Keith Morgan

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Independent investigation into
the death of Mr Keith Morgan,
a prisoner at HMP Cardiff,
on 10 December 2020
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, 2024
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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 Keith Morgan died from COVID-19 pneumonitis in hospital on 10 December
2020, while a prisoner at HMP Cardiff. He was 63 years old. He also had underlying
hypertension, diabetes and a duodenal ulcer. I offer my condolences to Mr
Morgan’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Morgan received at Cardiff
was equivalent to that he could have expected to receive in the community. He
made no recommendations.
5. We do not know when or where Mr Morgan contracted COVID-19, as he had
moved between prisons and attended court during the 14-day incubation period.
The decision that he should physically attend court, rather than use video-link, was
made by the court and therefore does not fall within the remit of the PPO. However,
we are satisfied that he was managed in line with national and local Prison Service
guidance on COVID-19 risk management and that he received timely and
responsive care when he contracted the virus.
6. We found no non-clinical issues of concern and make no recommendations.
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The Investigation Process
7. Health Inspectorate Wales commissioned an independent clinical reviewer to
review Mr Morgan’s clinical care at HMP Cardiff.
8. The PPO investigator reviewed Mr Morgan’s personal records, as well as Prison
Service and local policy documents. She investigated non-clinical issues, including
aspects of the prison’s response to COVID-19 and shielding prisoners; Mr Morgan’s
location; the security arrangements for his journey and admission to hospital; liaison
with his family; and whether early release was considered. She also considered
information provided by a prisoner.
9. The PPO family liaison officer wrote to a family representative, acting on behalf of
Mr Morgan’s wife and other family members, to explain the investigation. They had
a number of questions about Mr Morgan’s care. Those within the PPO’s remit and
related to his cause of death have either been addressed in correspondence, in this
report, or in the clinical review. Key questions and concerns were:
• The cancellation of medical appointments and difficulties booking an
appointment at Berwyn.
• What was the outcome of the healthcare assessment before Mr Morgan left
Berwyn?
• Was it appropriate for Mr Morgan to attend a court hearing, given his clinical
status?
• Was Mr Morgan part of a reverse cohort at Cardiff?
• Did Mr Morgan move cells at Cardiff and, if so, was this appropriate?
10. We shared our initial report with HM Prison and Probation Service (HMPPS). They
found a factual inaccuracy (also reported by Mr Morgan’s family representative)
which has been corrected.
11. We sent a copy of our report to Mr Morgan’s family representative. He made
several observations. An inaccuracy was corrected in the report and we responded
to his comments and questions in correspondence.
Previous deaths at HMP Cardiff
12. Mr Morgan was the ninth prisoner to die at Cardiff since December 2018. Of the
previous deaths, five were from natural causes (none with COVID-19) and three
were self-inflicted. There are no similarities between our findings in this
investigation and those of the previous deaths.
13. There have been no further COVID-19 related deaths at Cardiff since Mr Morgan’s.
COVID-19 (coronavirus)
14. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
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breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
15. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. People at high risk
(clinically extremely vulnerable) include those who have had an organ transplant;
have severe lung or kidney disease; or are having certain types of cancer or other
treatment which significantly increases the risk of infection. Examples of those at
moderate risk (clinically vulnerable) are people over 70; people under 70 with an
underlying health condition, such as diabetes, or chronic respiratory, heart, liver or
kidney disease; those with a weakened immune system; or who are very
overweight. (These lists are not exhaustive.)
16. In response to the initial pandemic outbreak, HM Prison and Probation Service
(HMPPS) introduced several measures to try and contain the outbreak - to be
implemented at local level, depending on the needs of individual prisons. (An
outbreak is defined as two or more prisoners, or staff, who are clinically suspected,
or have tested positive for COVID-19 within 14 days.) A key strategy is
‘compartmentalisation’ to cohort and protect prisoners at high and moderate risk;
isolate those who are symptomatic; and separate newly received prisoners from the
main population. Other measures include social distancing and the use of personal
protective equipment (PPE).
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Key Events
17. Mr Keith Morgan was convicted of fraud and remanded to HMP Cardiff on 24
September 2018. He was later sentenced to eight years and eight months
imprisonment for this and another offence.
18. Mr Morgan had suffered a major stroke three years before his imprisonment and
had several other medical conditions, including diabetes, asthma, arthritis, shadow
on the brain, poor eyesight (later diagnosed as macular degeneration) and mental
health problems.
HMP Berwyn
19. On 20 November, Mr Morgan transferred to HMP Berwyn. He lived on Ceiriog A
Lowers, also known as Snowdon, a unit for older men. When the COVID-19
pandemic began in March 2020, the unit was designated as the prison’s dedicated
shielding unit for those at high risk if they contracted the virus. As a clinically
vulnerable man, Mr Morgan continued to live on Snowdon.
20. In May 2020, Mr Morgan applied for release under the COVID-19 compassionate
release on temporary licence (ROTL) scheme. Although he met some of the criteria,
the ROTL board did not approve his application. They were concerned that the
media interest in his case remained high and that early release would undermine
public confidence.
Temporary transfer to HMP Cardiff
21. On 16 November, Mr Morgan attended Cardiff Crown Court for a hearing in
connection with Proceeds of Crime Act proceedings. A nurse at Berwyn had
assessed him and confirmed that he was fit for transfer.
22. Later that day, Mr Morgan was transferred to HMP Cardiff. At his reception health
screen, it was noted that Mr Morgan was expected to return to Berwyn when the
court hearing was finished. Mr Morgan was allocated to a single cell for medical
reasons and placed on the reverse cohort unit. A secondary health screen took
place on 18 November.
