Stuart Greener

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Independent investigation into
the death of Mr Stuart Greener,
a prisoner at HMP Nottingham,
on 16 October 2024
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 Stuart Greener died due to metastatic colorectal cancer (cancer that started in
the bowel then spreads to other parts of the body) on 16 October 2024, while a
prisoner at HMP Nottingham. He was 48 years old. We offer our condolences to Mr
Greener’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Greener received at
Nottingham was of a good standard and was equivalent to that which he would
have received in the community.
5. We found that Mr Greener was inappropriately restrained when he was admitted to
the hospital on 8 October 2024. His failing health and mobility was not properly
considered.
Recommendations
• The Governor and Head of Healthcare should implement a robust quality assurance
process, to ensure that healthcare staff properly record and authorising managers
evidence that they have taken into account medical information when completing
the escort risk assessment.
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The Investigation Process
6. HMPPS notified us of Mr Greener’s death on 16 October 2024.
7. NHS England commissioned an independent clinical reviewer to review the clinical
care Mr Greener received at Nottingham.
8. The PPO investigator investigated the non-clinical issues relating to Mr Greener’s
care.
9. We informed HM Coroner for Nottingham City and Nottinghamshire of the
investigation. The cause of death was determined at the hospital without need for
post-mortem. We have sent the Coroner a copy of this report.
10. The Ombudsman’s office wrote to Mr Greener’s next of kin, to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
Previous deaths at HMP Nottingham
11. Mr Greener was the eleventh prisoner to die at Nottingham in the last three years.
Of the previous deaths, seven were from natural causes, one was from drugs
toxicity, two were self-inflicted and one was a homicide. To the end of February
2025, there has been one more natural cause death at Nottingham.
12. In three recent investigations, we have highlighted that escort risk assessments did
not properly consider the health and mobility of the prisoner when determining
whether restraints were required during hospital visits. In their action plan to our
most recent recommendation, which we received in October 2023, Nottingham said
that they were reviewing their local escort risk assessment to ensure that
appropriate consideration of prisoners’ health and mobility were recorded, including
that healthcare staff complete the medical assessment.
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Key Events
13. On 27 April 2017, Mr Stuart Greener was sentenced to 12 years imprisonment for
attempted murder.
14. In January 2023, Mr Greener was released on licence. In June 2023, he was
recalled and sent to HMP Nottingham.
15. At the time of his arrival, healthcare staff documented that Mr Greener had been
diagnosed in July 2022 with stage four terminal colon cancer with multiple
secondary tumours. He remained under the care of Nottingham City Hospital for
palliative chemotherapy.
16. In July 2023, Mr Greener was informed by his oncologist that his prognosis had
reduced from two to three years to nine to twelve months.
17. Mr Greener was supported by the prison healthcare team, hospital and community
specialists. He remained relatively well and able to self-care on the wing, until
August 2024.
18. On 9 August, Mr Greener was admitted to hospital for significant disease
progression and, due to this rapid decline, he was transferred to Hayward House, a
specialist palliative care unit, for end of life care. After a few weeks, Mr Greener’s
health had improved so that he was well enough to return to Nottingham on 29
August.
19. On 2 September, Mr Greener was admitted to hospital again due to partial blockage
of his lower bowel. Mr Greener was advised to have a palliative stoma (surgery
allowing waste to leave the body) to relieve the symptoms, but he declined. He did
agree to have a new colonic stent inserted and a liquid diet to aid with his bowel
blockage to allow his return to Nottingham on 9 September
20. On 1 October, healthcare staff identified extensive distension of the abdomen
(stomach abnormally swollen or enlarged) and oedema of the legs (swollen legs).
21. On 8 October, Mr Greener was admitted to hospital as he had stopped passing
urine and had vomited faecal matter. Prison staff completed an escort risk
assessment before Mr Greener left for hospital, and concluded that he should be
restrained using an escort cable (a length of strong metal cable with a handcuff at
either end, one attached to the prisoner’s wrist and the other to an officer).
