Trevor Coady

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Independent investigation into
the death of Mr Trevor Coady,
a prisoner at HMP Bullingdon,
on 24 September 2021
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 HM 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 Trevor Coady died in hospital on 24 September 2021, while a prisoner at HMP
Bullingdon. The cause of his death was COVID-19 pneumonitis. He also had
underlying blood cancer. Mr Coady was 56 years old. I offer my condolences to his
family and friends.
4. The clinical reviewers found that Mr Coady’s care was equivalent to that which he
could have expected to receive in the community. They made recommendations
unrelated to his cause of death, which the Head of Healthcare should consider.
They also noted areas of good practice.
5. We make no recommendations on non-clinical issues.
6. We do not know whether Mr Coady caught the infection at the prison, or during a
hospital appointment.
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The Investigation Process
7. We were notified of Mr Coady’s death on 24 September 2021. NHS England and
NHS Improvement (NHSE&I) commissioned a review of Mr Coady’s clinical care at
HMP Bullingdon. The appointed clinical reviewer conducted this on their behalf.
8. PPO investigators investigated the non-clinical issues relevant to Mr Coady’s death.
9. The Ombudsman’s family liaison officer wrote to Mr Coady’s next of kin, his partner,
to explain the investigation and ask if there were any issues she wanted us to
consider. She did not respond.
10. We shared the initial report with HM Prison and Probation Service. They found no
factual inaccuracies.
Previous deaths at HMP Bullingdon
11. Mr Coady was the sixteenth prisoner at Bullingdon to die since September 2018. Of
the previous deaths, nine were from natural causes (one due to COVID-19), four
were self-inflicted and one was drug-related, and one was unascertained. There
have since been eight deaths, six from natural causes (one due to COVID-19), one
self-inflicted and one unascertained. There are no significant similarities between
our findings in the investigation into Mr Coady’s death and those of previous deaths
at Bullingdon.
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Background Information
COVID-19 (coronavirus)
12. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
13. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. In response to the
pandemic, HM Prison and Probation Service (HMPPS) introduced several
measures to try and contain outbreaks - to be implemented at local level, depending
on the needs of individual prisons. (A key strategy was ‘compartmentalisation’ to
cohort and protect prisoners at high and moderate risk; isolate those who are
symptomatic; and separate newly arrived prisoners from the main population.)
14. In September 2021, the shielding programme ended in the community, but HMPPS
continued to routinely offer shielding to clinically high-risk prisoners. This has since
been replaced by a system of individual risk assessments by clinical staff, to
determine the measures necessary to support such prisoners. The agreed
adjustments are documented in a Personal Management Plan, which is then
facilitated by operational staff.
15. COVID-19 policies on testing and managing symptoms have changed to align with
those for people in the community. Further guidance on managing COVID-19 in
prisons was issued and updated in September 2023.
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Key Events
16. Mr Trevor Coady was on remand at HMP Bullingdon between 9 and 27 April 2021,
charged with handling stolen goods. It was not his first time in prison.
17. At reception health screens and a GP review, it was noted that Mr Coady had blood
cancer (newly diagnosed), with a mass in his abdomen and enlarged lymph nodes
in his neck. (His diagnosis was later recorded as small lymphocytic lymphoma.) Mr
Coady also had type 1 diabetes, ischaemic heart disease, coronary artery disease
and congestive cardiac failure.
18. On 13 April, the GP urgently referred Mr Coady to a lymphoma specialist. On the
same day, healthcare staff gave him a letter advising that he was at high risk of
complications if he contracted COVID-19 and that he should shield. There is no
record of whether he did so, but it was noted that he refused the COVID-19 vaccine.
19. On 27 April, Mr Coady was convicted and released on bail to await sentencing.
20. On 30 July, Mr Coady was sentenced to 31 months imprisonment and returned to
Bullingdon. His reception health screen revealed no additional health concerns. He
was given advice about COVID-19 and again refused the vaccine. Due to his poor
health, he was offered a cell in the healthcare inpatient unit, but he declined. In line
with HMPPS’ national policy at that time, he was subject to reverse cohorting for 14
days, to avoid contact with other prisoners.
21. On 3 August, Mr Coady changed his mind and moved to the inpatient unit. A nurse
created a wide-ranging care plan and took clinical observations. As the results were
not within normal range, Mr Coady was sent to hospital (and returned on 7 August).
22. On 4 August, the prison began to consider Release on Temporary Licence (ROTL)
to facilitate hospital treatment and a family liaison officer was appointed. On 6
August, Mr Coady’s solicitors wrote to the Governor, requesting early release on
compassionate grounds.
23. When informed that his cancer was treatable, Mr Coady declined chemotherapy
and said he wanted to explore alternative therapies. Over the following weeks,
healthcare staff reviewed him hourly, increasing this to half-hourly when his
condition worsened. He was often challenging in his dealings with both healthcare
and hospital staff and did not always accept medical advice.
