John Eyre

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Independent investigation into
the death of Mr John Eyre,
a prisoner at HMP Swaleside,
on 20 November 2022
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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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 HMPPS in ensuring the standard of care received by
those within service remit is appropriate then our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of
systemic failure.
3. Mr John Eyre died of pneumonia on 20 November 2022 while a prisoner at HMP
Swaleside. He was 78 years old. We offer our condolences to Mr Eyre’s family and
friends.
4. The clinical reviewer concluded that the clinical care Mr Eyre received at Swaleside
was of a good standard and equivalent to that which he could have expected to
receive in the community.
5. We found that non-clinical care was generally of a good standard, with the
exception of escort risk assessment procedures which did not comply with national
policy requirements.
Findings
6. Staff completing risk assessments for Mr Eyre’s transfers to hospital did not consult
healthcare or seek authorisation from a Governor or nominated equivalent in line
with national policy requirement, on all but one occasion. We were therefore unable
to verify if these decisions were appropriate. We make the following
recommendation:
The Governor should ensure that all staff completing escort risk assessments
for prisoners taken to hospital involve healthcare input and authorisation by a
Governor or nominated equivalent, in line with the External Escorts Policy
Framework 2022.
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The Investigation Process
7. We were notified of Mr Eyre’s death on 20 November 2022.
8. NHS England commissioned an independent clinical reviewer to review Mr Eyre’s
clinical care at HMP Swaleside.
9. The PPO investigator investigated the non-clinical issues relating to Mr Eyre’s care
at HMP Swaleside.
10. The PPO family liaison officer wrote to Mr Eyre’s son and next of kin to explain the
investigation and to ask if he had any matters he wanted us to consider. Mr Eyre
raised concerns about his father’s clinical care which have been addressed in the
annexed clinical review. Mr Eyre also requested a copy of our report.
11. Mr Eyre’s family received a copy of the initial report. They raised a number of
questions on the factual accuracy of the report which have been addressed in the
report and through separate correspondence. They also raised a number of
questions about the clinical review, which have been addressed by the clinical
reviewer.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies in the report. They have accepted the finding
on escort risk assessments in the report.
Previous deaths at HMP Swaleside
13. Mr Eyre was the twenty third prisoner to die at HMP Swaleside since November
2019. Of the previous deaths, 10 were from natural causes, eight were self-inflicted,
and four were drug related. There are no similarities between our findings in the
investigation into Mr Eyre’s death and our investigation findings for the previous
deaths.
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Key Events
Background
14. On 3 August 2018, Mr Eyre was sentenced to 14 years and six months
imprisonment for sexual offences and transferred to HMP Swaleside.
15. At Mr Eyre’s initial health screening, healthcare staff recorded several health needs
including chronic kidney disease, ischaemic heart disease and memory loss. They
made a referral to the prison GP and created the appropriate care plans to manage
Mr Eyre’s conditions.
March - May 2022
16. On 1 March 2022, a prison GP reviewed Mr Eyre. Mr Eyre was dizzy and had a
headache, so the GP requested an urgent transfer to Accident and Emergency
(A&E). He was discharged later the same day and no concerns were raised by the
hospital.
17. During April and May, Mr Eyre’s overall health and mobility deteriorated. He had a
fall and was struggling to look after himself. Staff called a code blue emergency
(triggering a call for an ambulance) on two occasions when Mr Eyre’s blood sugars
were found to be dangerously low. He was treated for his existing kidney disease
and possible sepsis. When Mr Eyre returned to prison, he was moved into a cell on
the healthcare unit to ensure staff could regularly monitor his health.
18. On 30 May, Mr Eyre became disorientated and fell over in his cell. A code red was
called and healthcare staff dressed a cut on Mr Eyre’s eyebrow and provided pain
relief. They assessed that hospital care was not necessary. A prison GP reviewed
Mr Eyre later the same day and found his confusion was worsening, so called a
code blue. Mr Eyre was admitted to A&E where investigations revealed a possible
abdominal tumour. Mr Eyre was referred for further investigation and a biopsy
(medical procedure that involves taking a small sample of body tissue so it can be
examined under a microscope).