23. Mr Morgan appeared in court on 16, 17, 18 and 19 November.
24. On 25 November, Mr Morgan had a headache, dry cough and fatigue. A nurse
examined him, arranged for a swab to be taken for testing and placed him in
isolation. Mr Morgan was confirmed as COVID-19 positive the next day.
25. As he had tested positive, he was required to isolate for 10 days before he returned
to Berwyn.
26. Mr Morgan’s symptoms worsened. On 27 November, he was moved to the prison’s
healthcare inpatient unit, where he was monitored hourly.
27. On 30 November, a prison GP examined Mr Morgan, as he reported difficulty
breathing. The GP suspected a lower respiratory tract infection and sent Mr Morgan
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to hospital for a chest X-ray and further assessment. The hospital found no
evidence of a bacterial infection and he returned to the prison that evening.
28. Late on 3 December, Mr Morgan was short of breath, with low oxygen levels and a
high temperature. A nurse consulted the out of hours GP service, who advised that
he should be sent to hospital urgently. No ambulances were available, so Mr
Morgan was taken in prison transport just after midnight. He was escorted by two
prison officers in full PPE, using an escort chain (which was removed later that
morning). Prison healthcare staff contacted the hospital daily for updates.
29. Mr Morgan was moved from the accident and emergency department to the
COVID-19 ward early on the evening of 4 December. The prison then appointed a
family liaison officer, who immediately informed Mr Morgan’s wife that he was in
hospital and arranged for her to receive information directly from hospital staff.
30. When Mr Morgan’s condition worsened on 9 December, he was moved to the
intensive care unit and placed on a ventilator. Mr Morgan’s wife told the FLO that if
Mr Morgan died, she did not want anyone from the prison to notify her.
31. Mr Morgan died at 7.10am on 10 December. The family liaison officer complied with
the family’s wishes but spoke to Mr Morgan’s daughter the following day. A few
days later, she met family members at the prison and kept in touch with them to
provide information and support. Mr Morgan’s funeral was held on 7 January 2021.
In line with national policy, the prison contributed to the funeral expenses.
32. A prison manager and a representative of the staff care team debriefed the escort
officers and offered support. Notices were issued to staff and prisoners, informing
them of Mr Morgan’s death and reminding them of the support available.
Cause of death
33. There was no post-mortem examination as the Coroner accepted the hospital’s
certification that Mr Morgan’s death was due to COVID-19 pneumonitis
(inflammation of lung tissue). He also had a duodenal ulcer, hypertension and
diabetes mellitus, which did not cause, but contributed to his death.
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Findings
Clinical Findings
34. The clinical reviewer concluded that Mr Morgan’s clinical care at Cardiff was
equivalent to that he could have expected to receive in the community. He made no
recommendations.
35. Mr Morgan’s family were concerned about cancelled medical appointments. The
medical records show that Mr Morgan occasionally cancelled GP appointments
when they conflicted with legal appointments, but they were rebooked. Several
hospital appointments were cancelled, mostly by the hospital and sometimes by Mr
Morgan. Three hospital appointments were cancelled by the prison: one due to the
taxi not arriving; one for security reasons as Mr Morgan was aware of the
appointment in advance; and one due to a lack of escort officers. In April 2020, Mr
Morgan asked for eye appointments at hospital to be postponed until the pandemic
was over.
Management of Mr Morgan’s risk of infection from COVID-19
36. Guidance issued by the Welsh Government advised people at risk to shield
between March and August 2020. At Berwyn, Mr Morgan shielded on a dedicated
unit. When he transferred to Cardiff, he was managed in line with the national policy
which separates new arrivals and those attending court from other residents.
37. Before travelling to court each day, healthcare staff took Mr Morgan’s temperature,
explained the COVID-19 protocol and guidelines and advised him to speak to staff if
he had any symptoms or had contact with anyone suspected of or confirmed to
have COVID-19. Escort staff were provided with PPE. After the four-day hearing, Mr
Morgan remained at Cardiff to complete the required 14-day isolation period.
38. When Mr Morgan began to display symptoms of COVID-19, he was immediately
placed in protective isolation and tested. Deterioration in his condition was quickly
addressed by admission to the healthcare unit for closer monitoring and later to
hospital as an urgent admission.
39. Mr Morgan’s wife was concerned that Mr Morgan had been forced to attend court
and had moved cells. She believed that he would not have contracted the virus if he
had remained at Berwyn.
40. The question of why Mr Morgan was required to attend court in person and not via a
video-link is a matter for the court and is therefore outside the PPO’s remit.
41. There was no national requirement to shield between August and December 2020.
However, when he was not at court, Mr Morgan was isolated at Cardiff as a new
prisoner and he moved cells to the inpatient unit when he became unwell.
42. We do not know how, when, or where Mr Morgan contracted the infection. The
symptoms of COVID-19 are thought to develop between 5 to 14 days after a person
is infected with the virus. Therefore, Mr Morgan could have been exposed to it at
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Berwyn, Cardiff, during his attendance at court, or while travelling to and from
Cardiff.
43. We are satisfied that Mr Morgan was managed appropriately and in line with
national requirements. Staff were responsive to his reported symptoms and the
subsequent deterioration in his health and he was referred to secondary care when
he needed advanced treatment.
Sue McAllister CB
Prisons and Probation Ombudsman July 2021
Inquest
The inquest, held on 18 April 2024, concluded that Mr Morgan died from natural causes.
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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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