Jonathan Lawlor

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Independent investigation into
the death of Mr Jonathan Lawlor,
a prisoner at HMP Elmley,
on 19 October 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 Jonathan Lawlor died on 19 October 2023 of multi-organ failure caused by cocaine
toxicity while a prisoner at HMP Elmley. He was 42 years old. I offer my condolences to Mr
Lawlor’s family and friends.
Mr Lawlor had taken cocaine, a class A banned substance, which he had obtained illicitly
in prison. There was no evidence that prison staff had seen him under the influence of an
illicit substance during the four months he spent at Elmley and little evidence that he was
using illicit substances.
Although Mr Lawlor reported a headache to prison staff in the hours before his death, he
did not disclose any symptoms that would have indicated a need for urgent intervention.
Mr Lawlor only had two keywork sessions at Elmley due to significant staff shortages. The
prison has worked to address this issue and planned to re-start weekly keywork sessions.
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 11 June 2018, Mr Jonathan Lawlor was sentenced to six years in prison for
wounding with intent to cause grievous bodily harm and sent to HMP Elmley. He
progressed through his sentence and was released on licence from HMP Ford on
30 September 2022.
2. On 22 June 2023, Mr Lawlor was remanded to HMP Elmley, charged with murder.
Shortly after he arrived, staff started suicide and self-harm prevention procedures,
known as ACCT, as Mr Lawlor said he had refused to eat while in police custody.
3. Over the following three months, prison staff monitored Mr Lawlor frequently. They
oversaw the completion of ACCT procedures and arranged one-to-one sessions
with a psychologist. Other than intelligence on one occasion that a greetings card
for Mr Lawlor had tested positive for psychoactive substances (PS), there was no
evidence to suggest he was using illicit drugs.
4. At 8.10am on 19 October, an officer unlocked Mr Lawlor’s cell. Mr Lawlor told him
that he did not want to go to work as he had a headache. Over the next three hours,
staff went to Mr Lawlor’s cell four times, and he continued to report having a
headache.
5. At around 11.30am, an officer unlocked Mr Lawlor’s cell door and saw him lying on
the floor, with his upper body under his bed. He called out to an officer nearby,
entered the cell and radioed a medical emergency code. Additional staff arrived as
an officer moved Mr Lawlor from under the bed and started cardiopulmonary
resuscitation (CPR).
6. At 11.36am, a nurse arrived and took the lead. At around 11.40am, a GP arrived
and issued two different medications. However, at 11.49am, the GP advised staff to
stop CPR as it was clear that Mr Lawlor was dead. At 11.51am, ambulance
paramedics arrived at the cell and formally pronounced that he had died. The post-
mortem concluded that Mr Lawlor died from cocaine toxicity.
Findings
7. Mr Lawlor obtained cocaine illicitly in prison. There was no evidence that staff had
seen him under the influence of illicit substances at Elmley and there was little
intelligence that he was using illicit substances.
8. Mr Lawlor reported a headache to staff four times on 19 October. Staff appropriately
asked Mr Lawlor if he would like to see a nurse. We are satisfied that he did not
disclose any symptoms that would have indicated a need for urgent intervention.
9. Mr Lawlor only had two keywork sessions during the four months he was at Elmley
due to significant staff shortages. The prison told us that they planned to review
resources monthly throughout 2024, with the aim of increasing keywork provision to
weekly for all prisoners.
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The Investigation Process
10. HMPPS notified us of Mr Lawlor’s death on 19 October 2023.
11. The investigator issued notices to staff and prisoners at HMP Elmley informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
12. The investigator visited Elmley on 25 October. He obtained copies of relevant
extracts from Mr Lawlor’s prison record and interviewed three prisoners.
13. The investigator interviewed six members of staff from Elmley between 25 and 30
January 2024.
14. NHS England commissioned a clinical reviewer to review Mr Lawlor’s clinical care
at the prison. The investigator and clinical reviewer jointly interviewed healthcare
staff.
15. We informed HM Coroner for Mid Kent and Medway of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
16. The Ombudsman’s family liaison officer contacted Mr Lawlor’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. They
wanted to know:
• how long staff took to respond when they found Mr Lawlor unresponsive;
• what happened to his head; and
• why they found out that he had died from other prisoners.
We have addressed these concerns in this report.
17. Mr Lawlor’s family received a copy of the initial report. They did not raise any further
issues, or comment on the factual accuracy of the report.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out two factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Elmley
19. HMP Elmley holds remanded and sentenced men in six houseblocks with a mixture
of single and double cells. Oxleas NHS Foundation Trust provides mental health
services and provides 24-hour primary healthcare services, with input from Minster
Medical Group.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Elmley was in February and March 2022.
