Stephen Blackwell

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Independent investigation into the
death of Mr Stephen Blackwell,
a prisoner at HMP Oakwood,
on 18 January 2025
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
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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 Stephen Blackwell died in hospital of lung cancer on 18 January 2025, while a
prisoner at HMP Oakwood. He was 46 years old. We offer our condolences to his
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Blackwell received at
Oakwood was of a good standard and equivalent to that which he could have
expected to receive in the community. She made five recommendations relating to
the wider care Mr Blackwell received which the Head of Healthcare will wish to
address.
5. Due to concerns about his risk of falling and being unable to reach his emergency
cell bell if he needed help, Mr Blackwell was issued with a personal alarm.
However, records suggest that officers could not always hear it and had asked him
not to use it. The prison needs to ensure that prisoners issued with personal alarms
are located where they can be heard by staff and that staff have clear guidance on
how to respond to personal alarms.
Recommendations
• The Governor should carry out a review to:
• Establish whether personal alarms can be clearly heard by wing staff throughout
the day and night, or whether proximity of the cell to the wing office should be
considered when issuing one.
• Develop guidance on what is expected of wing staff when responding to
personal alarms; and
• Embed a robust quality assurance process to ensure that personal alarms are
being responded to promptly.
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The Investigation Process
6. HMPPS notified us of Mr Blackwell’s death on 19 January 2025.
7. NHS England commissioned an independent clinical reviewer to review Mr
Blackwell’s clinical care at HMP Oakwood.
8. The PPO investigator investigated the non-clinical issues relating to Mr Blackwell’s
care. She interviewed one member of staff from Oakwood on 9 May 2025.
9. The Ombudsman’s office wrote to Mr Blackwell’s son to explain the investigation
and to ask if he had any matters he wanted us to consider. He did not respond to
our letter.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. HMPPS pointed out a factual inaccuracy which has been
amended in this report. HMPPS provided an action plan which is annexed to this
report.
Previous deaths at HMP Oakwood
11. Mr Blackwell was the nineteenth prisoner to die at Oakwood since January 2022. Of
the previous deaths, 17 were from natural causes and one is still awaiting
classification. There are no similarities between the findings in our investigation into
Mr Blackwell’s death and the findings from our investigations into the previous
deaths.
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Key Events
12. On 16 August 2024, Mr Stephen Blackwell was sentenced to 11 years in prison for
sexual offences. He was moved to HMP Oakwood on 17 September.
13. On 1 October, Mr Blackwell went to the healthcare hub complaining of tingling in his
left arm. A healthcare assistant radioed a code blue (a medical emergency code
used when a prisoner is unconscious or having breathing difficulties that alerts
healthcare staff to attend and the control room to call an ambulance). A paramedic
at Oakwood responded and took Mr Blackwell’s clinical observations, which were all
within normal range. She cancelled the ambulance and scheduled a blood test for
the next day. Mr Blackwell said he had experienced this symptom before at his last
prison, but it had not been assessed.
14. On 2 October, Mr Blackwell had a blood test, which was abnormal. On 7 October, a
GP reviewed the results and was concerned about a high level of CRP (C-reactive
protein, a test for inflammation in the body). He advised to repeat the test in one
week. If the results were still abnormal, the GP would arrange an appointment with
Mr Blackwell.
15. On 15 October, an officer asked healthcare staff to check on Mr Blackwell as he
had weakness in his left arm. A nurse took his clinical observations and calculated a
NEWS2 score of zero. (The National Early Warning Score (NEWS2) is a tool used
to assess clinical deterioration. A score is calculated from the clinical observations
taken and the higher the score, the higher the risk. A score of zero is low risk.) She
asked for another blood test to be done the same day, the results of which were
abnormal.
16. On 18 October, a GP reviewed the blood test results and noted that the CRP level
was still high. The GP requested a follow up. On 21 October, a GP reviewed the
same set of blood test results and asked for the test to be repeated in two to three
weeks.
