Ronald Beamish

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Independent investigation
into the death of
Mr Ronald Beamish,
a prisoner at HMP Chelmsford,
on 3 October 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, 2026
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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 Ronald Beamish died in hospital of ischaemic heart disease on 3 October 2023,
while a prisoner at HMP Chelmsford. He was 86 years old. We offer our
condolences to Mr Beamish’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Beamish received at
Chelmsford was variable. Some aspects were equivalent to that which he could
have expected to receive in the community, but others were not. The clinical
reviewer made recommendations on wound management, adherence to the
national guidance on assessing and preventing falls in older people and
safeguarding. As the recommendations were not directly related to Mr Beamish’s
cause of death, we do not repeat them in this report, but the Head of Healthcare will
wish to consider them.
5. We found that the decision to restrain Mr Beamish for his journey to hospital and
while he was an inpatient was not justified given his advanced age, poor mobility
and intravenous treatment.
Recommendation
The Governor and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners taken to hospital understand the legal
position on the use of restraints and that, in all cases:
• healthcare staff accurately complete the medical information section of
the escort risk assessment to reflect how the prisoner’s health, medical
condition and mobility affects their risk of escape;
• authorising managers show that they have taken this information into
account and their decision is based on the risk the prisoner presents at
the time; and
• restraints are not used during serious or invasive treatment, unless
there are exceptional reasons for doing so.
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The Investigation Process
6. HMPPS notified us of Mr Beamish’s death on 3 October 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
Beamish’s clinical care at HMP Chelmsford.
8. PPO investigators investigated the non-clinical issues relating to Mr Beamish’s
care.
9. The Ombudsman’s office wrote to Mr Beamish’s daughter to explain the
investigation and to ask if she had any matters she wanted us to consider. Mr
Beamish’s daughter asked several questions about her father’s care. The issues
within our remit have been addressed in this report, the clinical review and in
separate correspondence.
10. We sent a copy of our report to Mr Beamish’s next of kin. She made several
observations and highlighted some personal concerns. Two factual errors she
identified have been amended.
11. The initial report was shared with HM Prison and Probation Service (HMPPS). They
found no factual inaccuracies and accepted the recommendation.
Previous deaths at HMP Chelmsford
12. Mr Beamish was the eighth prisoner to die at Chelmsford since October 2020. Of
the previous deaths, two were from natural causes and five were self-inflicted.
There have since been three further deaths. There are no significant similarities
between the findings in our investigation into Mr Beamish’s death and those from
our investigations into the previous deaths.
2 Prisons and Probation Ombudsman
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Key Events
13. Mr Ronald Beamish was convicted of sexual offences on 26 October 2022. He was
sentenced to three years imprisonment on 17 July 2023 and sent to HMP
Chelmsford. It was his first time in prison.
14. At his initial health screen, a nurse recorded that Mr Beamish had several existing
long-term health conditions, including type 2 diabetes, high cholesterol, stage 4
chronic kidney disease, diabetic retinopathy and a previous deep vein thrombosis.
His right leg had been amputated above his knee and he used a wheelchair. The
nurse noted that Mr Beamish’s blood pressure was raised.
15. On 31 July, an audit showed that Mr Beamish’s second-stage health screen was
overdue and it was held that day. Healthcare staff placed him on the long-term
conditions pathway and relevant care plans were created. He was also added to the
complex care register and monitored weekly at the Multi-Professional Complex
Care Caseload (MPCCC) meeting. Staff gave Mr Beamish an adapted cell in the
Enhanced Care Unit, a small unit for men with complex needs.
Deterioration in Mr Beamish’s health and admission to hospital
16. Mr Beamish’s daughter contacted the prison on 14 August to raise concerns about
her father’s health. Over the next few days, healthcare staff conducted additional
welfare checks to monitor his condition.
17. Mr Beamish was admitted to Broomfield Hospital on 17 August due to abdominal
pain, dehydration and vomiting. He was escorted by two prison officers, using an
escort chain (a long chain with a handcuff at each end, one of which is attached to
the prisoner and the other to an officer). During the afternoon, Mr Beamish
complained of wrist pain and bruising and a prison manager authorised removal of
the restraints. The escort staff on duty that evening were told to reapply the escort
chain.
18. Mr Beamish was diagnosed with a mild upper gastrointestinal bleed and treated
with intravenous medication and fluids. After he returned to the prison on 19
August, healthcare staff generally conducted welfare checks twice a day.