Inspectors reported that security and good order were maintained through an
attention to physical and procedural matters, including effective security intelligence
and positive staff-prisoner relationships. They found that prisoners were safe from
exposure to substance misuse and effective drug supply reduction measures were
in place.
21. In February 2023, an independent review of progress took place. The report said
that Elmley faced substantial staff shortages which meant that keyworker sessions
had stopped, but leaders were focused on how to make improvements with the
resources they had and were delivering more than many prisons with a similar or
better staffing position.
Independent Monitoring Board
22. 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 31 October 2022, the IMB
reported that there had been a steady increase in keywork that had been driven by
management monitoring. They also noted that regular perimeter patrols inside the
prison walls found an increase of items that had been thrown over the prison wall.
Previous deaths at HMP Elmley
23. Mr Lawlor was the seventeenth prisoner to die at HMP Elmley since October 2020.
Of the previous deaths, twelve were from natural causes, three were self-inflicted
and one was drug related. Since Mr Lawlor’s death and up to the end of 2023, there
have been three further deaths at Elmley, one from natural causes, one self-inflicted
and one for which we are awaiting the cause of death.
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Key Events
24. On 11 June 2018, Mr Jonathan Lawlor was sentenced to six years in prison for
wounding with intent to cause grievous bodily harm. He was sent to HMP Elmley.
25. Mr Lawlor progressed well through his sentence and was released on licence from
HMP Ford on 30 September 2022.
2023
26. On 22 June 2023, Mr Lawlor was remanded to HMP Elmley, charged with murder.
27. Shortly after he arrived, staff started suicide and self-harm prevention procedures,
known as ACCT, as Mr Lawlor had refused to eat in police custody. They admitted
him to the inpatient department and monitored him under constant supervision.
28. On 28 July, an officer saw Mr Lawlor for a keywork session and noted that he had
started eating again and said he wanted to make himself physically and mentally
stronger. He added that Mr Lawlor had a supportive family with whom he had
regular contact.
29. On 8 August, a Supervising Officer (SO) chaired an ACCT case review and noted
that Mr Lawlor continued to have regular contact with his family. She added that Mr
Lawlor said he was happy to keep working with the psychology team and that they
would continue ACCT monitoring, with hourly observations in place. Later that day,
prison staff submitted an intelligence report, stating that a greetings card addressed
to Mr Lawlor had tested positive for psychoactive substances (PS).
30. On 11 August, an officer saw Mr Lawlor for a keywork session. He recorded that Mr
Lawlor was annoyed about the time staff were taking to process a letter he had
sent. The officer explained that the process could take a while and that he would
contact the relevant team for an update.
31. On 18 August, an SO chaired an ACCT case review which a nurse attended. She
noted that Mr Lawlor said that he felt like every time he opened up, he got set back
and that going to a standard houseblock while on an ACCT would make him
vulnerable. He asked attendees to stop ACCT procedures, but they instead reduced
his ACCT monitoring to one conversation during the day and five observations at
night. He moved to Houseblock 4 (a standard wing) later that day.
32. On 23 August, a psychological therapist noted that she checked on Mr Lawlor
briefly as she was not able to offer him a full session. She recorded that he seemed
well and presented as positive.
33. On 29 August, an SO chaired an ACCT case review and noted that Mr Lawlor
seemed positive and engaged well. He said that he had settled on Houseblock 4
and was hoping to get a job in the prison gym when a space became available. The
SO added that attendees agreed to stop ACCT monitoring.
34. On 21 September, the psychological therapist saw Mr Lawlor for a psychology
session. He told her that he had recently had some intrusive thoughts and had had
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a panic attack. He said that he had felt better and more settled since moving to a
different spur on the houseblock.
35. On 5 October, the psychological therapist visited Mr Lawlor for a psychology
session, but he told her that he did not want to go ahead with it as he felt unwell.
There is no evidence that he presented as under the influence of illicit substances.
36. On 10 October, prison staff submitted an intelligence report stating that they had
detected what was likely a mobile phone signal coming from Mr Lawlor’s cell.
Security staff reviewed the intelligence and noted that it was possible that Mr Lawlor
was engaging in substance misuse. However, they decided that a further
assessment was not needed. There is no evidence to explain the reason for this
decision.
37. On 12 October, a Shannon Trust Facilitator recorded that Mr Lawlor had completed
his Shannon Trust mentor training and presented as enthusiastic throughout. (The
Shannon Trust trains prisoners to help other prisoners who have difficulty reading.)
