Terrance Dass

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Terrance Dass,
a prisoner at HMP Littlehey, on
20 September 2022
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© 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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 Terrance Dass died on 20 September 2022 of acute airway obstruction at HMP
Littlehey. He was 68 years old. We offer our condolences to his family and friends.
4. The clinical reviewer concluded that the healthcare Mr Dass received at Littlehey
was equivalent to that which he could have expected to receive in the community.
The clinical reviewer did not make any recommendations.
5. An Operational Support Grade did not radio a medical emergency code when Mr
Dass collapsed in his cell, instead she radioed for urgent assistance. While we do
not think this warrants a recommendation, the Governor of Littlehey should ensure
staff are aware of the correct procedure when involved in a medical emergency.
6. This version of my report, published on my website, has been amended to remove
the names of staff and prisoners involved in my investigation.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
7. NHS England commissioned a clinical reviewer to review Mr Dass’ clinical care at
the prison. The clinical reviewer’s report is annexed.
8. The PPO investigator, investigated the non-clinical issues relating to Mr Dass’ care,
including Mr Dass’ location, the security arrangements for his hospital escorts,
liaison with his family and whether compassionate release was considered.
9. We informed the Coroner for Cambridgeshire and Peterborough of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
10. Mr Dass had not identified a named next of kin.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not identify any factual inaccuracies.
Previous deaths at HMP Littlehey
12. Mr Dass was the 35th prisoner to die at HMP Littlehey since September 2020. Of
the previous deaths, 33 were from natural causes and one was drug related. There
are no similarities between our findings in the investigation into Mr Dass’ death and
our investigation findings for the previous deaths.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
13. On 8 August 2007, Mr Terrance Dass was remanded to HMP Brixton charged with
multiple sexual offences. He was 53 years old. Over the years that followed, Mr
Dass transferred between prisons on several occasions. His final transfer was on
13 October 2020, to HMP Littlehey.
14. Mr Dass had pre-existing medical conditions, including COPD (the name given to a
range of respiratory conditions), type 2 diabetes and joint pain caused by arthritis.
2020-2021
15. When Mr Dass arrived at Littlehey, a prison nurse carried out an initial health
screen. She noted his medical conditions and updated his care plans. She also
referred him to the prison’s long-term clinics to manage his care.
16. The next day, the pharmacist reviewed Mr Dass’ prescribed medications. She noted
that in previous prisons, there had been occasions when Mr Dass had not used his
inhaler as prescribed. She made sure that he understood how to use his inhaler and
explained to him the importance of using his medications as prescribed.
2022
17. On 12 January 2022, Nurse A carried out a respiratory review. She checked Mr
Dass’ inhaler technique and recorded his level of breathlessness; oxygen saturation
level and respiratory rate and they were all within a normal range. However, Mr
Dass told the nurse that he felt that his fostair inhaler (used to open the airways)
was not effective. He agreed to try a different type of inhaler.
18. On 2 February, Nurse B saw Mr Dass after he reported a shortness of breath. He
told her that he was struggling with the change of inhaler. She checked that he was
using the inhaler correctly, and noted that following her review, his condition had
improved.
19. On 4 February, Nurse C saw Mr Dass after staff raised concerns about his health.
Mr Dass said that he had developed a persistent cough and had noticed traces of
blood in his phlegm. The nurse took a note of his observations and recorded his
oxygen saturation level as 91% (95-100% is a normal oxygen saturation level). She
noted that he appeared generally unwell and considered that he may have
developed pneumonia. Mr Dass was taken to hospital by emergency ambulance for
further review.
20. In hospital, Mr Dass was diagnosed with a chest infection. He was admitted to
hospital as an inpatient and prescribed a course of antibiotics. He was discharged
from hospital and returned to the prison on 6 February.
21. On 9 April, Nurse A saw Mr Dass after he again reported shortness of breath. She
discovered that despite regular support from healthcare staff, he had not been using
his inhaler as prescribed. She reminded him of the importance of using his inhaler
correctly. Healthcare staff reviewed Mr Dass regularly over the months that
followed.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Events of 20 September
22. At 4.25am on 20 September, Mr Dass pressed his emergency cell bell and told
Operational Support Grade (OSG) that he was experiencing shortness of breath.
The OSG went to the wing office and telephoned the prison control room to inform
them of Mr Dass’ condition, and to ask for the other staff on duty to attend his cell.
She then left the wing office and made her way back to Mr Dass’ cell to wait with
him.
23. However, as soon as she arrived at his cell, Mr Dass collapsed face upwards onto
the floor. The OSG radioed an urgent message and asked for assistance. She did
not radio a medical emergency code blue (indicating that a prisoner is unconscious
or is having breathing difficulties). At 4.27am, staff in the control room telephoned
for an emergency ambulance.
24. Prison staff arrived at the cell shortly afterwards. They immediately entered the cell
and checked Mr Dass for signs of life, but there were none. They commenced
cardiopulmonary resuscitation (CPR) and attached a defibrillator to Mr Dass’ chest,
but it did not find a shockable rhythm.
25. At 4.46am, paramedics arrived. They noted that the defibrillator pads were still
attached to Mr Dass’ chest and that the officers were continuing with CPR. The
paramedics checked for signs of life, but there were none. They advised staff to
stop CPR. At 5.27am, the paramedics confirmed that Mr Dass had died.
Post-mortem report
26. The post-mortem report concluded that Mr Dass died of acute airway obstruction.
He also had coronary artery disease, which did not cause but contributed to his
death.
Lisa Burrell October 2023
Assistant Ombudsman
Inquest
12. The inquest, heard on 13 December 2023, concluded that Mr Dass died from
natural causes.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE