Michael Kinnear

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Michael Kinnear,
a prisoner at HMP Wymott,
on 11 May 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 Michael Kinnear died in a hospice of kidney cancer on 11 May 2023, while a
prisoner at HMP Wymott. He was 54 years old. We offer our condolences to Mr
Kinnear’s family and friends.
4. The clinical reviewer concluded that, with the exception of one element of care, the
clinical care Mr Kinnear received at Wymott was equivalent to that which he could
have expected to receive in the community. She found many examples of good
care but found that national guidance on caring for people at risk of malnutrition was
not followed. She made one recommendation which can be found in the clinical
review report.
5. When the prison submitted an early release on compassionate grounds (ERCG)
application for Mr Kinnear on 29 March, they did not include a consultant’s report as
required. This delayed the application and Mr Kinnear died before it could be
considered.
Recommendations
• The Governor and Head of Healthcare should ensure that Healthcare provide the
correct consultant report immediately after prognosis and the Governor ensures that
this is sent off with the ERCG application.
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The Investigation Process
6. HMPPS notified us of Mr Kinnear’s death on 11 May 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
Kinnear’s clinical care at Wymott.
8. The PPO investigator investigated the non-clinical issues relating to Mr Kinnear’s
care.
9. The PPO family liaison officer wrote to Mr Kinnear’s next of kin, his daughter, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond to our letter.
10. The initial report was shared with HMPPS. HMPPS pointed out some factual
inaccuracies and this report has been amended accordingly.
Previous deaths at HMP Wymott
11. Mr Kinnear was the twenty-third prisoner to die at Wymott since May 2020. Of the
previous deaths, 20 were from natural causes, one was self-inflicted, and one was
drug related. There are no similarities between our findings in the investigation into
Mr Kinnear’s death and our investigation findings for the previous deaths.
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Key Events
12. On 16 October 2015, Mr Michael Kinnear was sentenced to nine years
imprisonment for sexual offences. On 23 April 2021, he was moved to HMP
Wymott.
13. On 3 January 2023, a nurse and a GP saw Mr Kinnear as he had stomach pain, a
loss of appetite, vomiting and constipation. The nurse took blood samples and the
GP referred Mr Kinnear under the urgent two-week referral route for suspected
cancer.
14. On 5 January, a GP reviewed Mr Kinnear’s blood test results. They showed he had
severe hypercalcemia (very high levels of calcium in the blood). The GP arranged
for Mr Kinnear to be urgently transferred to hospital.
15. The following morning, Mr Kinnear discharged himself from hospital. A nurse at
Wymott spoke to Mr Kinnear about the risk of refusing treatment, but he did not
want to return to hospital. He told the nurse that while in hospital he had further
blood tests done and was told by a doctor he might have cancer. Later that day, the
GP asked for Mr Kinnear to be urgently transferred to hospital as his blood test
results were very abnormal, however, he refused to go.
16. On 7 January, staff started suicide and self-harm monitoring (known as ACCT) for
Mr Kinnear as they were concerned about his refusal to attend hospital for
treatment. The healthcare team spoke to Mr Kinnear about the risks of not having
treatment, but he continued to refuse to go to hospital.
17. On 9 January, a GP saw Mr Kinnear and told him that his liver function was very
abnormal and that his blood tests suggested he had kidney failure. Mr Kinnear
agreed to go to hospital and was admitted.
18. On 11 January, Mr Kinnear discharged himself from hospital. A nurse at Wymott
saw him on his return as he looked very unwell. Mr Kinnear told the nurse he was
struggling with his thoughts and mood at the hospital and was distrusting of the
hospital staff. He returned to hospital on 20 January for a CT scan. Staff stopped
ACCT monitoring the same day.
19. On 8 February, a GP saw Mr Kinnear. She told him the results of his CT scan and
that he had a diagnosis of renal cell cancer (kidney cancer) that had spread to his
liver and adrenal glands (glands at the top of each kidney). She told him that his
cancer was terminal.
20. On 2 March, Mr Kinnear saw an oncologist (cancer specialist) who advised that his
prognosis would likely be three months without treatment, or 12 months with
treatment. Mr Kinnear agreed to start treatment and was prescribed medication to
help treat his cancer.
21. On 22 March, staff started ACCT monitoring again as Mr Kinnear was refusing to
attend hospital for treatment.
22. On 24 March, Mr Kinnear said he did not want anyone to resuscitate him if his heart
or breathing stopped and signed an order to that effect.