38. Between 13 and 17 October, Mr Lawlor made 42 phone calls from the prison phone
system. (Calls from the prison phone system are recorded but staff do not normally
listen to them unless there is intelligence to suggest that is necessary.) The majority
of calls were to his partner. The investigator listened to a number of the calls. Mr
Lawlor did not mention using illicit substances.
Events of 19 October
39. At 8.10am on 19 October, an officer unlocked Mr Lawlor’s cell. At interview, he said
that Mr Lawlor was out of bed but told him that he did not want to go to work as he
had a headache.
40. At around 9.00am, the officer unlocked Mr Lawlor’s cell again so that he could
attend work, but Mr Lawlor continued to report a headache and asked to stay in his
cell. The officer told us that Mr Lawlor was lying on his bed. A short while later, the
psychological therapist arrived on the wing to see him for a psychology session, but
he chose not to engage.
41. At around 10.20am, a prisoner asked to see Mr Lawlor to give him his Shannon
Trust certificate and T-shirt. CCTV footage shows that an officer unlocked Mr
Lawlor’s cell and stood in the doorway until the prisoner had done so.
42. At around 10.43am, an officer arrived on the houseblock to collect Mr Lawlor for a
court-ordered psychiatric assessment by video-link. An officer went to Mr Lawlor’s
cell to get him, but he declined and said that he did not feel well. The officer, who
told us that she knew Mr Lawlor from a previous sentence, went to his cell to
explain the importance of the psychiatric assessment but he asked her to re-
arrange the appointment as he had a headache. At interview, the officer told us that
she asked Mr Lawlor if he wanted to see the healthcare team, but he said, “No, I
just want to sleep it off.” She added that he looked pale, but spoke clearly and did
not present any differently to her previous contacts with him.
43. At around 11.30am, an officer unlocked Mr Lawlor’s cell door so that he could
collect his lunch. He saw him lying on the floor, with his upper body under his bed.
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He shouted out to him but failed to get a response, so he called out to another
officer who was unlocking the cells on the other side of the landing.
44. The officer went into Mr Lawlor’s cell and at 11.33am, he radioed a medical
emergency code blue (which indicates that a prisoner is unconscious or has
breathing difficulties). He and the other officer moved Mr Lawlor from under the bed,
and noticed at that point that he was not breathing and had a cut on his head. One
of the officers asked two prisoners who were standing by the cell door to press the
general alarm due to the amount of noise on the radio network. (The control room
log shows that staff called an ambulance at 11.34am, so there was no delay despite
the radio network noise.)
45. At 11.35am, an SO arrived at the cell with several other officers. As they went into
the cell, an officer had just moved Mr Lawlor onto his back. The SO asked him to
start cardiopulmonary resuscitation (CPR) and cleared the cell of furniture. She took
over CPR. In the meantime, a physical education instructor arrived and asked staff
to collect a defibrillator.
46. At 11.36am, a nurse arrived and staff moved Mr Lawlor out of the cell for easy
access. She established an airway and applied a defibrillator, but it did not detect a
shockable rhythm. At 11.40am, a GP arrived. Over the next eight minutes, she gave
Mr Lawlor three doses of adrenaline and two doses of naloxone (used to reverse
the effects of opioids). At 11.49am, the GP advised staff to stop CPR as it was clear
that Mr Lawlor was dead. At 11.51am, ambulance paramedics arrived and formally
pronounced that Mr Lawlor had died.
Contact with Mr Lawlor’s family
47. At 12.00pm, the prison appointed an SO as the family liaison officer. She checked
Mr Lawlor’s prison record and established that he had named his partner and his
sister as his next of kin. Because of the nature of the offence Mr Lawlor was
charged with, the family liaison officer requested a police risk assessment before
visiting his partner’s address, but in the meantime, the prison received several calls
from Mr Lawlor’s family to say they had heard that he had died (we do not know
whether they were alerted by another prisoner or by someone outside the prison).
The family liaison officer consulted with two prison managers, who decided that she
should notify Mr Lawlor’s partner by phone.
48. At 2.55pm, the family liaison officer tried to phone Mr Lawlor’s partner twice but was
unable to get through. At 2.58pm, she phoned Mr Lawlor’s sister and broke the
news of Mr Lawlor’s death. (His partner was with his sister and found out at the
same time.) At 3.53pm, after giving Mr Lawlor’s sister some time to process the
information, the family liaison officer called her back to offer support and explain the
next steps.
49. The family liaison officer provided ongoing support to Mr Lawlor’s partner and
mother. His funeral took place on 1 December and the prison contributed towards
the cost, in line with national policy.
