Joseph Jukes

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Joseph Jukes,
a prisoner at HMP Holme
House, on 22 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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Joseph Jukes died of metastatic lung cancer (cancer which had spread) on 22
November 2022 while a prisoner at HMP Holme House. He was 85 years old. We
offer our condolences to Mr Jukes’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Jukes received at Holme
House was of a good standard and equivalent to that which he could have expected
to receive in the community. She found that the healthcare team demonstrated
compassion towards Mr Jukes at all times, especially when his health deteriorated.
The clinical reviewer made no recommendations.
5. We found no non-clinical issues of concern.
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The Investigation Process
6. NHS England commissioned an independent clinical reviewer to review Mr Jukes’
clinical care at Holme House.
7. The PPO investigator investigated the non-clinical issues relating to Mr Jukes’ care,
including Mr Jukes’ location, the security arrangements for his hospital escorts,
liaison with his family and whether compassionate release was considered.
8. The PPO family liaison officer wrote to Mr Jukes’ next of kin, his wife and his
daughter, to explain the investigation and to ask if they had any matters they
wanted us to consider. Neither responded to our letters.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Holme House
10. Mr Jukes was the twelfth prisoner to die at Holme House since November 2020. Of
the previous deaths, seven were from natural causes, one was from other non-
natural causes and three were self-inflicted. There are no similarities between our
findings in the investigation into Mr Jukes’ death and our investigation findings for
the previous deaths.
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Key Events
11. On 7 December 2016, Mr Joseph Jukes was sentenced to 15 years and six months
in prison for historic sex offences. He was sent to HMP Holme House.
12. Before sentencing, Mr Jukes had lived in a nursing home, where he needed 24-
hour support and care. Mr Jukes had had two heart attacks, he had hypertension
(high blood pressure), he used a wheelchair, his mobility was poor after having had
both hips replaced, and he had osteoarthritis in his knees, elbows and shoulders.
Mr Jukes lived in the inpatient unit.
13. From 8 December 2016, Mr Jukes had access to 24-hour healthcare. Healthcare
and secondary care providers regularly reviewed him, and social care staff
supported him with daily tasks.
2022
14. On 11 August 2022, a prison GP reviewed Mr Jukes. She noted that he had
reported pain and mild tenderness in his left lower ribs. Blood and urine tests were
carried out. Three of four blood test results were abnormal.
15. A prison GP reviewed Mr Jukes again on 15 August. He continued to complain of
abdominal pain. The GP thought that Mr Jukes may have diverticulitis (a digestive
condition affecting the large intestine). At further reviews on 18 and 25 August, Mr
Jukes continued to have left-sided pain in his abdomen and rib areas.
16. On 1 September, Mr Jukes told a prison GP that the pain was radiating from his left
armpit to his left hip. The GP referred Mr Jukes for a CT scan of his chest,
abdomen and pelvis, and for further blood tests.
17. Mr Jukes had a CT scan on 9 September, following which he was diagnosed with
primary cancer in the right lower lobe of the lung. The cancer had also spread
through the lung and to the bones and had likely spread to a kidney. Mr Jukes was
referred to the lung cancer pathway for palliative treatment.
18. On 13 September, a prison GP discussed Mr Jukes’ diagnosis with the Urgent and
Emergency Care Manager.
19. The following day, a prison GP met Mr Jukes to discuss the CT scan results. Mr
Jukes’ daughter was unable to attend but the GP considered that Mr Jukes fully
understood the diagnosis.
20. Between 14 and 19 September, the healthcare team continued to support Mr Jukes.
It was reported that he was free of pain. He experienced periods of confusion and
distress, but he was easily settled with the healthcare team’s reassurance.
21. On 20 September, with a nurse’s support, Mr Jukes had a telephone consultation
with a hospital consultant who advised Mr Jukes that he had significant cancer
disease. Mr Jukes declined further investigation to establish if the cancer had
spread to the brain. The consultant advised Mr Jukes that he would not benefit
from aggressive treatments and the side effects from them would likely shorten his
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life. The consultant advised that Mr Jukes would be best supported with palliative
care and symptom management.
22. The nurse asked the consultant if he would document Mr Jukes’ limited life
expectancy so that an application for early release on compassionate grounds
(ERCG) could be progressed. The consultant agreed to discuss this at a
multidisciplinary team (MDT) meeting and provide information about Mr Jukes’
disease progression and his prognosis.
23. The nurse added a palliative care support plan to Mr Jukes’ medical records on 20
September and spoke to Mr Jukes to plan his care. She told Mr Jukes there was a
high probability he had months to live due to the extent of his disease. When she
raised the possibility of ERCG, Mr Jukes said that he wanted to die at Holme
House.
24. A prison GP reviewed Mr Jukes on 22 September. The healthcare team reported
that Mr Jukes had been emotional and upset at times. Mr Jukes told the GP that if
he was granted ERCG, he would consider a nursing home, but not a hospice. Mr
Jukes continued to decline tests to see if the cancer had spread to his brain.
25. Mr Jukes’ diagnosis was discussed at an MDT meeting on 23 September. The
nurse noted that Mr Jukes’ health had notably deteriorated. The MDT ensured care
plans were in place and updated. Mr Jukes was referred to the Macmillan team for
support.
26. On 29 September, a Macmillan nurse saw Mr Jukes, whose pain was controlled.
No interventions were therefore needed.
27. At an MDT meeting on 14 October, it was noted that Mr Jukes’ preferred place to
die was a nursing home which required an application for ERCG.
28. A prison GP saw Mr Jukes on 27 October and noted a steady decline in Mr Jukes’
health. Mr Jukes was not in pain but had some crackles on both sides of his lungs.
Mr Jukes was prescribed oral antibiotics for a lower respiratory tract infection.
29. On 28 October, an MDT meeting noted that the healthcare team continued to
support, monitor and supervise him. It was documented that a discharge address
had not been secured to complete the ERCG paperwork.
30. On 7 November, a Macmillan nurse spoke to the healthcare team at Holme House
who told her that Mr Jukes had started being prescribed morphine sulphate tablets
because of his steadily declining health.
31. On 15 November, a prison GP noted that Mr Jukes was increasingly frail and
sleepy. A syringe driver was prescribed and started on 16 November, when Mr
Jukes was unable to swallow his oral medication.
32. Between 16 and 22 November, the healthcare team supported Mr Jukes with all his
care and health needs. Welfare checks were done frequently. Mr Jukes always
appeared to be comfortable. He was reported to be steadily deteriorating and was
sleeping for longer periods, with reduced food and fluid intake.
33. At 9.03am on 22 November, a prison GP confirmed Mr Jukes’ death.
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Cause of death
34. A hospital doctor established that Mr Jukes had died from metastatic lung cancer.
The coroner accepted the cause of death, and no post-mortem examination was
carried out.
Kimberley Bingham
Acting Ombudsman April 2023
Record of Inquest
35. The inquest into Mr Jukes death was held on 22 February 2023 and a verdict of
natural causes was recorded. The Coroner concluded that Mr Jukes death was due
to metastatic lung cancer. He also had cerebrovascular disease and hypertension
but these did not contribute to his death.
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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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