Laurence Hughes

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Laurence
Hughes, a prisoner at
HMP Littlehey, on 1 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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
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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 HM 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 Laurence Hughes died in hospital on 1 April 2023 of bronchopneumonia while a
prisoner at HMP Littlehey. He was 81 years old. We offer our condolences to Mr
Hughes’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Hughes received at HMP
Littlehey was equivalent to what he could have expected to receive in the
community. The clinical reviewer made no recommendations.
5. We found no non-clinical issues of concern.
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The Investigation Process
6. On 1 April 2023, HMPPS informed us of Mr Hughes’ death.
7. NHS England commissioned an independent clinical reviewer to review Mr Hughes’
clinical care at Littlehey.
8. The PPO investigator investigated the non-clinical issues relating to Mr Hughes’
care.
9. The PPO family liaison officer wrote to Mr Hughes’ daughter to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked about Mr Hughes’ clinical care in prison, and why she was not informed that
Mr Hughes was going to hospital within 72 hours. We have answered her questions
in the clinical review and our report. Mr Hughes’ daughter also asked about the care
Mr Hughes received in hospital and we have responded in separate
correspondence.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Hughes family received a copy of the initial report. They did not make any
comments.
Previous deaths at HMP Littlehey
12. Mr Hughes was the forty fifth prisoner to die at Littlehey since April 2020. Of the
previous deaths, 41 were from natural causes, two were self-inflicted and one was
drug related. There are no similarities between our findings in the investigation into
Mr Hughes’ death and our investigation findings for the previous deaths.
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Key Events
13. On 16 March 2022, Mr Laurence Hughes was remanded to HMP Elmley for sexual
offences. He was 80 years old. On the 10 June, he was sentenced to eight years in
prison and remained at Elmley.
14. Mr Hughes had some medical conditions when he arrived in prison. He had an ulcer
on his left foot which needed dressing weekly, type 2 diabetes, but was not taking
any medication, a damaged vertebrae and gout.
15. On 10 August, Mr Hughes was transferred to HMP Littlehey.
16. Following his arrival at Littlehey, a nurse completed Mr Hughes’ initial health
screen. She recorded that he had poor mobility and noted that this needed to be
followed up at his secondary health screen the next day.
17. On 11 August, a nurse completed Mr Hughes’ secondary screen. Mr Hughes said
that he was diabetic but was in remission and was no longer taking his medication,
metformin (used to treat type two diabetes). She recorded Mr Hughes as being
elderly, frail and using a walking stick. Mr Hughes denied any previous falls and
could walk well with his stick.
18. In September, Mr Hughes developed ulcers on his toes. Healthcare staff dressed
and treated him, but as the ulcers healed, he developed an ulcer on his left ankle
and had pressure damage to his heels and toes.
19. In November, Mr Hughes was diagnosed with neuropathy (nerve damage which
can cause loss of sensation, pain and weakness) and was prescribed a
buprenorphine patch (strong pain relief) to help manage his pain. (He did not use
the patches consistently.)
20. On 21 November, a palliative care consultant met with Mr Hughes for an 80 year
old plus review, and to discuss symptom management and pain relief for his
neuropathy diagnosis. They also discussed an advance care plan (ACP – where
clinicians have conversations with patients and make decisions about future care
and support requirements).
21. On 12 December, Mr Hughes had a scheduled hospital appointment and was
escorted to hospital. Mr Hughes had some X-rays and the results showed that he
had osteomyelitis (inflammation and swelling in the bone). When he returned to
Littlehey, healthcare staff saw him and advised him to keep taking his pain relief,
gently mobilise when he could and to continue to change his dressings when
necessary.
22. On 19 December, the palliative care consultant and an occupational therapist
visited Mr Hughes in his cell. Mr Hughes said that he was struggling to stand and
complained of pain in his feet, ankles and knees. Mr Hughes was non-compliant
with medication and did not want additional aids or support from social care. Mr
Hughes agreed to use the buprenorphine patches to try and get his pain under
control and it was agreed social care would visit him daily for additional support.