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23. On 29 March, staff submitted an application for Mr Kinnear’s early release on
compassionate grounds (ERCG) to the Public Protection Casework Section (PPCS)
of HMPPS. PPCS asked for a report from Mr Kinnear’s oncologist. This was still
outstanding when Mr Kinnear died.
24. On 8 April, an officer found Mr Kinnear on the floor in his cell and radioed a code
blue (a medical emergency code used when a prisoner is unconscious or having
breathing difficulties that alerts staff to attend and the control room to call an
ambulance). The healthcare team responded to the code and helped Mr Kinnear
back to his bed. They were concerned that his breathing was rapid and blood
pressure was low. The ambulance crew arrived and took him to hospital.
25. On 11 April, Mr Kinnear was seen by the palliative care team in hospital. They
explained that he would not receive any further active treatment for his cancer and
would be kept comfortable.
26. On 13 April, a palliative care doctor at the hospital told the healthcare team at
Wymott that Mr Kinnear was approaching the end of his life and he had a prognosis
of days to weeks. Staff stopped ACCT monitoring on 19 April.
27. On 24 April, Mr Kinnear was moved to a hospice for palliative care. He had told staff
that he wanted to return to Wymott, however as Wymott were unable to meet his
24-hour care needs, the doctors agreed it was in his best interests to be moved to a
hospice.
28. On 11 May, at approximately 12.52am, Mr Kinnear died.
Cause of death
29. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Kinnear’s cause of death
as metastatic renal cell carcinoma (kidney cancer).
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Findings
Compassionate release application
30. Release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. A clear
medical opinion of life expectancy is required. The criteria for early release are set
out in the Early Release on Compassionate Grounds (ERCG) Policy Framework.
Among the criteria is that the risk of reoffending is expected to be minimal, further
imprisonment would reduce life expectancy, there are adequate arrangements for
the prisoner’s care and treatment outside prison, and release would benefit the
prisoner and his family. An application for early release on compassionate grounds
must be submitted to the Public Protection Casework Section (PPCS) of HMPPS.
31. Paragraph 4.25 of the ERCG Policy Framework says, ‘The application must include
a multidisciplinary report completed by all roles currently caring for the prisoner.
This must include, but is not limited to, a report from the prison GP/locum and an
additional report from the medical specialist(s) – this is usually a consultant –
involved in the care of the prisoner. The reports should provide a diagnosis,
assessment of incapacity/frailty, prognosis, treatment pathway/plan and, where
applicable, a clear indication of life expectancy’.
32. The prison submitted an ERCG application to PPCS on 29 March 2023, without a
report from a consultant as required. This meant that PPCS were unable to
progress the application. A caseworker from PPCS responded the same day to
request a consultant report.
33. On 28 April, the healthcare team sent a list of questions to Mr Kinnear’s consultant
at St Catherine’s Hospice and asked him to complete them for his ERCG
application. The consultant asked for a multi-disciplinary team (MDT) meeting
before completing the questions as he had only been responsible for Mr Kinnear for
four days. An MDT meeting took place on 3 May. The healthcare team asked for an
update on the questions on 10 May, following a meeting at the hospice. On 11 May,
Mr Kinnear died.
34. The PPO investigator was told by the lead GP at Wymott that they do not routinely
request consultant reports when completing ERCG applications.
35. Mr Kinnear’s oncologist gave him his prognosis on 2 March. We consider that the
prison should have asked for a report at that stage, with a view to submitting the
ERCG application as soon as possible. The fact that they did not, unnecessarily
delayed the ERCG process. We recommend:
The Governor and Head of Healthcare should ensure that Healthcare provide
the correct consultant report immediately after prognosis and the Governor
ensures that this is sent off with the ERCG application.
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Good Practice
36. On 3 March 2023, following his terminal diagnosis, Mr Kinnear was added to the
palliative care register at Wymott. From this point onwards he was no longer cuffed
or restrained when attending hospital or on an escort.
37. The Governor at Wymott told the PPO investigator that their general policy, based
on the dying well in custody charter, is to not apply restraints once a prisoner has
been added to the palliative care register unless the risk requires. This is to provide
comfort to prisoners and their families during a difficult time. This is reflective of a
compassionate approach to applying restraints and is considered good practice.
Adrian Usher
Prisons and Probation Ombudsman November 2023
Inquest
The inquest, held on 5 July 2024, concluded that Mr Kinnear 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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