Melvin McFadden

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Independent investigation into
the death of Mr Melvin
McFadden, a prisoner at HMP
Northumberland, on 12 March
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 HM Prisons 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 Melvin McFadden died in hospital on 12 March 2023, while a prisoner at HMP
Northumberland. He was 73 years old. The cause of his death was kidney and
heart failure caused by kidney cancer. He also had underlying hypertension and
colon cancer. We offer our condolences to Mr McFadden’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr McFadden received at
Northumberland was of a good standard and equivalent to that which he could have
expected to receive in the community. However, she made recommendations on
the need for clinical observations to be taken during medical assessments; and for
healthcare staff to obtain daily updates when a prisoner is an inpatient in hospital.
5. We consider that the decision to restrain Mr McFadden when he was taken to
hospital was not justified given his age and poor state of health, neither was it
appropriate for restraints to be used during chemotherapy at previous outpatient
appointments.
Recommendations
• The Director should ensure that all staff undertaking risk assessments for prisoners
taken to hospital understand the legal position on the use of restraints and that
assessments fully take into account the prisoner’s health; are based on the actual
risk the prisoner presents at the time; and are not used during serious or invasive
treatment, unless there are exceptional reasons for doing so.
• The Operational Security Group Director for HMPPS should monitor, over the next
three months, how many prisoners at HMP Northumberland are escorted to hospital
without restraints (for inpatient admissions and outpatient appointments) and report
back to the Ombudsman.
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The Investigation Process
6. HMPPS notified us of Mr McFadden’s death on 13 March 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
McFadden’s clinical care at HMP Northumberland.
8. The PPO investigator investigated the non-clinical issues relating to Mr McFadden’s
care.
9. The PPO family liaison officer wrote to Mr McFadden’s next of kin, his daughter, to
explain the investigation and to ask if she had any matters for the investigation to
consider. Mr McFadden’s daughter asked if healthcare staff had followed up her
father’s concerns about his breathing difficulties, swollen legs and stopping his
blood pressure medication (and whether this had impacted on his health). These
issues have been addressed in the clinical review report.
10. Mr McFadden’s daughter received a copy of the initial report. She did not report any
factual inaccuracies.
11. We shared the initial report with HM Prison and Probation Service. They found no
factual inaccuracies and accepted our recommendations. The HMPPS action plan
has been annexed to this report.
Previous deaths at HMP Northumberland
12. Mr McFadden was the eighteenth prisoner at Northumberland to die since March
2020. Of the previous deaths, ten were from natural causes, six were self-inflicted
and one was due to substance misuse. There have been three further deaths from
natural causes.
13. We have previously made a recommendation about security risk assessments and
the inappropriate use of restraints. Northumberland undertook to provide training for
those involved in completing such assessments, as well as a briefing for healthcare
staff. They also intended to quality assure ten per cent of completed risk
assessments and discuss the findings at safer prisons and security meetings
chaired by the Director and Deputy Director, respectively.
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Key Events
14. Mr Melvin McFadden was remanded to prison on 22 July 2011 and was later
convicted of sexual offences. On 21 December, he was given an indeterminate
sentence, with a minimum period to serve of three years.
15. Mr McFadden’s medical conditions included gout and longstanding hypertension
(high blood pressure).
16. Mr McFadden transferred from HMP Holme House to HMP Northumberland on 9
September 2013. He did not fully engage with the reception and secondary health
screens and declined most of the assessments, such as the NHS health check to
detect early signs of chronic conditions, such as kidney disease.
2021
17. On 29 April 2021, a stool sample from Mr McFadden, tested under the Bowel
Cancer Screening Programme, showed abnormalities. Mr McFadden was referred
for additional assessments, but he declined further tests and investigations,
including a colonoscopy. The GP and nurses at the prison repeatedly spoke to him
about the risks of refusing and the possibility that he might have cancer, but he
persistently declined.
18. A referral was made to Macmillan Cancer Support. A Macmillan nurse held an
introductory meeting with Mr McFadden on 13 August and then saw him regularly.
Over the following months, healthcare staff reviewed Mr McFadden weekly and took
blood tests.
2022
19. In January 2022, ultrasound scans revealed masses in both kidneys and Mr
McFadden agreed to be referred urgently to a specialist, under the NHS pathway
for suspected cancer. Blood tests were taken, as well as CT scans of his chest,
abdomen, pelvis and both kidneys.
20. On 9 March, a consultant urologist confirmed that Mr McFadden had terminal
kidney cancer. A nurse at the prison discussed the diagnosis with him that day. On
10 March, the consultant told him that his cancer was incurable and his treatment
would be palliative only, to relieve the symptoms. Healthcare staff completed a
detailed assessment of Mr McFadden’s care needs and the complex care team
discussed him twice a month. At that time, it was too soon to give a prognosis of his
life expectancy.
21. In June, Mr McFadden began oral chemotherapy. The pharmacist at the prison
talked to him about the treatment cycle and possible side effects.
22. On 22 July, a consultant oncologist told Mr McFadden that there was a shadow in
his sigmoid colon (the last section of the bowel, attached to the rectum), which
needed further investigation.
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23. On 28 October, Mr McFadden was informed by the hospital that the tumour in his
kidney had grown and there was another mass. He re-started chemotherapy.
2023
24. On 4 January 2023, Mr McFadden had a scan which showed a mass in his sigmoid
colon. He was immediately told that he had colon cancer. As he was asymptomatic,
it was decided that he should continue with his existing palliative chemotherapy and
treatment for the bowel cancer would be reviewed if he developed symptoms.