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23. On 20 January 2023, the prison appointed a Family Liaison Officer (FLO), due to Mr
Hughes’ decline in health.
24. On 30 January, a GP at the prison saw Mr Hughes about his ulcers. Mr Hughes
agreed to take amitriptyline (a medication used to manage neuropathic and nerve
pain) at night.
25. On 6 February, the palliative care consultant saw Mr Hughes. He told her that he
had not been taking amitriptyline at night because he thought the dose was too
high. She advised him that this medication would help him with the pain at night.
She noted that Mr Hughes had deteriorated since the last visit and showed
increased frailty.
26. On 14 February, a new FLO was appointed.
27. On 24 February, Mr Hughes’ carer pressed the emergency cell bell because Mr
Hughes had fallen over. Two officers attended the cell and found Mr Hughes under
his desk, but he was conscious and breathing. One officer told a nurse that Mr
Hughes had banged his head during the fall. The nurse said he would come and
check on Mr Hughes before officers assisted him up with the air bag (which is used
to assist people with getting up off the floor).
28. The nurse attended Mr Hughes’ cell and assessed him. Mr Hughes had a NEWS2
Score (a scoring system that detects the deterioration in patients - a score of 7+
requires emergency response) of 7, a very high temperature of 38.2, a very high
pulse rate of 135 beats per minute and a very low blood pressure at 87/71. Staff
called an ambulance to take Mr Hughes to the hospital and the nurse said his vital
signs needed to be monitored every 15 minutes until the ambulance arrived.
29. An ambulance arrived and took Mr Hughes to hospital. Two officers escorted him,
and he was not restrained.
30. The hospital staff confirmed that Mr Hughes needed to stay in hospital for more
tests and observations. Mr Hughes did not return to Littlehey.
31. Mr Hughes still had the ulcer on his ankle when he was taken to hospital. He had
been supported by the healthcare team with regular dressing changes and ulcer
reviews and management, but the ulcer would not heal.
32. On the 1 March, the FLO contacted Mr Hughes’ daughter and informed her that her
father was not well and had been admitted to hospital. Arrangements were made for
Mr Hughes’ family to visit him. Mr Hughes’ daughter raised concerns that the prison
had not told her Mr Hughes was in hospital until six days after his admission. The
FLO explained that Mr Hughes had not been assessed as seriously ill when he was
sent to hospital on 24 February but had been admitted for on-going monitoring. He
said that he had informed Mr Hughes’ family as soon as it became clear that Mr
Hughes was seriously unwell, and he had been able to identify the correct next of
kin details.
33. On 7 March, the palliative care consultant informed prison healthcare staff that Mr
Hughes was being treated for sepsis, which had occurred from the ulcers and
wounds on his feet.
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34. On 14 March, Mr Hughes was diagnosed with COVID-19. His health began to
deteriorate, and he became less responsive to treatment. Staff started an
application for compassionate release on Mr Hughes’ behalf. Mr Hughes died
before the application was completed.
35. On 24 March, hospital staff told a nurse at Littlehey that Mr Hughes was not taking
his medication, he was also not allowing staff to check his pressure areas and
change the dressings.
36. On 29 March, a prison manager approved an application for a special purpose
licence, so that Mr Hughes could receive palliative care at hospital. This meant that
one prison officer remained with him.
37. That day, a palliative care nurse at the hospital contacted the healthcare team at
Littlehey, to inform her that Mr Hughes had deteriorated, and they were making a
referral to a hospice. Mr Hughes died before the application was made.
38. On 1 April, it was confirmed that Mr Hughes had died in hospital.
Post-mortem report
39. The post-mortem report gave Mr Hughes’ cause of death as bronchopneumonia.
Hypertensive heart disease was also listed as a contributory factor.
Adrian Usher
Prison and Probation Ombudsman January 2024
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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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