Selby Wardle

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Selby Wardle,
a prisoner at HMP Hull, on 8
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
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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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.
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.
Mr Selby Wardle died on 8 May 2023 of acute myocardial ischaemia (reduced blood flow
to the heart) at HMP Hull. He was 72 years old. I offer my condolences to Mr Wardle’s
family and friends.
The clinical reviewer concluded that the healthcare Mr Wardle received at HMP Hull was
of a good standard and equivalent to what he could have expected to receive in the
community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman December 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
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Summary
Events
1. On 22 October 2009, Mr Selby Wardle was remanded to HMP Leeds, charged with
rape.
2. Mr Wardle had several medical conditions, which included bicuspid aortic valve
disorder (a form of heart disease) and hypertension (high blood pressure). Mr
Wardle also needed and was provided with appropriate care for a range of other
health conditions.
3. On 26 March 2010, Mr Wardle received an indeterminate sentence for public
protection (IPP) with a minimum tariff of 12 years in prison. Mr Wardle was
transferred to several different prisons and on 10 November 2017, he was
transferred to HMP Hull.
4. Healthcare staff referred Mr Wardle to the long-term conditions pathway clinic at
Hull and offered him annual reviews, which he declined to attend.
5. On 30 June 2020, a GP at Hull completed a health check on Mr Wardle and
conducted a QRisk2 assessment (a tool for predicting cardiovascular risk). The
results showed that he had a high risk (over 20% chance) of a heart attack within
the next ten years.
6. On 24 November 2022, Mr Wardle was sentenced to a further nine years in prison
for sexual offences.
7. At about 5.00am on 8 May 2023, an Officer Support Grade (OSG) was conducting
the morning routine check and saw Mr Wardle lying on the floor of his cell,
unresponsive. The OSG radioed a medical emergency code and nursing and prison
staff responded and started cardiopulmonary resuscitation (CPR).
8. Ambulance paramedics arrived and took over CPR, but at 5.27am, a paramedic
confirmed that Mr Wardle had died.
Findings
9. The clinical reviewer concluded that the care Mr Wardle received at HMP Hull was
of a good standard and equivalent to what he could have expected to receive in the
community.
10. The clinical reviewer was satisfied that healthcare staff made good efforts to
manage Mr Wardle’s long-term conditions and appropriate care plans were put in
place for his conditions.
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The Investigation Process
11. On 9 May 2023, HMPPS notified us of Mr Wardle’s death. The investigator issued
notices to staff and prisoners at HMP Hull informing them of the investigation and
asking anyone with relevant information to contact her. No one responded.
12. The investigator obtained copies of the relevant extracts from Mr Wardle’s prison
and medical records.
13. NHS England commissioned a clinical reviewer to review Mr Wardle’s clinical care
at the prison.
14. We informed HM Coroner for Hull of the investigation. He gave us the results of the
post-mortem examination. We have sent the Coroner a copy of this report.
15. The Ombudsman’s family liaison officer wrote to Mr Wardle’s sister to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
no specific questions.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
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Background Information
HMP Hull
17. HMP Hull is a category B local prison for remanded and convicted prisoners over
the age of 18. It holds approximately 1,000 male prisoners. Spectrum Community
Health CIC provides healthcare services at the prison.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Hull was in April 2018. Inspectors reported that
the health provision was reasonable and governance was mostly effective, but
some health services had deteriorated since the last inspection. The team offered
an appropriate range of primary care clinics within an acceptable time limit. Social
care assessments were timely, and the provision was reasonably good. Healthcare
staff supported prisoners with the greatest mental health needs well, but the range
of interventions and staffing resources did not meet all low-level needs.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to July 2022, the IMB reported that
the previous healthcare provider City Health Care Partnership (CHCP) was failing
prisoners, with poor and inadequate service provision. The healthcare centre
provided a wide range of physical and mental health services, however the
effectiveness and quality of the delivery for those services were lacking under the
CHCP provider.
Previous deaths at HMP Hull
20. Mr Wardle was the sixteenth prisoner to die at Hull since May 2020. Of the previous
deaths, 11 were from natural causes, and four were self-inflicted. There are no
significant similarities with our findings in the investigation into Mr Wardle’s death
and the findings of the previous deaths at Hull.
