Robin Matthews

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Robin Matthews,
a prisoner at HMP Isle of Wight,
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, 2025
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
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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 Robin Matthews died of heart failure on 1 April 2023, at HMP Isle of Wight. He
was 68 years old. We offer our condolences to Mr Matthews’ family and friends.
4. The clinical reviewer concluded that the clinical care Mr Matthews received at Isle of
Wight was partially equivalent to that which he could have expected to receive in
the community. She found that Mr Matthews’ end of life care was compassionate
and reactive to his needs, but she made several recommendations about his wider
clinical care which the Head of Healthcare will need to address.
5. We found no non-clinical issues of concern. We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Matthews’ death on 1 April 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
Matthews’ clinical care at Isle of Wight.
8. The PPO investigator investigated the non-clinical issues relating to Mr Matthews’
care.
9. The PPO family liaison officer wrote to Mr Matthews’ son to explain the investigation
and to ask if he had any matters he wanted us to consider. He did not have any
questions but asked for a copy of our report.
10. The initial report was shared with Mr Matthews’ son. He did not make any
comments.
11. The initial report was shared with HMPPS. There were no factual inaccuracies.
Previous deaths at HMP Isle of Wight
12. Mr Matthews was the twenty-seventh prisoner to die at Isle of Wight since March
2020. Of the previous deaths, 20 were from natural causes, five were self-inflicted
and one was from unknown causes.
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Key Events
13. On 7 September 2017, Mr Robin Matthews was sentenced to 18 years
imprisonment for sexual offences. On 31 May 2018, he was moved to HMP Isle of
Wight.
14. Mr Matthews had diabetes, high blood pressure, high cholesterol and he had
previously had a heart attack. He also had a learning disability.
15. When he arrived at Isle of Wight, the healthcare team found Mr Matthews was
struggling with his memory and his mobility. He was seen daily by carers who
helped him with all aspects of his self-care.
16. On 25 March 2022, Mr Matthews’ carers found that he was unwell. They 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). A nurse took his clinical observations. She found that his oxygen levels
were low and that he tested positive for COVID-19. He was taken to hospital by
ambulance and admitted.
17. On 4 April, Mr Matthews was discharged from hospital to the inpatient healthcare
unit (IHU) at Isle of Wight. The healthcare team continued to monitor Mr Matthews’
clinical observations as his breathing rate and oxygen levels were fluctuating. Later
in the evening, a nurse found Mr Matthews lying on the floor and he told her he had
hit his head. His breathing rate continued to deteriorate, and he was taken to
hospital. While in hospital he was diagnosed with COVID-19 pneumonia. He was
discharged back to the IHU at Isle of Wight the next day.
18. On 6 April, healthcare staff again found Mr Matthews on the floor of his cell. He
again told them that he had hit his head. The healthcare team found no sign of an
injury but continued to monitor him.
19. On 3 May, a GP at Isle of Wight saw Mr Matthews. He told Mr Matthews that he had
been diagnosed with cerebral atrophy (loss of brain cells) and was to be moved to
the IHU for treatment.
20. Mr Matthews’ condition continued to fluctuate. He was frequently admitted to the
IHU for periods of rehabilitation, and then moved back to his standard prison cell
when he was well enough.
21. On 11 August, Mr Matthews was short of breath and coughing. Healthcare staff
took his clinical observations, which were abnormal, and phoned for an ambulance.
He was taken to hospital for a chest X-ray and was subsequently admitted. Hospital
doctors diagnosed Mr Matthews with aspiration pneumonia (inflammation of the
lungs caused by something such as water or food getting into the lung).
22. On 13 August, Mr Matthews agreed with hospital doctors to put a Do Not Attempt
Resuscitation (DNAR) order in place. This meant he would not be resuscitated if his
heart or breathing stopped.
23. On 17 August, Mr Matthews was discharged from hospital back to the IHU. His
mobility continued to deteriorate and over the following months he had several falls.
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24. On 28 February 2023, a nurse saw Mr Matthews. She found he was in pain when
she moved his legs, and he told her he had fallen the day before (he had not told
staff of this at the time). She took his clinical observations, which were normal, and
arranged for him to see the GP the next day. Mr Matthews told the GP that he had
pain in the left-hand side of his chest. The GP found no sign of injury but increased
his pain relief.
25. On 4 March, Mr Matthews’ carers found him in his cell feeling unwell and confused.
The healthcare team took his clinical observations and found that he had low
oxygen levels and blood pressure. They gave him oxygen and transferred him to
hospital.
26. While in hospital, Mr Matthews was treated for a chest infection. He was given
intravenous antibiotics and oxygen. A nurse on the ward told the healthcare team at
Isle of Wight that his health had deteriorated, and he would be started on palliative
care.
27. On 13 March, the prison started an application for Mr Matthew’s early release on
compassionate grounds. This was not progressed before Mr Matthews died.
28. On 18 March, a nurse at Isle of Wight spoke to a nurse on the hospital ward who
told her that Mr Matthews was diagnosed with an acute kidney injury (AKI – where
the kidneys stop working properly) and pneumonia. While in hospital, Mr Matthews
also tested positive for COVID-19.
29. On 24 March, Mr Matthews was discharged from hospital. He was moved to the
IHU for palliative care. The hospital doctors and healthcare team at Isle of Wight
agreed that Mr Matthews would only be admitted to hospital again if he suffered an
injury, not if his health deteriorated.
30. On 31 March, Mr Matthews’ breathing slowed. At approximately 10.43pm, two
nurses found him unresponsive and not breathing. As there was no one available
who could verify Mr Matthews’ death, the prison staff called for an ambulance. At
2.31am on 1 April, a paramedic confirmed that Mr Matthews had died.
Post-mortem report
31. The post-mortem report concluded that Mr Matthews died of severe congestive
cardiac failure caused by ischemic heart disease and high blood pressure. Chronic
obstructive pulmonary disease (COPD - a group of lung conditions that cause
breathing difficulties) and idiopathic pulmonary fibrosis (where the lungs become
scarred and breathing becomes increasingly difficult) were also listed as
contributory factors.
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Findings
Governor to note
32. 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.
33. The prison started an ERCG application for Mr Matthews on 13 March, when his
condition was deteriorating in hospital. However, we could find no evidence that any
action was taken beyond completing basic details on the application form.
34. The prison told the PPO investigator that the ERCG application was started by a
staff member at the direction of the senior management team. They were unable to
say why it was not progressed any further.
35. We accept that Mr Matthews died just over two weeks after the ERCG application
was started and so it is unlikely that a decision could have been made in that time.
However, we would expect that once an ERCG application is started, that staff are
clear on who is responsible for coordinating the completion of the application form
so that it is progressed and submitted promptly to PPCS.
Adrian Usher
Prisons and Probation Ombudsman November 2023
Inquest
At the inquest, held on 14 October 2025, the Coroner concluded that Mr Matthews 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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