17. On 26 October, an officer radioed a code blue as Mr Blackwell had spasms in his
left arm. A paramedic at Oakwood responded and assessed him in his cell. She
took his clinical observations, which were all within normal range, and found no
weakness in his left arm at the time. She cancelled the ambulance and requested a
GP appointment.
18. On 29 October, while at education, Mr Blackwell had spasms in his arm. A nurse
assessed him, took his clinical observations, and calculated a NEWS2 score of
zero. She noted that there was no weakness in his left arm and recorded that he
was awaiting a GP appointment for this ongoing issue.
19. Later that day, Mr Blackwell went to the medical kiosk and told staff that he had lost
the use of his arm, was struggling to breathe, and kept collapsing. Healthcare staff
did not assess him again that day.
20. On 1 November, a GP examined Mr Blackwell to check how well his brain, spinal
cord and nerves were working. Mr Blackwell said he had collapsed at education that
morning, and a few days ago. He was unable to use his left arm and complained of
pressure in his head. The GP referred him to A&E for further assessment.
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21. On 2 November, while at hospital, Mr Blackwell had a CT scan which showed
multiple growths on his brain, which could be tumours.
22. On the morning of 3 November, Mr Blackwell discharged himself from hospital
against medical advice, which meant he did not have more tests on his brain.
23. Later that evening, Mr Blackwell’s cellmate found him collapsed on the floor and
called for help. A nurse took his clinical observations, which were normal, and found
he was conscious and alert. Mr Blackwell told her that he had pressure in his head,
so she advised he went back to hospital. An ambulance was called, and
paramedics took him to A&E.
24. On 4 November, Mr Blackwell had a further CT scan, which showed he had cancer
that had spread to his brain. Doctors told him that further tests were needed to find
the source of the cancer.
25. On 13 November, Mr Blackwell had a CT tap (where a CT scan is used to guide a
doctor, taking a small amount of fluid from the spinal cord to check for infections or
other conditions). The results suggested he had lung cancer, but the doctors were
unsure if this started in the lung or if it had spread from another part of the body.
26. On 15 November, a lung specialist told Mr Blackwell that his cancer was terminal,
and he would be started on palliative care.
27. On 18 November, a nurse at Oakwood referred Mr Blackwell to the palliative in-
reach care team for support with managing his symptoms when he returned from
hospital. On 20 November, Mr Blackwell was discharged and returned to Oakwood.
28. On 22 November, Mr Blackwell was allocated a wing carer to help him with daily
activities including making his bed and cleaning his cell. Mr Blackwell struggled to
do these tasks independently due to weakness in his arm and poor balance.
29. On 26 November, a nurse assessed Mr Blackwell in his cell. He told her that he had
a terminal diagnosis but was going to have any available treatment to prolong his
life.
30. On 27 November, a nurse at Oakwood completed a falls assessment for Mr
Blackwell. She referred him to Occupational Therapy (OT, helps people improve
their ability to perform everyday activities) to see if there were any supportive
measures that could be put in place to help him with his balance. She also
undertook a clinical risk assessment on the use of restraints on Mr Blackwell for his
visits to hospital and recommended that he should not be handcuffed due to his
diagnosis and frailty in his left arm and leg.
31. On 3 December, a nurse at Oakwood was told by the palliative care team that Mr
Blackwell’s prognosis was six months to a year, and he would be told this at his
next hospital appointment. The nurse asked the hospital to provide a report
confirming his prognosis so they could start an Early Release on Compassionate
Grounds (ERCG) application.
32. On 6 December, an oncologist (cancer doctor) diagnosed Mr Blackwell with lung
cancer that had spread to other parts of his body. He told him that his prognosis
was between six months to a year. Mr Blackwell was handcuffed for his hospital
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appointment. This was due to a member of healthcare staff accessing the wrong
record. She acknowledged that in future she must check the prisoner number rather
than searching just by surname. Mr Blackwell was not handcuffed again after this.