24. On 2 September, Mr Coady and his haematology consultant discussed treatment
options. A nurse from the prison accompanied him to the appointment. He was
informed that acalabrutinib (a type of chemotherapy drug) would extend his life
expectancy by 15 to 20 years, but he would only live for 3 to 6 months without the
proposed treatment. Mr Coady disagreed. He felt it would not be effective and he
would achieve a better result with organic fruit and vegetables, as well as
alternative therapies. The next day, Mr Coady changed his mind, and a hospital
appointment was arranged.
25. On 11 September, Mr Coady went to hospital to be checked for possible sepsis and
returned the same day.
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26. Mr Coady refused to attend a hospital appointment on 16 September, as it
coincided with a family visit. Healthcare staff spoke to him about the importance of
the appointment, but he insisted that he would not go.
27. On 17 September, a nurse discussed with Mr Coady concerns that he had raised
about his care. She then arranged for him to be moved to a cell closer to the
nurses’ office and reminded him of the risks to his health by refusing to attend
appointments and delaying treatment.
COVID-19 test and final admission to hospital
28. Between 18 and 20 September, Mr Coady felt particularly unwell, with a raised
temperature, low blood oxygen level and low blood pressure. A GP prescribed
antibiotics for a chest infection. On 20 September, Mr Coady tested positive for
COVID-19 and was placed in protective isolation.
29. On 21 September, a healthcare assistant, took clinical observations. Using the
National Early Warning Score 2 (NEWS2), she calculated an overall score of 7,
which indicated the need for an urgent assessment by a critical care team. (NEWS2
is a clinical assessment tool to detect acute illness).
30. Mr Coady was taken to hospital and treated in the respiratory high dependency unit.
He was escorted by two prison officers. No restraints were used and ROTL was
approved for his admission.
31. On 24 September, Mr Coady became unresponsive. Attempts to resuscitate him
were unsuccessful and he died.
32. Hospital staff informed Mr Coady’s partner of his death and the prison’s family
liaison officer contacted her to offer condolences and support. The family liaison
officer kept in touch over the following weeks.
33. A member of the care team spoke to the escort staff and a representative of the
prison chaplaincy supported healthcare staff.
34. Mr Coady’s funeral took place on 19 October. The prison contributed to the funeral
expenses, in line with national policy.
Cause of death
35. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Coady’s cause of death
as COVID-19 pneumonitis. Mr Coady also had untreated advanced small
lymphocytic lymphoma.
Inquest
36. An inquest was completed on 24 March 2022 and concluded that Mr Coady’s death
to have been the result of natural causes.
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Findings
Clinical Findings
37. The clinical reviewers concluded that Mr Coady’s clinical care was equivalent to that
which he could have expected to receive in the community. However, they identified
areas for improvement, including escalation of worsening symptoms; completing
formal mental incapacity assessments; and advance care planning. As these issues
were not directly related to the cause of Mr Coady’s death, we do not repeat them in
this report. Full details of the clinical findings are in the clinical review report and the
Head of Healthcare will need to consider the recommendations.
38. The clinical reviewers also found several examples of good practice, such as
regular and thorough monitoring; multi-disciplinary meetings with a broad range of
professionals; and effective liaison between the dietician and the catering services.
They also noted excellent record keeping by Healthcare Assistant Karen Blackman.
Management of Mr Coady’s risk of infection from COVID-19
39. During the pandemic, HMPPS’ national policy required prisons to implement
protective measures to manage the risks associated with COVID-19. This included
identifying and offering shielding to prisoners at the highest risk of serious illness
from COVID-19; and isolating newly arrived prisoners, as well as those returning
from periods away from the prison.
40. Healthcare staff notified Mr Coady that he was high risk of complications from
COVID-19. However, there was no evidence that he was given the option to shield,
in line with national guidance at that time. Neither was there any record of whether
he self-isolated after inpatient admissions to hospital.
41. We recognise that as a resident in the inpatient unit, Mr Coady’s contact with the
wider prison was restricted and healthcare staff would have been very aware of the
necessary precautions for patients in the unit. However, it is important for the
wellbeing of both prisoners and staff that prisons demonstrably follow the guidance
on managing those at risk during a pandemic. Given the lapse of time and the
change in COVID-19 policies, we make no further comment.
Monitoring Mr Coady after he contracted COVID-19
42. Mr Coady was promptly tested and isolated, and closely monitored in response to
symptoms of COVID-19. When his clinical observations suggested he was
deteriorating, healthcare staff sent him to hospital quickly.
43. We do not know where Mr Coady contracted COVID-19. The symptoms are thought
to develop up to 14 days after the person is infected with the virus, so he could
have been exposed to it at Bullingdon, or during a hospital appointment.
Adrian Usher
Prisons and Probation Ombudsman December 2023
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