25. On 2 March, Mr McFadden had an outpatient appointment at Freeman Hospital, for
cancer treatment. He was escorted by two prison officers. Single handcuffs were
used, which were replaced by an escort chain during treatment.
26. While Mr McFadden was at the hospital, a GP at the prison received the results of a
blood test that had been requested the previous day. As the results showed
abnormalities, he immediately informed Mr McFadden’s hospital consultant. After
Mr McFadden’s planned treatment, he had further tests and was diagnosed with
cellulitis. He was then admitted as an inpatient and treated with intravenous
antibiotics. The handcuffs were removed at 6.15pm on 3 March.
27. On 5 March, the prison informed Mr McFadden’s daughter that Mr McFadden was
in hospital. The escort staff facilitated telephone calls between them and prison
managers later gave permission for visits.
28. Overnight on 8/9 March, Mr McFadden deteriorated suddenly and hospital doctors
believed his condition to be terminal. It was agreed that he would not be
resuscitated if his heart or breathing stopped and the hospital asked to speak to his
next of kin. Mr McFadden spoke to his daughter after he was given the diagnosis. It
was noted that a prison manager would appoint a family liaison officer.
29. At 8.55pm on 12 March, the prison’s family liaison officer introduced herself to Mr
McFadden’s daughter. They discussed his condition and the processes in the event
of his death. Mr McFadden died three hours later, at 11.55pm and the family liaison
officer informed his daughter shortly afterwards.
30. The prison contributed to the costs of Mr McFadden’s funeral, which was held on 27
March.
Post-mortem report
31. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr McFadden’s cause of
death as renal and cardiac failure, due to metastatic kidney cancer. Hypertension
and colon cancer also contributed to but did not cause his death.
32. The inquest, held on 6 December 2023, concluded that Mr McFadden died from
natural causes.
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Non-Clinical Findings
Restraints, security and escorts
33. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes account of health and mobility.
34. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
35. Mr McFadden was a category C prisoner, on the enhanced level of the prison’s
privileges scheme. The medical section of the security risk assessment for his
appointment on 2 March, indicated that he was due to receive chemotherapy or life-
saving treatment; and that there was no objection to the use of restraints, but they
would need to be removed for treatment.
36. Mr McFadden was assessed as low risk on security aspects, such as the risk of
escape and the likelihood of outside assistance to do so. The decision was that
single handcuffs should be used, which should be reduced to an escort chain during
treatment, “if requested by a medical professional.” A review of Mr McFadden’s risk
took place the day after he was admitted as an inpatient and it was decided that
restraints were unnecessary, due to his age, poor health and mobility.
37. HMPPS’ Prevention of Escape – External Escorts Policy Framework, encourages
sensitive handling when considering the use of restraints, to ensure that the needs
of security are balanced against the clinical needs of a seriously ill prisoner. It
explicitly states that, “the use of restraints on a prisoner receiving chemotherapy (or
other lifesaving treatment) is degrading and inhumane, unless justified by other
relevant considerations”. In addition, it says that restraints should not be used when
mobility is severely limited due to advanced age, or disability, unless there is
intelligence to suggest that an escape attempt might be made.
38. Use of restraints during Mr McFadden’s invasive cancer treatment indicates either a
lack of awareness, or deliberate disregard of the policy. The Ombudsman has
repeatedly criticised HMPPS culture on this issue as being too risk averse and there
not being a sufficiently strong body of evidence to support that aversion.
39. In response to previous recommendations to Northumberland, the Director
proposed several measures to address this issue, such as training staff and
auditing risk assessments. We are concerned that they have not been effective. We
recommend:
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The Director should ensure that all staff undertaking risk assessments for
prisoners taken to hospital understand the legal position on the use of
restraints and that assessments fully take into account the prisoner’s health;
are based on the actual risk the prisoner presents at the time; and are not
used during serious or invasive treatment, unless there are exceptional
reasons for doing so.
The Operational Security Group Director for HMPPS should monitor, over the
next three months, how many prisoners at HMP Northumberland are escorted
to hospital without restraints (for inpatient admissions and outpatient
appointments) and report back to the Ombudsman.
Director to note
40. Prison Service Instruction (PSI) 64/2011, about safer custody, states that prisons
must have arrangements in place for an appropriate member of staff to engage with
the next of kin of prisoners who are either terminally or seriously ill. In addition, the
PSI and Prison Rule 22 says that a prisoner’s next of kin should be informed
immediately if they become seriously ill, or if there is an unpredicted or rapid
deterioration in their physical health. Northumberland did not comply with these
policies.
41. When Mr McFadden was admitted to hospital, his condition was not initially thought
to be life-threatening. However, given that he was already terminally ill, we consider
that the prison staff should have exercised their discretion to notify his daughter as
soon as he became an inpatient and it became clear that he would be in hospital for
more than a day.
42. After he deteriorated significantly on 9 March and prison staff knew that he was
likely to die, there should have been greater urgency in either appointing a family
liaison officer, or another point of contact at the prison, to provide information and
support.
43. The prison said that during the COVID-19 pandemic, information sharing between
the healthcare provider and operational staff was poor. However, they felt this had
greatly improved, particularly in instances of prisoners with terminal or serious
illness.
44. As contact with prisoners’ families is an issue we have raised previously, we hope
that this improvement is sustained.
Adrian Usher
Prisons 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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