June - July 2022
19. On 11 June, prison staff received a telephone update from the hospital.
Investigations had revealed possible abdominal lymphoma (cancerous tumours in
the lymphatic tissues of the abdomen). They were still waiting for Mr Eyre’s biopsy
result.
20. On 17 June, Mr Eyre was discharged from hospital back to Swaleside. He was
offered a space on the healthcare unit but declined because he felt isolated, lonely
and could not readily contact his family there. After a discussion around the risks of
not returning to the healthcare unit, Mr Eyre signed a disclaimer form confirming
that he was acting against medical advice.
21. On 17 July, Mr Eyre met with healthcare to create a Life Limiting Care Plan. He
shared his wishes about how he would like to be cared for in the final stages of his
life. Healthcare organised day-to-day clinical monitoring and support, welfare
checks and a wing carer for Mr Eyre. The local authority completed a social care
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assessment and provided an air mattress and cushion to ensure Mr Eyre was
comfortable.
22. On 18 July, Mr Eyre attended hospital for an endoscopy (a nonsurgical procedure
used to examine a person's digestive tract). The procedure was cancelled because
Mr Eyre had not been advised to ensure ‘nil by mouth’ procedures prior to his
appointment. Hospital staff said they would contact the prison to reschedule the
procedure.
August - October 2022
23. On 5 August, Mr Eyre was taken to A&E again due to concerns about dehydration.
Hospital staff planned to complete Mr Eyre’s endoscopy and biopsy during his
admission but this was not actioned. The reason for this is not recorded in the
medical notes, which say that a subsequent inpatient biopsy (no date given) did not
show any significant results or the nature of Mr Eyre’s malignancy. Hospital staff
scheduled a bronchoscopy (to look directly at the airways in the lungs) as part of
their ongoing investigation into further lymphoma, related to the abdominal
lymphoma already found. Mr Eyre was treated for sepsis over a three-week period,
during which time the prison healthcare team made regular contact.
24. On 15 August, Mr Eyre was escorted to hospital for an outpatient appointment in
restraints. When Mr Eyre returned to prison later in the day, staff advised him to
stay on the healthcare unit for monitoring purposes but Mr Eyre declined and said
he was willing to sign another disclaimer. Managers made a decision to override the
disclaimer on medical grounds, to ensure Mr Eyre received the appropriate clinical
support.
25. On 30 August, Mr Eyre’s son contacted the prison to share details of a biopsy
appointment that had been arranged in hospital that day. Mr Eyre did not eat or
drink ahead of his appointment, as requested by the hospital, but the transfer was
cancelled due to a lack of escort staff.
26. On 31 August, Mr Eyre’s blood pressure reduced and he was transferred to A&E
with a single handcuff. Prison staff stayed in contact with the hospital who said Mr
Eyre was being treated for anaemia and a urine infection. Mr Eyre stayed in hospital
where his condition worsened and staff started feeding him through a nasogastric
tube (to deliver fluid that contains nutrients directly into the stomach) and
intravenous fluids. Hospital staff continued to investigate Mr Eyre’s lymphoma and a
transfer to another hospital was organised to continue this.
27. On 21 October, the lead nurse at Swaleside, who had been closely involved with Mr
Eyre, visited the hospital to discuss his care needs.
28. On 25 October, a nurse was informed by the hospital that Mr Eyre would be
discharged back to prison later in the day. She advised that Swaleside could not
provide the appropriate care, but Mr Eyre was returned to the healthcare unit the
next day. Healthcare put regular checks in place.
29. On 29 October, Mr Eyre fell in his cell. Healthcare staff checked his basic
observations, which were within normal ranges. They increased their regular
checks.
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30. On 31 October, staff observed that Mr Eyre was becoming more confused and less
responsive. His health deterioration score was medium so staff transferred him to
A&E in a wheelchair and on a single chain without handcuffs.
November 2022
31. On 3 November, Mr Eyre completed an application for early release on
compassionate grounds (ERCG). On 9 November, the Governor reviewed Mr
Eyre’s ERCG application and decided not to approve it on the basis he did not have
a terminal diagnosis.
