John Chapman

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr John Chapman,
a prisoner at HMP Gartree,
on 14 October 2025
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, 2026
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
OFFICIAL - FOR PUBLIC RELEASE
Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Mr John Chapman died of heart disease on 14 October 2025, at HMP Gartree. He
was 80 years old. We offer our condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Chapman received at
Gartree was of a good standard and equivalent to that which he could have
expected to receive in the community. He made two recommendations not relating
to Mr Chapman’s death, which the Head of Healthcare will wish to address.
5. We found that there were delays in submitting an Early Release on Compassionate
Grounds (ERCG) application for Mr Chapman and that it was incomplete when
submitted, which meant it was not considered before Mr Chapman died.
Recommendations
• The Governor and Head of Healthcare should review the Early Release on
Compassionate Grounds (ERCG) process and ensure that:
• Staff responsible for completing applications understand the ERCG Policy
Framework including the requirement to provide a consultant’s report when
submitting the ERCG application.
• A nominated person is responsible for coordinating applications, and ensuring
applications are completed fully before submission.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
6. HMPPS notified us of Mr Chapman’s death on 14 October 2025.
7. NHS England commissioned an independent clinical reviewer to review Mr
Chapman’s clinical care at HMP Gartree.
8. The PPO investigator investigated the non-clinical issues relating to Mr Chapman’s
care.
9. The Ombudsman’s office wrote to Mr Chapman’s next of kin, to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond to our letter.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. They provided an action
plan which is annexed to this report.
Previous deaths at HMP Gartree
11. Mr Chapman was the fifteenth prisoner to die at HMP Gartree since October 2022.
Of the previous deaths, eight were from natural causes, three were self-inflicted,
two were drug related and two remain under investigation. Up to the end of January
2026, there have been no further deaths.
12. Our investigation into a previous death at Gartree in September 2024, which
involved a terminally ill prisoner, found that staff had not considered starting an
ERCG application. The prison told us that they had arranged monthly meetings
between the healthcare provider, safer custody, and the offender management unit,
to discuss all issues relating to end of life care including ERCG applications. The
prison said the meeting would be used to track any ERCG applications and monitor
their progress.
13. An investigation into a death at Gartree in February 2025 found that the prison
failed to resubmit an updated ERCG application when the prisoner’s condition
deteriorated significantly (the original application was refused on the basis that the
prisoner still posed a risk to the public). In December 2025, Gartree told us that
ERCG was reviewed weekly in a multidisciplinary meeting to discuss prisoners with
a terminal illness.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
14. In September 2017, Mr John Chapman was sentenced to life imprisonment for
murder. On 22 September 2022, he was moved to HMP Gartree.
15. Mr Chapman had several significant health conditions including diabetes.
16. In February 2025, Mr Chapman was diagnosed with peripheral vascular disease (a
condition where the arteries narrow and blood flow to the limbs is reduced). This led
to a below the knee amputation of his left leg in April.
17. On 30 April, Mr Chapman was discharged back to Gartree. He returned to hospital
between 1 and 27 May. During this admission, prison healthcare staff reviewed him
on the ward. They raised concerns about Mr Chapman's mobility.
18. On 9 June, during a multidisciplinary team (MDT) meeting at Gartree, staff
expressed concerns about Mr Chapman’s deteriorating health and his increasing
frailty. He was not eating properly or getting out of bed. His leg wound was
deteriorating. He struggled to swallow and his mental health was deteriorating.
Healthcare staff decided to refer Mr Chapman back to the vascular team for advice.
19. On 11 June, Mr Chapman was admitted to hospital with a chest and urine infection.
In hospital, medical staff discussed CPR with Mr Chapman and he decided that he
did not want to be resuscitated if his heart or breathing stopped. Hospital staff
completed a RESPECT document (used to record a patient’s wishes) and Mr
Chapman signed it recording his decision. This decision remained in place until his
death.
20. On 13 June, Mr Chapman returned to Gartree.
21. There is no record of when staff discussed an application for Early Release on
Compassionate Grounds (ERCG) for Mr Chapman but the application form was
sent to a GP at Gartree on 26 June. He completed ‘Section 4 GP Report’ of the
ERCG application by 2 July. The GP recorded Mr Chapman’s prognosis was poor
and he was unlikely to live beyond three months. The GP said that in his clinical
opinion, discharge to a nursing home would be the most appropriate environment
for Mr Chapman.
22. On 28 June, Mr Chapman was readmitted to hospital. He remained in hospital for
several months. During this admission to hospital Mr Chapman became frailer and
more unwell.
23. On 3 July, a community offender manager (COM) was asked to complete Section 5
of the application for ERCG and a prison offender manager (POM) was asked to
complete Section 6 of the application.
24. The COM reported Mr Chapman had no arrangement yet in the community to
provide for his care or manage his risk and this would require assessment if he
were approved for early release. This section was completed by 16 September.
25. The POM agreed that ERCG was appropriate, given the medical prognosis outlined
in section 4 by the GP and the high level of nursing support needed by Mr
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Chapman, providing there was an appropriate plan to manage Mr Chapman’s risk
to children. This section was completed by 22 August.
26. In September, surgeons discussed with Mr Chapman amputating his lower right leg
below the knee. On 15 September, Mr Chapman decided not to undergo a further
amputation and he moved to Kettering General Hospital for palliative care.
27. On 18 September, a prison governor was asked to complete Section 7 of the
application for ERCG. An unsigned and undated entry at section 7a states, “It is
evident that Mr Chapman is in deteriorating health, with a prognosis of 3-month
survival although this cannot be certain. His mobility is poor linked to his recent
amputation and age is a factor overall. There will need to be a risk management
plan to assure no child contact which will be overseen by the COM.” An entry at
section 7b of the application states, “A placement in a care home would be the
preferable outcome, work has not taken place in respect of this at this time.”
