Kenneth Light

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Kenneth Light,
a prisoner at HMP Stafford, on
20 April 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, 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. 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 Kenneth Light died in hospital on 20 April 2023 of pneumonia, caused by lung
cancer, while a prisoner at HMP Stafford. He was 79 years old. We offer our
condolences to Mr Light’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Light received at Stafford
was of a good standard and equivalent to what he could have expected to receive
in the community. She made recommendations about clinical observations,
assessments, and training, which we do not repeat here, but which the Head of
Healthcare will wish to address.
5. Stafford did not provide us with the escort risk assessment for the 11 April 2023. As
a result, we were unable to assess whether the restraints used on Mr Light for his
final admission to hospital were appropriate.
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The Investigation Process
6. NHS England commissioned an independent clinical reviewer to review Mr Kenneth
Light’s clinical care at Stafford.
7. The PPO investigator investigated the non-clinical issues relating to Mr Light’s care.
8. The PPO family liaison officer wrote to Mr Light’s wife to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond
to our letter.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Stafford
10. Mr Light was the twenty-sixth prisoner to die at Stafford since April 2020. Of the
previous deaths, 24 were from natural causes and two were self-inflicted. There are
no similarities between our findings in the investigation into Mr Light’s death and our
investigation findings for the previous deaths.
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Key Events
11. On 23 September 2019, Mr Kenneth Light was sentenced to eight years and eight
months in prison for indecent assault on a child. He was transferred to HMP
Birmingham. A year later, Mr Light received an additional sentence of nine years in
prison for rape of a female aged 16 or over.
12. Mr Light had several pre-existing medical conditions, including chronic obstructive
pulmonary disease (COPD – a collection of lung diseases that cause respiratory
symptoms), ischemic heart disease and type 2 diabetes.
13. On 26 January 2021, Mr Light was transferred to HMP Stafford.
14. On his arrival, a nurse completed Mr Light’s initial health screen and identified his
long-term medical conditions. The next day, a nurse completed Mr Light’s
secondary health screen and created care plans for his long-term medical
conditions. He received appropriate medications for his conditions and was
provided with a rescue pack to help manage his COPD. (A rescue pack is an
emergency medical pack for COPD patients at risk of an exacerbation of the
condition.)
15. On 16 August 2022, Mr Light reported to a nurse that he was coughing up
discoloured phlegm and had lost some weight. The nurse completed a chest
examination, arranged for him to have a chest X-ray, and created a care plan. Mr
Light said that he was reluctant to use his rescue pack as he felt it was a different
kind of cough. Healthcare staff completed daily observations on Mr Light for the
next ten days.
16. Mr Light had an X-ray on 5 September. A couple of days later, a nurse reviewed the
X-ray results and recorded that an ill-defined mass had been identified in Mr Light’s
right lung. The nurse arranged for Mr Light to have an urgent CT scan. The CT scan
results indicated that Mr Light did have a mass on his right lung. On 27 October, Mr
Light had a phone call with a respiratory consultant, who told him that it was highly
likely he had lung cancer but would need a PET scan to confirm diagnosis. Mr Light
had a PET scan on 23 November.
17. On 8 December, a senior hospital registrar saw Mr Light and informed him that
although the results of the PET scan strongly suggested lung cancer, he would like
Mr Light to have a CT scan of his head and a lung biopsy to confirm the diagnosis
and check for possible secondary disease. On 13 December, Mr Light had a CT
scan and the results did not show any signs of brain cancer. However, the biopsy
results confirmed that Mr Light had cancer.
18. In light of his diagnosis, the healthcare team at the prison held weekly multi-
disciplinary team (MDT) meetings to discuss Mr Light’s care needs. On 6 January,
the MDT noted that Mr Light was struggling with increased pain and moved him to
the prison’s specialist care unit for symptom management and support. Healthcare
staff created a cancer care plan and reviewed him daily.
19. On 19 January 2023, an oncology specialist discussed treatment options with Mr
Light and he signed a consent form to start radiotherapy treatment. He received five
radiotherapy treatments between 1 and 7 February.
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20. On 23 January, an Advanced Nurse Practitioner from a local hospice visited Mr
Light, along with a nurse from the prison, and asked him if he wanted to be
resuscitated in the event his heart or breathing stopped. Mr Light said that he did
not and signed an order to that effect.
21. On 2 March, a consultant oncologist informed Mr Light that he would not receive
further treatment and indicated that his future treatment plan would now involve
symptom management and supportive care.
22. On 5 April, a nurse recorded that Mr Light had fallen and that he had hurt his right
hip and elbow. Healthcare staff assessed him and monitored him during the night.
Healthcare staff said that Mr Light was walking around his cell and had normal
range of movement in all limbs.
23. The next day, a nurse asked a GP at the prison to review Mr Light after his fall the
previous day. The GP noted that Mr Light had restricted movement in his right leg
and was in pain when he rotated it. He discussed a possible fractured hip with Mr
Light, but Mr Light declined to go to hospital because he had a visit already
arranged in the afternoon. The GP recorded that Mr Light had the mental capacity
to make this decision and, if he deteriorated, he needed to be referred to hospital
urgently. Healthcare staff did not ask him to sign a disclaimer form for refusing to
attend A&E as they should have done.
24. On 10 April, a nurse recorded that Mr Light had fallen in his cell while going to the
toilet. She did not record his NEWS2 score. (National Early Warning Score is a tool
which improves the detection and response to clinical deterioration in adult
patients.) Mr Light injured his left hip and was in considerable pain. Later that day, a
Healthcare Assistant recorded Mr Light’s NEWS2 score as six. He did not escalate
this to a senior clinician as he should have done. However, at 9.47pm, a nurse
recorded his NEWS2 score as one. Healthcare staff observed Mr Light throughout
the night and no concerns were raised.
25. On 11 April, a GP at the prison saw Mr Light after his fall the previous day. Mr Light
had pain in his hip and his left foot was rotated outwards. The GP advised him that
he needed to go to hospital to assess whether he had fractured his hip and Mr Light
agreed. Mr Light was sent to hospital and was escorted by two officers. We do not
know if Mr Light was restrained.
26. Later that day, the hospital informed healthcare staff at the prison that Mr Light had
fractured his left hip and needed surgery.
27. On 18 April, Mr Light was placed on end-of-life care and, on 20 April, it was
confirmed that Mr Light had died.
Cause of death
28. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Light’s cause of
death as pneumonia caused by advanced squamous cell carcinoma of the lungs
(lung cancer). He also had diabetes, ischaemic heart disease, neck of femur fragility
fracture due to cancer and osteoporosis which did not cause but contributed to his
death.
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Governor to note
Retention of evidence
29. PSI 58/2010 on the Prisons and Probation Ombudsman requires prisons to ensure
that all evidence relevant to a death in custody is retained and that evidence is
made available to the PPO.
30. Stafford did not provide us with the escort risk assessment for the 11 April 2023 and
told us that they could not locate it. The bedwatch log paperwork indicated that no
restraints were used on Mr Light for the duration of the bedwatch, but we are unable
to verify this and are not able to assess whether the restraints used during the
escort were appropriate for Mr Light. We bring this matter to the Governor’s
attention.
Adrian Usher
Prisons and Probation Ombudsman August 2023
At the inquest held on 29 August 2024, the coroner concluded that Mr Light died of 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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