32. On 7 November, bedwatch officers contacted prison staff to confirm that Mr Eyre
was being moved to the Intensive Care Unit (ICU) due to him struggling to breathe
and to offer better support. Hospital staff asked for Mr Eyre’s next of kin to be
informed of his condition. A Family Liaison Officer was appointed and made contact
with Mr Eyre’s family. Hospital and prison staff were in daily contact.
33. On 16 November, a nurse visited Mr Eyre in hospital. Hospital staff updated her on
Mr Eyre’s biopsy results which did not indicate lymphoma. Mr Eyre’s family were
supported to visit him in hospital.
34. On 20 November at 9.34pm, Mr Eyre’s family decided to withdraw life support.
Prison staff were notified that Mr Eyre had passed away.
Post-mortem report
35. The post-mortem report concluded that Mr Eyre died of pneumonia caused by
obstructive liver disease.
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Findings
Clinical care
36. The clinical reviewer concluded that the clinical care provided to Mr Eyre at
Swaleside was of a good standard and equivalent to that which he could have
expected to receive in the community. He makes recommendations for improved
care planning processes and compliance with outpatient appointments which did
not directly impact on Mr Eyre’s death but should be addressed by the Head of
Healthcare.
Non-clinical care
37. We found that the non-clinical care provided to Mr Eyre was generally of a good
standard. Staff were responsive to Mr Eyre’s needs and transferred him to hospital
when he required increased clinical provision. However, we found issues with
escort risk assessment procedures at Swaleside.
Escort risk assessments
38. His Majesty’s Prison and Probation Service published Prevention of Escape -
External Escorts Policy Framework in 2022. The Framework contains mandatory
requirements for staff managing transfers for prisoners, including multidisciplinary
risk assessment for each transfer to ensure the use of restraints is appropriate, and
the need for authorisation of restraints decisions by a Governor or equivalent
manager.
39. The Graham Judgment 2007 made clear that prison staff need to distinguish
between the prisoner’s risk of escape when fit (and the risk to the public in the event
of an escape) and the prisoner’s risk when he has a serious medical condition. The
judgement found that prison staff must consider medical opinion about the
prisoner’s ability to escape and keep this under review as circumstances change.
Public protection is critical, but security measures must be proportionate to a
prisoner’s individual circumstances.
40. Mr Eyre was transferred to hospital on six occasions in the six months before his
death. On all but one of the escort risk assessments we saw, he was restrained with
either a single or double handcuff based on his offending risk. Only one of the risk
assessments contained input from healthcare and authorisation by a Governor or
equivalent, despite national policy requirements. On this occasion restraints were
initially applied and then removed.
41. When we asked for an explanation on why some of the risk assessments were not
completed appropriately, Swaleside said they were unable to locate any signed
assessments. They could not provide an explanation for the lack of healthcare
input. We are unable to say whether the decisions made were appropriate in light of
Mr Eyre’s health deterioration and in line with the Graham Judgement, due to the
lack of healthcare input.
42. The final escort risk assessment completed before Mr Eyre died, on 20 November,
included the necessary healthcare input and Governor sign off. Handcuffs were
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removed following the 24-hour review by a Governor, which appears appropriate
based on Mr Eyre’s very poor health and lack of mobility, which would have
significantly reduced his risk of offending.
43. It is vital that prison staff understand their responsibility to consult healthcare and
prison managers when making restraints decisions, to ensure they take into
consideration all of the appropriate factors. Therefore, we make the following
recommendation:
The Governor should ensure that all staff completing escort risk assessments
for prisoners taken to hospital involve healthcare input and authorisation by a
Governor or nominated equivalent, in line with the External Escorts Policy
Framework 2022.
Inquest
44. The inquest into Mr Eyre’s death concluded on the 30 November 2022. The
coroner confirmed that Mr Eyre died from natural causes.
Regulation 28 report to prevent future deaths
45. The investigation concluded on 12 August 2024. At the end of the inquest. The
coroner’s concerns were:
• There was no concrete escalation route when prison healthcare staff
challenged the appropriateness and sustainability of discharge from the acute
setting.
• There was no national guidance document, or national policy in place, which
outlined whether a prisoner should be returned to a custodial setting in the
absence of the prison healthcare provider's concerns being considered by the
patient's consultant.
Adrian Usher
Prisons and Probation Ombudsman March 2025
Prisons and Probation Ombudsman 7
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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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