33. On 17 December, following a social care assessment, prison staff gave Mr
Blackwell a personal wrist alarm so he could alert officers if he had fallen or needed
urgent help. (A personal alarm emits a loud sound when pressed, which continues
until it is switched off by pressing a button on the alarm.) However, Mr Blackwell
refused to wear it as it was dirty. A nurse asked for a replacement alarm to be
issued, which was given to him the next day. Mr Blackwell was still awaiting a
formal prognosis from the hospital for his ERCG application.
34. On 2 January 2025, Mr Blackwell told a palliative care nurse that he did not want to
proceed with his application for ERCG until after he had completed immunotherapy
treatment (where the immune system is used to treat cancer). Due to his anxiety,
prison staff paused his application and continued to speak to him about his
concerns.
35. On 7 January, at around 8.15pm, Mr Blackwell pressed his personal alarm. When
an officer responded, Mr Blackwell said he was having chest pains, and the officer
radioed a code blue. A nurse arrived and found Mr Blackwell alert, sitting on his
bed. Mr Blackwell said that he had had a bad convulsion before pressing his alarm
and he thought he was having a stroke. The nurse took his clinical observations and
checked for any signs of weakness that would indicate a stroke. The nurse
assessed that Mr Blackwell appeared stable, but did not cancel the ambulance as
they wanted the paramedics to assess him. When the ambulance arrived,
paramedics did an electrocardiogram (ECG, a test to check the rhythm and
electrical activity of the heart) and took further clinical observations, which were all
normal. The paramedics advised that Mr Blackwell did not need to go to hospital,
but healthcare staff should contact them again if his symptoms worsened.
36. On 15 January, Mr Blackwell told a nurse at Oakwood that he was worried that if he
was released, his treatment would not continue to the same standard. The nurse
reassured him that this would not affect his treatment. However, he said he still did
not want to continue with the ERCG application at this time. She agreed to continue
to speak with him about this.
Events on 16 January
37. On 16 January at 10.31pm, Mr Blackwell pressed his emergency cell bell. An officer
attended his cell within two minutes. Mr Blackwell told him that he was in pain.
38. Later that evening, Mr Blackwell pressed his personal wrist alarm. A prisoner in a
neighbouring cell pressed his emergency cell bell at 10.46pm to alert officers to Mr
Blackwell’s alarm. An officer responded at 10.47pm. The officer then visited Mr
Blackwell’s cell and advised him to use his cell bell for any further assistance, as he
would not be able to hear the personal alarm. Mr Blackwell did not press his cell bell
again that evening.
39. On 17 January, at around 4.30am, an officer carried out a roll count (a check to
confirm prisoners are in their cells). The officer did not report any issues.
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40. At around 7.45am, an officer unlocked the cells on Mr Blackwell’s wing. Officers are
supposed to get a positive response from each occupant during unlock to ensure
they are alive and well. During an internal investigation, the officer said that she had
tried to get a response from Mr Blackwell and she heard a grunt. She did not open
the door fully and so did not get a visual sighting of him. The investigation
concluded that the officer had not properly checked on Mr Blackwell and a formal
warning was issued.
41. At around 7.50am, a prisoner alerted an officer as they found Mr Blackwell on the
floor of his cell. Mr Blackwell told the officer that he had tried to get out of bed and
slipped at approximately 4.00am. When the officer asked why he had not pressed
his wrist alarm, Mr Blackwell said that he had been ‘told off’ for pressing it the night
before. A nurse took his clinical observations and calculated a NEWS2 score of 1
(which is low risk) and found no signs of injury. She arranged for social care staff to
help clean up Mr Blackwell and make him more comfortable.
42. At 3.25pm, a nurse and social worker reviewed Mr Blackwell to see whether he
needed more support in place. Mr Blackwell’s carer was in his cell and told the
nurse that Mr Blackwell had not got out of bed since the morning and had not eaten.
