William Stapylton

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Independent investigation into the
death of Mr William Stapylton,
a prisoner at HMP Holme House,
on 6 March 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
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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 William Stapylton died of bronchopneumonia caused by gangrene in his foot on
6 March 2023, at HMP Holme House. He was 64 years old. We offer our
condolences to Mr Stapylton’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Stapylton received at
Holme House was of a good standard and equivalent to what he could have
expected to receive in the community. She made recommendations about clinical
handovers, a missed welfare check in January 2023, delays in completing a falls
risk assessment and recording clinical scores and mental health capacity
assessments accurately, which we do not repeat here but which the Head of
Healthcare will wish to address.
5. We found no non-clinical issues of concern. We make no recommendations.
Prisons and Probation Ombudsman 1
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The Investigation Process
6. HMPPS notified us of Mr Stapylton’s death on 6 March 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr
Stapylton’s clinical care at Holme House.
8. The PPO investigator investigated the non-clinical issues relating to Mr Stapylton’s
care.
9. The PPO family liaison officer wrote to Mr Stapylton’s brother, 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. The initial report was shared with HMPPS. They did not find any factual
inaccuracies.
Previous deaths at HMP Holme House
11. Mr Stapylton was the twentieth prisoner to die at Holme House since March 2020.
Of the previous deaths, 15 were from natural causes, three were self-inflicted and
one was drug related. Up to the end of 2023, there have been three deaths from
natural causes since Mr Stapylton’s death. There are no similarities between the
findings in our investigation into Mr Stapylton’s death and the findings from our
investigations into the other deaths.
2 Prisons and Probation Ombudsman
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Key Events
12. On 26 November 2021, Mr William Stapylton was sentenced to 14 years in prison
for sexual offences and sent to HMP Durham.
13. Mr Stapylton had a complex and long medical history of heart disease and Type 2
diabetes which were diagnosed before he went to prison. He used a walking stick
and Zimmer frame to move around. For several years he had refused medical
treatment and had been assessed as having the mental capacity to make such
decisions. At Durham, Mr Stapylton signed a Do Not Attempt Cardiopulmonary
Resuscitation (DNACPR) order confirming that he did not want anyone to
resuscitate him if his heart or breathing stopped.
14. On 2 March 2022, Mr Stapylton was transferred to HMP Holme House.
15. During his reception health screen at Holme House, Mr Stapylton confirmed his
wishes to only have medication for symptom control but not to have any regular
medication, treatment and visits to hospital. Mental health staff conducted an
assessment and concluded that Mr Stapylton had the mental capacity to make
treatment decisions. Mr Stapylton agreed to have an allocated named nurse and to
be added to the complex case register to discuss his healthcare needs. He said that
he was aware that his refusal to have any treatment for his heart condition and
diabetes could be detrimental. Mr Stapylton said that his preferred place of death
was in prison.
16. On 3 March at Mr Stapylton’s secondary health screen, a GP at the prison
discussed the DNACPR order and completed an emergency health care plan
(EHCP) to update Mr Stapylton’s preferences for all aspects of his care and
treatment. The next day, healthcare staff added Mr Stapylton to the palliative care
register. However, he declined any input from the palliative care team.
17. Healthcare staff met Mr Stapylton regularly and they tried to encourage him to allow
them to monitor his conditions. He refused to have any diabetic or cardiac reviews,
vaccinations or medication. He stressed that he did not want to attend hospital
under any circumstances. The mental health team assessed that Mr Stapylton had
the mental capacity to make these decisions.
18. On 17 May, Mr Stapylton complained about a loss of sensation in his feet.
Healthcare staff completed a referral to a podiatrist who diagnosed a fungal nail
infection and prescribed a lacquer to treat this.
19. On 4 August, healthcare staff noted that Mr Stapylton had a toe infection. He
refused oral antibiotics and agreed to topical antibiotics.
2023
20. On 20 January 2023, a GP at the prison reviewed Mr Stapylton and diagnosed
possible impending sepsis. However, Mr Stapylton refused to have blood tests,
referral to hospital or antibiotics and only agreed to pain relief. He was again
assessed as having the capacity to make these decisions. He agreed to move to
the prison’s inpatient unit for closer monitoring.
Prisons and Probation Ombudsman 3
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21. Mr Stapylton’s left foot began to deteriorate and despite frequent GP reviews, he
refused any treatment or a hospital referral. His left foot became infected, and it was
suspected this had caused sepsis. He was bedbound and healthcare staff arranged
for his cell door to remain unlocked to allow them to attend to his needs easily.
22. On 6 March 2023, healthcare staff found Mr Stapylton unresponsive in his cell in the
prison’s healthcare unit. Paramedics attended and confirmed his death.
Post-mortem report
23. The post-mortem report concluded that Mr Stapylton died of bronchopneumonia
caused by gangrene of the foot. Established ischaemic heart disease was also
listed as a contributory factor.
Good practice
24. Prison GPs and healthcare staff ensured that Mr Stapylton was fully aware of the
consequences of refusing treatment for his medical conditions. His decisions to
refuse treatment limited his healthcare options. Mental health specialists assessed
that he had the capacity to refuse treatment on a regular basis. Healthcare staff
continued to engage with him and offered a good level of support.
Adrian Usher
Prisons and Probation Ombudsman March 2024
Inquest
The inquest, held on 3 May 2024, reached the following narrative conclusion:
Mr Stapylton had been offered medical treatment and assistance on a number of
occasions but refused medical treatment, he declined and died.
4 Prisons and Probation Ombudsman
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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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