Martin Oakman

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Independent investigation into
the death of Mr Martin Oakman
a prisoner at HMP Littlehey on
5 April 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. On 5 April 2020, Mr Martin Oakman died in hospital of Methicillin-Sensitive
Staphylococcus Aureus (MSSA – a bacterial infection) and a spinal epidural
abscess, while a prisoner at HMP Littlehey. COVID-19 was a contributory factor.
He was 59 years old. I offer my condolences to Mr Oakman’s family and friends.
3. My Oakman reported no health concerns and had no contact with healthcare at
Littlehey until 21 February, when he was seen by a prison GP after reporting back
problems. He was prescribed anti-inflammatory medication and pain relief. On 24
February, Mr Oakman was taken to hospital for a neurological assessment after
reporting worsening back pain and a droop to the side of his face.
4. On 27 February, he was moved to the critical care unit of Addenbrookes Hospital.
His condition gradually improved and on 12 March he was moved to a standard
ward.
5. On 29 March, he tested positive for COVID-19. His condition deteriorated and he
died on 5 April.
6. The clinical reviewer concluded that the clinical care Mr Oakman received in prison
was of a good standard and equivalent to that which he could have expected to
receive in the community.
7. We did not find any non-clinical issues of concern and we have made no
recommendations.
The Investigation Process
8. NHS England commissioned an independent clinical reviewer to review
Mr Oakman’s clinical care at the prison. The clinical reviewer’s report is attached
as Annex 1.
9. The PPO investigator investigated non-clinical issues, including the prison’s
response to COVID-19 and shielding prisoners and the security arrangements for
his hospital escorts.
10. The Ombudsman’s family liaison officer contacted Mr Oakman’s next of kin, his
partner, to explain the investigation. Mr Oakman’s partner asked why no MRI or
CT scans were done when he first reported back problems. She also said that he
had told her that there had been no hot water or heating on his wing for months
which she said made hygiene difficult, and she asked how and where he contracted
MSSA. These issues are addressed in the clinical review.
11. Mr Oakman’s partner received a copy of the initial report. She did not raise any
further issues, or comment on the factual accuracy of the report.
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12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies in the clinical review which has been
amended accordingly. The action plan has been annexed to this report.
13. This version of my report, published on my website, has been amended to remove
the names of staff and prisoners involved in my investigation.
Previous deaths at HMP Littlehey
14. Mr Oakman was the sixteenth prisoner to die at Littlehey since March 2018. Of the
previous deaths, 14 were from natural causes (including two COVID-19 related
deaths in March 2020) and one was self-inflicted. There have been two deaths
from natural causes since and one self-inflicted death. There have been no COVID-
19 related deaths at Littlehey since Mr Oakman’s.
COVID-19 (coronavirus)
15. COVID-19 is an infectious disease that affects the lungs and airways. On 11
March, the World Health Organisation (WHO) declared COVID-19 as a worldwide
pandemic.
16. COVID-19 can make anyone seriously ill, but the risk is higher for some
people. People at high risk include those who have a severe lung condition; are
having certain types of treatment for cancer; or have a condition with a very high
risk of getting infections. Those at moderate risk include people over 70; people
with a lung condition or a chronic medical condition, such as diabetes, heart, liver,
or chronic kidney disease; or those who are very obese (this list is not exhaustive).
17. To reduce the spread of the virus, the Government introduced voluntary and
mandatory actions, such as ‘social distancing’ and ‘lockdown’ (on 16 and 23 March,
respectively). Public Health England (PHE), HM Prison & Probation Service
(HMPPS) and NHS England worked together to devise measures to contain the
outbreak, achieve social distancing, reduce the risk to the most vulnerable in
prisons in England and protect the NHS (by reducing the number of people
requiring specialist care in community-based hospitals).
18. On 13 March, PHE’s National Health and Justice team issued an interim notice
providing advice on preventing and controlling outbreaks of COVID-19 in prisons.
