paramedic crew told a senior officer that they were concerned about the quality
of basic life support and CPR delivered by prison healthcare staff, particularly
regarding Mr Funnell’s airway management, chest compression technique, and use
of the defibrillator. They later completed a written report to highlight these issues.
Contact with Mr Funnell’s family
43. Lewes appointed an officer as the family liaison officer and another officer as the
deputy family liaison officer. That evening, the family liaison officer and a chaplain
went to Mr Funnell’s mother’s house and informed her that he had died.
Support for prisoners and staff
44. After Mr Funnell’s death, the Head of Safer Custody 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.
45. The prison posted notices informing other prisoners of Mr Funnell’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Funnell’s death.
Post-mortem report
46. A post mortem examination established that Mr Funnell died from a heart attack
caused by left ventricular hypertrophy and dilation (the left side of the heart
becomes thicker and enlarged), coronary artery atherosclerosis (the arteries that
supply blood to the heart muscle become hard and narrow due to the build-up of
fatty materials), electrolyte disturbance (imbalances in body salts and minerals)
owing to vomiting, and withdrawal from drugs and alcohol.
47. The clinical reviewer noted that the left ventricular hypertrophy and coronary artery
atherosclerosis had not previously been diagnosed. He found that they meant that
Mr Funnell’s risk of a significant cardiac event (such as cardiac arrest) would be
notably increased and that he would be more susceptible to cardiac complications
associated with alcohol and drug withdrawal.
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48. Toxicology tests showed that Mr Funnell had taken methadone (low in comparison
to the range that is typically seen in individuals who have been receiving a daily
prescription), benzodiazepines, codeine and paracetamol. The report found that
these substances did not materially contribute to Mr Funnell’s death.
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Findings
Substance misuse management
49. The clinical reviewer found that Mr Funnell was appropriately assessed and referred
when he arrived at HMP Lewes on 15 December. Prescribing of (as required)
diazepam and methadone was appropriate to his symptoms and withdrawal scale
scores. When Mr Funnell presented with symptoms of alcohol withdrawal at around
5.00am on 16 December, the clinical reviewer found that he was appropriately
given diazepam in line with Practice Plus Group’s (PPG) Standard Operating Policy
for Assessment and Management of Alcohol Dependence.
50. However, the clinical reviewer concluded that the overall care Mr Funnell received
for alcohol withdrawal was not equivalent to that which he would expect to receive
in the community.
51. While the provision of diazepam when Mr Funnell presented with symptoms in the
early morning of 16 December was appropriate, the clinical reviewer found that
follow up care was not in line with PPG policy. The policy states that a reducing
regime of diazepam should commence when a prisoner’s CIWA-Ar score exceeds
10 within 48 hours of arrival at Lewes. Instead, when Mr Funnell’s score was
recorded as 18, he received one ‘as required’ dose with no further provision. Mr
Funnell did not receive another dose of diazepam and there was no further proper
assessment of his withdrawal or CIWA-Ar score.
52. At 9.20am on 16 December, when a substance misuse nurse reviewed Mr Funnell,
his clinical observations were recorded. However, the nurse did not obtain a current
CIWA-Ar score. Later in the day, when Mr Funnell said that he felt unwell, and
having vomited earlier in the day, the nurse did not clinically assess him or record a
current CIWA-Ar score, and instead simply recorded a welfare check. The clinical
reviewer found that simple welfare checks were contrary to PPG policy and should
not be used in the observation of prisoners at risk of alcohol withdrawal
complications.
53. The clinical reviewer described the lack of additional CIWA-Ar assessments as a
critical error which meant that there was no objective assessment of the severity of
Mr Funnell’s condition for much of the day. He concluded that this meant that
opportunities to act upon potentially reversible clinical deterioration could have been
missed.
Staffing on K Wing
54. We were told that a lack of prison staff availability was the reason why Mr Funnell
could not be unlocked for an in-person review at 2.00pm on 16 December. Local
policy is that a cell cannot be unlocked unless two prison officers are present.
Instead, one officer was working alone on K Wing, as standard on a Saturday.
55. PPG policy states that, “For patients who are displaying severe withdrawal or are at
higher medical risk during detox, increased face-to-face observations will be
required. This will require physical access to the patient and opening cells during
the night. A process for this should be agreed with the prison. If clinicians are
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unable to access the patient the reasons for this and any escalation should be
clearly documented”. There is no evidence that the lack of staff to unlock Mr
Funnell’s cell was escalated to a duty manager.
56. At 2.00pm, Mr Funnel should have had a face-to-face assessment. The clinical
reviewer said that it is possible that an opportunity to recognise a deterioration in Mr
Funnell’s health was missed by not carrying out a full clinical assessment at that
time. Given the nature of the population on K Wing, it is likely that face-to-face
clinical assessments will often be required to ensure prisoner safety. It is
concerning that staffing levels at the weekend do not easily allow this. We make the
following recommendation:
The Governor and Head of Healthcare should ensure that healthcare staff
have entry to prisoner’s cells on K Wing at the weekend, to allow face to face
clinical assessments when required.
PPG Policy
57. While the clinical reviewer identified some areas of PPG policy that were not
followed, he also found that the Standard Operating Policy for Assessment and
Management of Alcohol Dependence was potentially unclear. The policy contained
contradictory advice about the frequency of monitoring and dosage based on
CIWA-Ar scores that were not always defined in the policy. The policy is currently
under review. We make the following recommendations:
The Head of Healthcare should ensure that the Standard Operating Procedure
for Assessment and Management of Alcohol Dependence is revised,
including that:
• Staff are given clear guidance about how to manage alcohol withdrawal
within 48 hours of arrival in custody;
• Staff understand when and how to complete CIWA-Ar assessments and
prescribe and provide medications including diazepam in line with clinical
expectations.
Emergency response
58. The attending ambulance service paramedics highlighted several technical issues
with the quality of the CPR delivered by the healthcare staff. The clinical reviewer
identified that they were concerned that:
• There was a delay in oxygen delivery to Mr Funnell as the oxygen cylinder was
not initially connected to the bag-valve-mask.
• There was inadequate initial airway management.
• Chest compressions were not being carried out correctly. Compressions were
applied to Mr Funnell’s abdomen rather than his thorax. National UK
resuscitation guidelines advise that high-quality chest compressions with
minimal interruption and early defibrillation remain priorities in cardio-pulmonary
resuscitation.
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• Mr Funnell’s clothing had not been removed and was covering the defibrillator
paddles creating a potential fire risk.
59. The clinical reviewer noted that the nurses who attended the emergency response
were trained to Intermediate Life Support (ILS), which is refreshed annually. He
concluded that, overall, the timeliness of the emergency response was satisfactory.
He said that while the issues raised by the ambulance service paramedics were
concerning, it is debatable if these issues would have materially changed the
outcome for Mr Funnell.
60. We make the following recommendation:
The Head of Healthcare should ensure that staff are competent to carry out
cardiopulmonary resuscitation in line with national guidance and arrange for
additional training as required.
Good practice
61. The control room operator transferred the ambulance service telephone call to the
wing office to obtain direct, up to date information from the medical emergency.
62. The duty manager arranged for both vehicle gates at the front of the prison to be
opened simultaneously which meant that the ambulance paramedics quickly
entered the prison and were promptly at Mr Funnell’s side.
Inquest
63. The inquest into Mr Funnell’s death concluded on 30 September 2025. The jury
concluded that his death was due to the effects of drug and alcohol withdrawal that
was exacerbated by a series of omissions by healthcare and prison staff.
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