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Support for prisoners and staff
50. After Mr Lawlor’s death, a prison manager 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.
51. The prison posted notices informing other prisoners of Mr Lawlor’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 Lawlor’s death.
Post-mortem report
52. The post-mortem report found that Mr Lawlor died of acute multi-organ failure
caused by cocaine toxicity. He also had pulmonary congestion and oedema (a
build-up of fluid in the body which causes swelling) which did not cause but
contributed to his death. Mr Lawlor had an injury on the right side of his head with
some bleeding. This did not cause his death. The post-mortem report states that the
most probable cause of his injury was a fall in which he hit his head on one of the
bolts that connected the metal bed frame to the cell floor.
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Findings
Illicit substances
53. The post-mortem examination confirmed that Mr Lawlor died of multi-organ failure
caused by cocaine toxicity. Cocaine is a Class A banned substance which Mr
Lawlor obtained illicitly in prison.
54. Although staff found a greetings card addressed to Mr Lawlor that tested positive for
PS two months before he died and mobile phone scanning detected a signal
coming from his cell just over a week before his death, there was no significant
intelligence or evidence to suggest that he was using illicit substances at Elmley.
There was nothing in the wing observation book in the seven days before Mr
Lawlor’s death to suggest he was using drugs. All the wing staff we interviewed said
that they had never seen him under the influence during his time at Elmley. In
addition to this, the three prisoners interviewed said that Mr Lawlor presented as his
usual self in the days leading to his death.
55. HMPPS’s Drug Strategy, published in April 2019, highlights the importance of
building a picture of the security risks to enable prisons to better to target their
resources to tackle them. At the time of Mr Lawlor’s death, Elmley had a drug
strategy dated 2022-2023. The strategy acknowledged that illicit drugs presented a
threat to the security and safety of staff and prisoners. It set out measures to target
illicit drug trafficking, including the use of intelligence, scanning prisoners’ mail, the
use of drug detection dogs and a body scanner.
56. At interview, the Head of Drug Strategy told us that when staff see a prisoner under
the influence (UTI), they complete a UTI form and healthcare visit the prisoner for a
review. He said that while the prison occasionally found cocaine coming in, it was
not particularly commonplace. He said that the security team had conducted a
review since Mr Lawlor’s death which had not identified any significant intelligence
linked to the ingress of cocaine. He also said that the drug strategy was currently
being reviewed and updated and was due to be published in May 2024. We are
satisfied that these actions are appropriate.
57. While we are concerned that Mr Lawlor was able to obtain cocaine, an illicit Class A
drug, at Elmley, the prison has a comprehensive drug strategy in place that they
were in the process of reviewing and updating. Before Mr Lawlor’s death, there had
not been a drug-related death at Elmley in over two years. The death was related to
morphine, which was prescribed, and there was no evidence of illicit substance use.
Considering this and the fact that the drug strategy is being updated, we are
satisfied that Elmley is making credible progress to reduce the supply and demand
for illicit substances. We therefore do not make a recommendation.
Events of 19 October
58. Mr Lawlor reported a headache to prison staff four times between 8.00am and
11.00am on 19 October but they did not request a healthcare review. At interview,
an officer told the investigator that staff do not routinely contact the healthcare team
if a prisoner reports a headache and Mr Lawlor did not at any point ask him to do
so. Another officer told us that although Mr Lawlor looked pale, she did not think it
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was unusual for him. There is no evidence that prison staff suspected that he was
under the influence of drugs.
59. It is appropriate that staff asked Mr Lawlor if he wanted to see the healthcare team
and we are satisfied that he did not disclose any symptoms to warrant urgent
healthcare intervention such as a seizure or difficulty speaking.
Keywork
60. Mr Lawlor only had two keywork sessions during the four months he was at Elmley.
The Head of Residence and Services told the investigator that at the time of Mr
Lawlor’s death, staff shortages significantly affected keywork delivery and the
prison’s priority was to deliver one monthly session to each prisoner during regime
hours. However, he said that this was not always possible given how busy and
understaffed the prison was at the time.
61. The Head of Residence and Services told us that the prison was currently reviewing
the keywork strategy for 2023-24, which states that the prison plans to monitor
keywork monthly in 2024 and increase provision as the staffing picture improves.
He said that the prison’s aim was to revert to the original Offender Management in
Custody (OMiC) model which requires all officers to hold a caseload of up to six
prisoners and to see them for weekly keywork sessions. We are satisfied that this
action was appropriate. We do not make a recommendation.
Inquest
62. At the inquest, which took place on 18 November 2024, the Coroner concluded that
Mr Lawlor died as a result of an accident.
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