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Key Events
21. On 22 October 2009, Mr Selby Wardle was remanded to HMP Leeds charged with
sexual offences. On 26 March 2010, he received an indeterminate sentence for
public protection (IPP) for rape with a minimum tariff of 12 years. On 24 November
2022, Mr Wardle was sentenced to a further nine years in prison for other sexual
offences.
22. Mr Wardle had a number of pre-existing health conditions, including bicuspid aortic
valve disorder, hypertension, osteoarthritis (degeneration of joint cartilage and
underlying bone) in both knees, prostate cancer in 2012, incontinence lumbar
spondylosis (an age-related degeneration of the vertebrae and disks in lower back)
arthritis, a hernia, asthma and high cholesterol.
23. On 30 June 2020, a GP at Hull calculated that Mr Wardle had a QRISK2 score of
27.97% which meant he had more than a one in four chance of having a heart
attack or stroke in the next 10 years. He discussed this with Mr Wardle and decided
to increase his statin medication to 40mg. Mr Wardle understood and was happy
with the plan.
24. During Mr Wardle’s time at Hull, he declined to attend numerous care planning
appointments, long-term condition reviews, annual reviews and hospital
appointments. For some of the missed appointments, Mr Wardle had signed a
disclaimer. Healthcare staff had no concerns about Mr Wardle’s capacity to make
these decisions. Mr Wardle’s last annual review took place on 2 December 2022,
but he declined to attend a care planning appointment on 21 March 2023.
25. On 18 April, a GP at the prison saw Mr Wardle, re-prescribed his medications, and
asked healthcare staff to complete a routine blood test. On 3 May, Mr Wardle
attended the clinic for his blood test. A Healthcare Assistant found that his blood
pressure was raised. There is no evidence that she escalated this to a senior
clinician as she should have done.
26. On 5 May, a GP at the prison reviewed Mr Wardle’s blood test results and they
were normal.
Events of 8 May 2023
27. At about 5.00am on 8 May, an OSG conducted the morning routine check and saw
Mr Wardle lying on the floor of his cell, unresponsive. He radioed a code blue
(indicating a prisoner is unconscious or is having breathing difficulties). Nursing and
prison staff responded to the code blue and went to Mr Wardle’s cell. They started
CPR and attached a defibrillator, which advised no shock to be given.
28. At 5:20am, ambulance paramedics arrived and took over Mr Wardle’s care and at
5.27am, a paramedic confirmed that Mr Wardle had died.
Contact with Mr Wardle’s family
29. On 8 May, the prison appointed a family liaison officer. He telephoned Mr Wardle’s
sister and informed her that Mr Wardle had died.
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30. Mr Wardle’s funeral took place on 18 May. The prison contributed to the funeral
costs in line with prison policy.
Support for prisoners and staff
31. After Mr Wardle’s death, a prison manager debriefed the staff who were involved
with the incident, to ensure they had the opportunity to discuss any issues arising,
and to offer support. Trauma in Management (TRiM) and PAM assist also offered
support to staff during this debrief.
32. The prison posted notices informing other staff and prisoners of Mr Wardle’s death
and offering support.
Post-mortem report
33. The post-mortem report gave Mr Wardle’s cause of death as acute myocardial
ischaemia, caused by ischaemic heart disease and severe coronary atheroma. He
also had chronic kidney disease and hypertension which did not cause but
contributed to his death.
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Findings
Clinical care
34. The clinical reviewer concluded that the clinical care Mr Wardle received at Hull was
of a good standard and was equivalent to what he could have expected to receive
in the community.
35. The clinical reviewer found that healthcare staff appropriately initiated and updated
the care plans for Mr Wardle’s long-term conditions.
36. The clinical reviewer made two recommendations about ensuring there is a process
in place to manage prisoners who refuse to attend medical appointments and
escalating unusual events, which we do not repeat in this report, but which the
Head of Healthcare will wish to address.
Good practice
37. Healthcare staff offered Mr Wardle appropriate care for his long-term health
conditions, including annual reviews. They saw him regularly and provided good
continuity of care.
38. Prison and healthcare staff responded well to the emergency response on 8 May
2023.
Inquest
39. At the inquest held on 2 July 2024, the coroner concluded that Mr Wardle died of
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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