22. The medical assessment section of the escort risk assessment was blank. Prison
staff told us that it was completed separately but they could not locate it after Mr
Greener died. In the escort risk assessment, prison staff assessed that Mr Greener
was a low risk of escape and to the public.
23. On 11 October, a palliative stoma was arranged but Mr Greener declined the
intervention because of the pain he was experiencing.
24. On 12 October, bedwatch staff recorded that Mr Greener’s condition continued to
decline, that his stomach and legs were severely swollen and that his mobility was
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extremely limited. An operational manager authorised that the handcuffs should be
removed.
25. On 15 October, Mr Greener continued to deteriorate, becoming drowsy and
requiring oxygen therapy. He was placed onto the end-of-life care pathway. Mr
Greener declined the opportunity to contact his next of kin.
26. On 16 October, Mr Greener died in hospital.
Post-mortem report
27. The Coroner chose not to request a post-mortem examination and relied on the
cause of death proposed by the hospital. The was recorded as metastatic colorectal
cancer (cancer that started in the bowel and spreads to other parts of the body).
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Findings
Clinical findings
28. The clinical reviewer considered that the care Mr Greener received at Nottingham
was of a good standard and equivalent to that which he could have expected to
receive in the community. The clinical reviewer commended Mr Greener’s named
nurse for her consistent professionalism and compassion to ensure that Mr Greener
received optimal palliative care within the prison environment.
Restraints, security and escorts
29. 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. 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.
30. Mr Greener was a 48-year-old man, who had a history of poor health and a terminal
cancer diagnosis. When he was admitted to hospital on 8 October 2024, he had
oedema (swollen legs) which affected his mobility and his admission was following
a period in which he had vomited faecal matter (indicating a serious health issue).
31. The medical assessment of the escort risk assessment is missing, and we do not
therefore know the extent to which Mr Greener’s current health and mobility were
considered in the escort risk assessment. Nevertheless, his symptoms and medical
history on that occasion, in line with the High Court judgement, meant that it is likely
that his risk could have been effectively managed by the officers accompanying him
without the use of restraints. The decision to restrain him was not proportionate to
his risk.
32. We frequently raise concerns about how well healthcare staff understand, or feel
empowered, to make a meaningful contribution to the risk assessment process,
such as in this case. In March 2024, we recommended that NHS England develop
national guidance for establishments to develop local standard operating
procedures for healthcare input into restraints risk assessments. This
recommendation was accepted, and NHS England told us that they are working
with HMPPS to review the Prevention of Escapes – External Escorts Policy
Framework, with particular focus on the escort risk assessment. We also welcome
the work that the Operational Security Group Director has undertaken to review and
amend the national risk assessment form, mandate its use and provide additional
guidance to staff responsible for making decisions about the use of restraints.
33. We have made previous recommendations about the use of restraints at
Nottingham, and particularly about proper completion and consideration of the
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medical assessment. In their response to our most recent recommendation
(received in October 2023), Nottingham said that they were reviewing the local
escort risk assessment and providing refresher training to staff responsible for
completing risk assessment sections. They said that their review would ensure that
every risk assessment was fully completed before discharge to hospital, including
that healthcare staff complete the medical assessment with the prisoners’ current
medical condition and whether it affects their mobility and ability to escape.
Nottingham said that their training would include sessions for authorising managers
to include evidencing that healthcare information had been considered.
34. Although Nottingham has taken this action, it is apparent from Mr Greener’s case
that escort risk assessments do not always consider pertinent health information. It
is important that staff properly consider the prisoner’s health and mobility when
determining the appropriate use of restraints. We make the following
recommendation:
The Governor and Head of Healthcare should implement a robust quality
assurance process, to ensure that healthcare staff properly record and
authorising managers evidence that they have taken into account medical
information when completing the escort risk assessment.
Inquest
35. The inquest into Mr Greener’s death concluded on 14 January 2025, and returned a
verdict of natural causes.
Adrian Usher
Prisons and Probation Ombudsman July 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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