Alan Giles

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Independent investigation into
the death of Mr Alan Giles,
a prisoner at HMP Wayland, on
7 December 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, 2025
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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.
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.
Mr Alan Giles died of citalopram (prescribed antidepressant medication) toxicity on 7
December 2023 at HMP Wayland. He was 71 years old. I offer my condolences to Mr
Giles’ family and friends.
Mr Giles was prescribed citalopram throughout his time in prison and had been stable on
the same dosage for over three years. No clinical concerns with his dosage were raised
and healthcare staff reviewed him regularly. The healthcare team were satisfied that Mr
Giles was taking his medication appropriately. There is no evidence that Mr Giles was at
risk of suicide and self-harm or that he intentionally took more citalopram than he should
have done.
The clinical reviewer concluded that the clinical care Mr Giles received at Wayland was
good and equivalent to what he could have expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman December 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. On 19 November 2019, Mr Alan Giles was remanded to HMP Chelmsford charged
with shooting and wounding with intent to do grievous bodily harm. On 29 May
2020, he was sentenced to 10 years in prison. He remained at Chelmsford until he
was transferred to Swaleside in July 2020, he then later transferred to Wayland in
April 2023.
2. Mr Giles had pre-existing medical conditions which included depression and
hypertension. He was managed appropriately by healthcare staff for his conditions.
Mr Giles was prescribed 40mg of citalopram (antidepressant), which he was
allowed to keep in his cell.
3. Between April and September, the GP at Wayland considered whether Mr Giles’
citalopram dose should be reduced to 20mg (in line with national guidance related
to the maximum citalopram dosage for people aged over 65). The GP conducted
tests and concluded that the dose should remain at 40mg.
4. At around 11.40am on 7 December, an officer found Mr Giles unresponsive in his
bed. The officer raised the alarm and staff attended. Healthcare staff identified signs
that Mr Giles had died and so stopped resuscitation efforts. At 12.41pm, the
paramedics confirmed that Mr Giles had died.
Findings
5. The clinical reviewer concluded that the clinical care Mr Giles received at Wayland
was good and equivalent to what he could have expected to receive in the
community.
6. Mr Giles was prescribed citalopram throughout his time in prison. The clinical
reviewer concluded that the GP’s decision to keep Mr Giles on the higher dose of
citalopram was reasonable and based on a clinical decision that the benefits
outweighed the risks.
7. There were no concerns highlighted from the healthcare team that Mr Giles was not
taking his medication appropriately.
8. The Head of Healthcare, and the pharmacist at Wayland, could not confirm whether
Mr Giles had taken more than his daily dose of citalopram because his medication
was not returned to healthcare following the cell clearance after Mr Giles died.
9. There is no evidence that Mr Giles was at risk of suicide and self-harm or that he
intentionally took more citalopram than he should have done.
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The Investigation Process
10. HMPPS notified us of Mr Giles’ death on 7 December 2023.
11. The investigator issued notices to staff and prisoners at HMP Wayland informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Giles’ prison and
medical records.
13. NHS England commissioned a clinical reviewer to review Mr Giles’ clinical care at
the prison.
14. We informed HM Coroner for Norfolk of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
15. The Ombudsman’s office contacted Mr Giles’ family to explain the investigation and
to ask if they had any matters they wanted us to consider. The family did not raise
any concerns but asked for a copy of our report.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
17. Mr Giles family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Wayland
18. HMP Wayland is a category C prison which holds convicted adult men. Practice
Plus Group provides the physical and mental healthcare services.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Wayland was in April 2022. Inspectors reported
that health services were well led and partnership working between health care
teams and the wider prison had improved since the last inspection. They also
reported complex patients were reviewed regularly through a strong
multidisciplinary approach. Daily handovers were well attended by representatives
from all services and provided a forum for sharing pertinent patient information and
service updates.
Independent Monitoring Board
20. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to May 2023, the IMB reported that
prisoners’ attitudes towards general healthcare was not encouraging. They reported
a low proportion of prisoners found it easy to contact healthcare and two thirds of
prisoners reported a dissatisfaction with healthcare surgeries.