28. On 22 September, Mr Chapman’s medical record noted he was on palliative care
and his prognosis was likely two to three months.
29. On 29 September, the prison submitted the ERCG application to the Public
Protection Casework Section (PPCS) of HMPPS.
30. On 30 September, PPCS told Gartree that they were unable to assess the ERCG
application as it was incomplete. It required a consultant’s report containing
diagnosis, date of diagnosis, treatment and future treatment plans, assessment of
frailty, mobility, physical capacity, and the rate of deterioration in Mr Chapman’s
conditions and a prognosis, including life expectancy.
31. PPCS also told Gartree that they could not assess the ERCG as it required a clear
release and risk management plan, with an identified release address, and an
assessment by the COM of the agreed medical facility and how Mr Chapman’s risks
would be safely managed there.
32. On 1 October, Mr Chapman’s medical records noted he remained on end-of-life
treatment and his prognosis was likely two to three months.
33. On 2 October, Gartree wrote to PPCS to explain that Mr Chapman did not have a
COM. The COM was only assigned to provide further information to support an
adult social care assessment for Mr Chapman and was unable to provide the
information required by PPCS. Gartree asked PPCS for advice on who was
responsible for completing the required risk management plans. PPCS advised that
if the prison was applying for early release, a COM must be allocated to complete
the necessary assessments.
34. On 2 October, Gartree emailed the Probation Service asking that the information
required by PPCS from a COM be arranged.
35. On 9 October, Mr Chapman returned to Gartree
36. On 10 October, a Marie Curie specialist palliative care nurse saw Mr Chapman.
Medical staff discussed transferring Mr Chapman to a hospice facility. The palliative
care nurse thought that Mr Chapman was too unwell to be moved. She asked Mr
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Chapman if he wished to remain at the prison. She reported Mr Chapman nodded.
Mr Chapman was seen regularly by nurses providing end-of-life supportive care.
37. On 13 October, the Probation Service replied to Gartree and said that for a COM to
complete a full risk management plan they required a full assessment and care plan
from social care. The COM was asked to follow this up. Gartree provided a care
and support assessment by Leicestershire County Council Adult Social Care that
had begun in June 2025 and updated in September.
38. On 14 October, Mr Chapman became drowsy and unresponsive and at about
4.40am was unresponsive with no pulse. An ambulance attended and paramedics
verified death.
Cause of death
39. The Coroner decided that a post-mortem examination was not necessary and gave
the cause of death as ischaemic heart disease (reduced blood flow to the heart due
to a build-up of fatty substances in the coronary arteries).
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Clinical findings
40. The clinical reviewer concluded that the clinical care Mr Chapman received at
Gartree was of a good standard and equivalent to that which he could have
expected to receive in the community.
41. The clinical reviewer made two recommendations not related to Mr Chapman’s
death that the Head of Healthcare will wish to address.
Early Release on Compassionate Grounds (ERCG)
42. Early release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. The criteria
for early release are set out in the Early Release on Compassionate Grounds
(ERCG) Policy Framework. An application for ERCG must be submitted to the
Public Protection Casework Section (PPCS) of HMPPS.
43. Sections 4.11 to 4.15 of the ERCG Policy Framework provide guidance on the
timeliness of applications. It recognises the complex nature of the application, often
involving multiple agencies and stresses the importances of expediting those
applications, so all necessary information can be submitted. The framework warns
that applications should only be submitted once all relevant information has been
obtained. It recommends the prison collect as much information as soon as possible
to avoid delaying an application to PPCS should circumstances change rapidly.
44. Gartree recognised Mr Chapman’s poor and deteriorating health and the
expectation he would not live beyond three months. They started an application for
ERCG on 26 June 2025. However, it was not submitted until three months later, on
29 September, and was incomplete.
45. Gartree did not submit a consultant’s report with the application. This requirement is
clearly set out at section 4.25 of the ERCG Policy Framework. The investigator
wrote to the Head of Healthcare to ask whether this report was obtained or
requested. They did not reply.
46. Section 4.28 of the ERCG Policy Framework says:
“Applications where it is anticipated that social care will be continued or initiated
upon release must include social care assessments and post release care plans. A
Community Offender Manager (COM) together with local authorities will be required
to define the level of personal care required to be delivered in the community and
the availability to the prisoner.”
47. Mr Chapman had significant care needs. An up-to-date care assessment was not
submitted with the application. Gartree and the appointed COM did not appear to
understand this necessary part of the application, instead offering to complete the
assessment if early release was granted.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
48. Gartree also failed to provide a risk management plan to PPCS explaining how any
risk posed to the public by Mr Chapman would be managed, saying it would be
assessed if early release was granted.
49. This illustrates a significant misunderstanding of the ERCG process by staff at
Gartree.
50. We have made recommendations to Gartree on ERCG following deaths in
September 2024 and February 2025. The prison told us that there were monthly
meetings to discuss and track ERCG applications. Yet the delays in Mr Chapman’s
ERCG application show that more work needs to be done to improve the ERCG
process at Gartree.
51. We recommend:
The Governor and Head of Healthcare should review the Early Release on
Compassionate Grounds (ERCG) process and ensure that:
• Staff responsible for completing applications understand the ERCG Policy
Framework including the requirement to provide a consultant’s report
when submitting the ERCG application form.
• A nominated person is responsible for coordinating applications, and
ensuring applications are completed fully before submission.
Inquest
52. At the inquest, held on 16 March 2026, the Coroner concluded that Mr Chapman
died from natural causes.
Adrian Usher
Prisons and Probation Ombudsman May 2026
Prisons and Probation Ombudsman 7
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