Mr Blackwell had pain in his legs and was unable to stand. The nurse took his
clinical observations and calculated a NEWS2 score of 12 (which indicates a very
high risk) and radioed a code blue as she suspected Mr Blackwell had sepsis (a life-
threatening condition where the body's response to an infection damages its own
tissues and organs). An ambulance arrived and paramedics took Mr Blackwell to
hospital for further treatment.
43. At hospital, Mr Blackwell continued to deteriorate overnight and despite treatment,
he died on 18 January.
Cause of death
44. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave the cause of death as
severe pneumonia (an infection in the lungs), caused by metastatic lung cancer
(cancer which has spread to other parts of the body).
45. At the inquest, held on 31 July 2025, the Coroner concluded that Mr Blackwell died
from natural causes.
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Findings
Clinical findings
46. The clinical reviewer concluded that the care Mr Blackwell received at Oakwood
was of a good standard overall and was equivalent to that which he could have
expected to receive in the community.
47. While the clinical reviewer made some recommendations, mainly about healthcare
systems and potential training needs, she did not find any elements of healthcare
delivery that would have impacted negatively on Mr Blackwell or his cause of death.
48. We do not repeat the clinical reviewer’s recommendations here, but the Head of
Healthcare will wish to address them.
Use of personal alarms
49. All cells are equipped with an emergency cell bell which prisoners should press if
they require urgent help. When a cell bell is pressed, an alarm is sounded in the
wing office and a display shows which cell has activated their cell bell. A light is also
activated outside the cell. The cell bell is switched off by a member of staff going to
the cell and deactivating the bell by switching it off outside the cell. Staff are
expected to respond within five minutes. Cell bell use is recorded to show the time
cell bells are activated and deactivated by staff.
50. Prisoners at risk of falls or who may not be able to easily access their emergency
cell bell, may be issued with a personal alarm, as Mr Blackwell was. Personal
alarms emit a loud sound from the device itself. There is no notification in the office
of a personal alarm being activated and no record of when personal alarms are
activated or deactivated. A response relies on a member of staff on the wing
hearing the personal alarm, or a prisoner in a nearby cell pressing their cell bell to
alert staff.
51. There were evidently problems with officers being able to hear Mr Blackwell’s
personal alarm. On the evening of 16 January, a neighbour pressed his emergency
cell bell to alert staff that Mr Blackwell had activated his personal alarm. When an
officer responded, he told Mr Blackwell not to use his personal alarm as he would
not hear it and to use his cell bell instead. This defeats the whole point of a personal
alarm which is issued to those who may not be able to access the cell bell, either
because they have fallen or have poor mobility within the cell.
52. The next morning, Mr Blackwell was found on the floor of his cell. He told the officer
that he had not pressed his personal alarm as he had been ‘told off’ during the night
for pressing it.
53. The investigator interviewed the Head of Safety at Oakwood, who has oversight of
the use of personal alarms. She said that staff were expected to respond within five
minutes, in line with expected response times for cell bells, though she said there
was no written policy. It was her understanding that personal alarms could be heard
in the wing office and she was unaware of the issues raised in this case. She said
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she would investigate to establish if it was a widespread issue. (We have not been
able to confirm if she has yet carried out the review.)
54. The Head of Safety told the investigator that currently, there is no consideration of
where prisoners who have personal alarms are located, in relation to the wing
office. She also told the investigator that currently there is no written policy on how
officers should respond to personal alarms, specific training provided, or quality
assurance process. She agreed that this was something she would address.
55. We recommend:
• The Governor should carry out a review to:
• Establish whether personal alarms can be clearly heard by wing staff
throughout the day and night, or whether proximity of the cell to the wing
office should be considered when issuing one.
• Develop guidance on what is expected of wing staff when responding to
personal alarms; and
• Embed a robust quality assurance process to ensure that personal alarms
are being responded to promptly.
Adrian Usher
Prisons and Probation Ombudsman September 2025
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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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