Previous deaths at HMP Wayland
21. Mr Giles was the fifth prisoner to die at Wayland since December 2021. Of the
previous deaths two were self-inflicted and two were natural causes. Up to the end
of August 2024, there have been two further deaths since Mr Giles’ death, one was
from natural causes, and one was self-inflicted.
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Key Events
22. On 19 November 2019, Mr Alan Giles was convicted of shooting and wounding with
intent to do grievous bodily harm and was remanded to HMP Chelmsford.
23. On 29 May 2020, Mr Giles was sentenced to 10 years in prison.
24. Mr Giles had a significant medical history including a previous diagnosis of
depression. He was appropriately prescribed medication to manage his medical
conditions.
HMP Wayland
25. On 5 April 2023, Mr Giles was transferred to HMP Wayland.
26. A nurse completed Mr Giles’ initial health assessment. She noted that he was well
in himself and did not express any thoughts of suicide or self-harm. She noted that
he had suffered with recurrent psychotic depression since 1996 and was prescribed
citalopram (antidepressant) in the community. She referred Mr Giles to the prison’s
mental health team. Healthcare staff completed a medication reconciliation review.
It was noted that Mr Giles had been taking 40mg of citalopram for the past three
years and no concerns were raised. They prescribed him 40mg of citalopram, and
following a risk assessment he was allowed to keep his medication in his cell.
27. On 6 April, a member of the mental health team saw Mr Giles for a mental health
review. She noted that he said that he had had no recent contact with the mental
health team. He said that he suffered with depression, but this was well managed
with 40mg of citalopram. Following the assessment, Mr Giles was discharged from
the mental health team’s care.
28. On 17 April, a GP at the prison emailed the pharmacy team to question Mr Giles’
dose of citalopram due to his age and the risks associated with a higher dose and
requested a medical review. The GP saw Mr Giles on 9 May. Mr Giles said that he
found the current dose of 40mg of citalopram helpful, so he did not change the
dose.
29. On 18 September, a prison GP received an email from the community pharmacist,
who advised that the maximum advised dosage of citalopram for a person over 65
was 20mg. The GP arranged a face-to-face appointment with Mr Giles and
completed an ECG (electrocardiogram). The ECG results were within a normal
range and no other clinical concerns were identified. The GP decided to continue
with higher dose (40mg) of citalopram. Because the ECG results were normal there
was no need for healthcare staff to consider treatment risks any further, which was
in line with the relevant guidance.
30. The GP told us that Mr Giles’ mental health was stable and due to him recently
having been transferred to Wayland, a change to the dosage of citalopram was not
made. He said that Mr Giles’ ECG results were within the normal limits, so he was
clinically satisfied that there was no evidence of harm with the prescribed dose at
that time. He also said that if Mr Giles’ dose was reduced, it could have impacted on
his mental health. He considered the risks and benefits of the current dose outside
of the recommended dose and made the clinical decision to continue with 40mg.
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31. No concerns were raised about Mr Giles’ health over the months that followed. He
continued to collect his prescriptions on time and healthcare staff considered that
he was taking his medication as prescribed.
32. On 21 November 2023, Mr Giles collected his 28-day prescription of citalopram
from the medications hatch and no concerns were raised.
Events of 7 December 2023
33. At around 11.40am on 7 December, an officer was told that Mr Giles had not
collected his lunch, so she went to his cell and called his name, but Mr Giles did not
respond. She approached his bed and noticed he was very pale and unresponsive.
34. The officer attempted to radio a medical emergency code blue (indicating a prisoner
is unconscious or is having breathing difficulties), but due to another transmission
taking place at the same time, her message was not transmitted. Another prisoner
was nearby, so she asked him to press the general alarm and she shouted, ‘code
blue’. A Supervising Officer (SO) and another officer attended.
35. The other officer and the SO attempted to get a verbal response from Mr Giles but
were unsuccessful. The officer said that Mr Giles felt warm to touch. At approximately
11.50am, he radioed a code blue, and an ambulance was called. A nurse attended
and, with the help of the officer, moved Mr Giles to the floor.