19. On 27 August, Mr Beamish felt unwell. He vomited, his respiratory rate was raised
and he appeared confused. He was admitted to hospital, with a urinary tract
infection and was later diagnosed with a deep vein thrombosis. He was treated
intravenously Mr Beamish was again restrained with an escort chain. A risk
assessment dated 29 August, instructed escort staff to use double handcuffs for
travel and an escort chain during treatment and consultations. The restraints were
removed on 31 August, as a nurse had difficulty finding a vein. They were reapplied
for a scan on 7 September.
20. On 31 August, a hospital consultant decided that Mr Beamish should not be
resuscitated if his heart or breathing stopped. A ‘do not attempt cardiopulmonary
resuscitation’ (DNACPR) order was completed and the prison was informed.
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21. On 22 September, Mr Beamish was discharged from hospital and sent to a
community rehabilitation centre. However, his condition worsened and he was
admitted to Basildon University Hospital on 28 September. He was treated for a
urinary tract infection and pneumonia.
22. On 1 October, a hospital doctor discussed end of life decisions with Mr Beamish.
The escort officers noted that it was unclear whether he understood what was said.
23. Mr Beamish died on 3 October.
Post-mortem report
24. The post-mortem report concluded that Mr Beamish died of ischaemic heart
disease. Pneumonia and hypertensive heart disease also contributed to his death.
4 Prisons and Probation Ombudsman
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Non-Clinical Findings
Restraints, security and escorts
25. 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 into account the prisoner’s health and
mobility.
26. 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.
27. These requirements are reflected in the HMPPS policy framework, Prevention of
Escapes – External Escorts, which states that restraints will not normally be
necessary when mobility is severely limited due to advanced age or disability,
unless there is intelligence to suggest that there will be an attempt to escape.
28. The judgements about how Mr Beamish’s health and mobility affected his risk were
inconsistent. The clinical section of the risk assessment on 17 August indicated that
he was incapacitated, with a life-threatening condition and the one completed for 27
August noted that he was an amputee and wheelchair user. In spite of this, both
clinical assessments considered that he could escape unaided and operational staff
authorised the use of an escort chain each time.
29. The clinical opinion on the risk assessment for 29 August, was that Mr Beamish
was unable to escape unaided, yet the level of restraints was raised to double
handcuffs for travel and an escort chain during treatment and medical consultations.
30. Mr Beamish was a category C prisoner on the enhanced level of the prisoners’
incentives scheme. He was described as compliant with no adverse behaviour or
disciplinary problems. The security risk assessments identified no potential to
escape and no reasons why restraints were necessary.
31. The security risk assessment process appears to be poorly understood by some
healthcare and operational staff. It is difficult to see how any objective assessment
of Mr Beamish’s risk could have concluded that an 86-year-old, amputee and
wheelchair user, weakened by multiple chronic health conditions and undergoing
invasive treatment, had the ability to escape unaided from two prison officers. It is
particularly inexplicable that double handcuffing, which is usually required for
moving category A or B prisoners in good health was necessary at any point. We
have repeatedly criticised HMPPS culture on this issue as being unduly risk averse.
We believe that, in this instance, the use of restraints was unjustified, inhumane and
showed a lack of decency by those involved in the assessments. We recommend:
Prisons and Probation Ombudsman 5
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The Governor and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners taken to hospital understand the legal
position on the use of restraints and that, in all cases:
• healthcare staff accurately complete the medical information section of
the escort risk assessment to reflect how the prisoner’s health, medical
condition and mobility affects their risk of escape;
• authorising managers show that they have taken this information into
account and their decision is based on the risk the prisoner presents at
the time; and
• restraints are not used during serious or invasive treatment, unless
there are exceptional reasons for doing so.
Governor to note
Liaison with Mr Beamish’s family
32. 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.
33. Prison staff did not inform Mr Beamish’s daughter that he had been admitted to
hospital. We consider it unacceptable that she found out by ringing local hospitals to
locate him, 11 days after his admission. Given that we have not identified similar
issues in other cases at Chelmsford, we have not made a recommendation.
However, the Governor will want to reflect on the circumstances that allowed this to
hdxmkl-00pp juhik.,appen to Mr Beamish’s family and ensure learning is identified.
Inquest
34. At an inquest held on 16 December 2025, the coroner concluded that Mr Beamish
died from natural causes.
Adrian Usher
Prisons and Probation Ombudsman September 2024
6 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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