HMPPS issued further instructions over the following weeks with guidance on the
appropriate use of personal protective equipment (PPE), hygiene, cleaning
schedules and stock checks. The guidance set out the importance of effective
preventative measures and that methodical cleaning would help prevent infection
spread.
Key Events
19. On 15 February 2019, Mr Martin Oakman was sentenced to eight years in prison for
sexual offences and sent to HMP Bedford. On 1 March, he moved to HMP
Littlehey.
20. Mr Oakman did not have any significant medical history and he had no significant
contact with healthcare until February 2020.
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21. On 21 February, Mr Oakman told a prison nurse that was unable to move around
because of back problems. He had normal sensation in his hands and feet and
could pass urine. The same day, a prison GP assessed Mr Oakman and
prescribed anti-inflammatory medication and pain relief.
22. On 24 February, Mr Oakman went to the healthcare unit in a wheelchair and
needed the assistance of two people to stand. He complained of pain in his lower
back and a prison nurse noted a droop on the left side of his face. Mr Oakman’s
pulse and oxygen saturation level were normal. Healthcare staff arranged for an
ambulance to take Mr Oakman to Hinchingbrooke Hospital for a neurological
assessment. He was accompanied by two prison officers but not restrained.
23. The next day, Mr Oakman moved to the acute admissions unit because his
neurological symptoms had deteriorated, and he was unable to lift his legs without
assistance and his co-ordination was poor. Mr Oakman had a scan of his spine.
24. On 27 February, Mr Oakman was moved to the critical care unit at Addenbrookes
Hospital with a possible diagnosis of spinal tuberculosis (TB). Mr Oakman was
ventilated, and his condition was reported as critical but stable.
25. On 29 February, Mr Oakman tested positive for MSSA. (MSSA is a bacterial
infection found in the nose, throat or skin of approximately one-third of the
population. It is harmless unless it has an opportunity to enter the body through a
cut in the skin, when it can cause a serious infection.)
26. Mr Oakman’s condition stabilised and he was removed from the ventilator on 3
March. Mr Oakman had another scan and the diagnosis of spinal TB was not
confirmed.
27. Mr Oakman’s condition improved and on 12 March, he was moved to a general
ward. The same day, the prison bedwatch officers were advised to wear surgical
masks. The Head of Healthcare at Littlehey recommended that the officers were
withdrawn from Mr Oakman’s room to prevent and control infections.
28. On 29 March, Mr Oakman was tested for COVID-19. His condition deteriorated and
on 31 March, his condition was described as critical. On 1 April, results showed
that Mr Oakman had tested positive for COVID-19. He was sedated, had fluid in
both lungs, was ventilated and receiving life support.
29. Mr Oakman died at 3.30pm on 5 April.
30. There was no post-mortem and the Coroner accepted the cause of death provided
by a hospital doctor who found that that Mr Oakman died of Methicillin-Sensitive
Staphylococcus Aureus due to a spinal epidural abscess (a collection of pus
between the outer covering of the spinal cord and the bones of the spine). He also
had COVID-19, which did not cause but contributed to his death.
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Findings
Clinical Findings
31. The clinical reviewer concluded that the clinical care Mr Oakman received in prison
was of a good standard and equivalent to that which he could have expected to
receive in the community. When Mr Oakman presented with back pain on 21
February, healthcare assessed him appropriately, and he was sent to hospital
promptly for further investigations when his symptoms deteriorated on 24 February.
32. The clinical reviewer found that Mr Oakman tested positive for MSSA five days after
his admission to hospital. She could not say where or how Mr Oakman contracted
the infection.
Management of Mr Oakman’s risk of catching COVID-19
33. Mr Oakman displayed no symptoms of COVID-19 while he was at Littlehey. He
was not diagnosed as COVID-19 positive until 29 March, by which time he had
been in hospital for 34 days. It, therefore, seems likely that Mr Oakman contracted
COVID-19 in hospital rather than at Littlehey.
Inquest
34. The inquest, heard on 12 June 2024, concluded that Mr Oakman died from natural
causes.
Sue McAllister CB November 2020
Prisons and Probation Ombudsman
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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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