36. The officer started CPR while the nurse attached a defibrillator. The nurse
attempted to insert an airway, but he observed rigor mortis in Mr Giles’ jaw and
upper arms. At 11.55am, all resuscitation attempts were stopped, and the
Ambulance Service was updated. The paramedics arrived at the prison at 12.36pm
and confirmed Mr Giles’ death at 12.41pm.
Contact with Mr Giles’ family
37. After Mr Giles’ death, the prison appointed two officers as family liaison officers. Mr
Giles had not provided any next of kin details when he entered prison. The family
liaison officers exhausted all avenues available to locate a family member.
38. With the support of the coroner’s officer, Mr Giles’ brother was found. The family
liaison officers contacted him on 14 December 2023 and informed him of Mr Giles’
death and offered their condolences.
39. The prison contributed towards the cost of Mr Giles’ funeral in line with national
policy.
Support for prisoners and staff
40. After Mr Giles’ death, a manager debriefed the staff involved in the emergency
response to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team also offered support.
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41. The prison posted notices informing other prisoners of Mr Giles’ death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr Giles’ death.
Post-mortem report
42. The post-mortem gave Mr Giles’ cause of death as citalopram toxicity. The
pathologist said that the toxicology analysis revealed a citalopram level which was
outside the therapeutic range and was described as in the grey area of non-
contributing and possibly fatal. The pathologist attributed Mr Giles’ death to
citalopram toxicity, although it was not possible to be completely certain that this
was the cause of death.
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Findings
Clinical care
43. The clinical reviewer concluded that Mr Giles received a good standard of clinical
care which was equivalent to what he could have expected to receive in the
community. Mr Giles required minimal support from healthcare staff, but he was
reviewed accordingly for his medical conditions.
44. Mr Giles was prescribed citalopram throughout his time in prison. There were no
concerns highlighted from the healthcare team that Mr Giles was not taking his
medication appropriately. Mr Giles was 68 years old when he was prescribed
citalopram in 2020 at another prison and had been stable on 40mg dosage for three
years. This dose was above the recommended maximum dose for a man of his age
and so the GP at Wayland carried out tests, including an ECG, before concluding
that the benefits to Mr Giles’ mental health outweighed the possible risk of
maintaining the higher dose. The clinical reviewer concluded that this was an
appropriate and reasonable clinical decision.
45. The Head of Healthcare confirmed that a medication risk assessment was
completed when Mr Giles arrived at Wayland before he was authorised to keep his
medication in his cell. Staff had not had any reason to suspect that he was not
taking his medication as prescribed.
46. According to his medical records, Mr Giles collected a 28-day prescription of
citalopram on 21 November 2023. Healthcare and pharmacy staff could not confirm
whether Mr Giles had taken more than his prescribed daily dose of citalopram prior
to his death because his medication was not returned to healthcare following the
clearance of his cell after his death.
47. There is no evidence that Mr Giles was at risk of suicide and self-harm or that he
intentionally took more citalopram than he should have done.
Governor to note
Cell clearances
48. When a prison cell is cleared, prison officers are required to return any medication
to the healthcare team. We asked the Head of Safer Custody at Wayland about
their cell clearance process regarding in possession medication, and whether any
changes had been made to the policy following Mr Giles’ death. He said that any
medication found in a cell should be secured separately and returned to healthcare
staff for review. He said it was not possible to say whether Mr Giles’ medication was
in his cell when it was cleared. He said that Wayland was reviewing the cell
clearance process.
49. As a review of cell clearance processes is already underway, and staff have been
reminded of the actions they should take if they find medication during a cell
clearance, we make no recommendation but bring this to the Governor’s attention.
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Contact with Mr Giles’ family
50. Mr Giles had not listed a named next of kin in his prison records. When he died, the
nominated family liaison officer went to some lengths to identify a member of his
family. The news of Mr Giles’ death was broken to his family seven days later.
51. The prison told the investigator that after arrival at the prison it is the prisoner’s
responsibility to inform staff if and when they want to update their next of kin details
and that staff do not regularly check. This is contrary to national policy. We make no
recommendation, but the Governor will wish to assure himself that the process for
identifying and checking next of kin details is sufficiently robust.
Inquest
52. At the inquest held on 6 January 2025, the coroner concluded Mr Giles died of
citalopram toxicity.
8 Prisons and Probation Ombudsman
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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