Ann-Marie Pyle

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Ms Ann-Marie Pyle,
a prisoner at HMP Drake Hall,
on 30 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Ms Ann-Marie Pyle died of ischaemic heart disease caused by coronary artery atheroma
(a build-up of plaque in the arteries around the heart) on 30 September 2021, while a
prisoner at HMP Drake Hall. She was 61 years old. I offer my condolences to those who
knew her.
The clinical reviewer concluded that overall, the clinical care provided to Ms Pyle was not
equivalent to that which she could have expected to receive in the community. She found
that when Ms Pyle’s cholesterol levels and blood pressure were identified as raised, no
follow-up action taken to address the associated risks. It is not possible to say whether
this impacted on the outcome for Ms Pyle, but we are concerned that the same practice
might impact on outcomes for other patients.
We found no non-clinical issues of concern.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman December 2022
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. Ms Ann-Marie Pyle was serving a life sentence for manslaughter. She had served
time in several prisons before moving to Drake Hall in 2018.
2. Ms Pyle was not comfortable around men and the prison healthcare team provided
female-led care wherever possible. This was more difficult to control when Ms Pyle
required support from the community hospital, which could not guarantee the
availability of female staff.
3. Ms Pyle’s cholesterol levels had been above average for two years and she took
regular prescribed medication to manage this. Her levels were supposed to be
checked annually, but there is no evidence of a test in 2021.
4. On 14 September 2021, Ms Pyle’s blood pressure was recorded as high for the first
time. There is no evidence that action was taken in response to this.
5. At around 7.00am on 30 September, an officer checked that Ms Pyle was in her
room during the morning roll check. She thought that she was asleep, so did not try
to talk to her. Later that morning, Ms Pyle did not attend her workplace. At around
8.45am, an officer found Ms Pyle unresponsive in her room and radioed an
emergency code.
6. Healthcare staff arrived and assessed that rigor mortis was present so did not
continue to try to resuscitate Ms Pyle, in line with national guidelines. Paramedics
arrived at 9.10am and confirmed her death at 9.30am.
7. The post-mortem examination found that Ms Pyle died of heart disease.
Findings
8. When Ms Pyle refused to engage with male professionals, the healthcare team at
Drake Hall ensured that clinical care was female-led, wherever possible. This was
outside their control when Ms Pyle attended the local hospital.
9. Ms Pyle died unexpectedly. However, healthcare staff did not follow national
guidelines when managing her cholesterol levels and blood pressure before her
death. When raised readings were taken, no follow-up action was taken to address
the associated risks.
Recommendations
• The Head of Healthcare at HMP Drake Hall should ensure that healthcare staff take
appropriate action in response to abnormal readings for blood pressure and
cholesterol, in line with the National Institute for Health and Care Excellence (NICE)
guidelines.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Drake Hall informing
them of the investigation and asking anyone with relevant information to contact
her. One resident made contact with the investigator and was interviewed by
telephone.
11. The investigator visited HMP Drake Hall on 22 November 2021. She obtained
copies of relevant extracts from Ms Pyle’s prison and medical records and
interviewed six members of staff.
12. NHS England commissioned an independent clinical reviewer to review Ms Pyle’s
clinical care at the prison. The clinical reviewer conducted joint interviews with the
investigator and healthcare staff by video conference on 22 November.
13. We informed HM Coroner for Staffordshire South of our investigation. The Coroner
gave us the results of the post-mortem examination. We have sent him a copy of
this report.
14. The Ombudsman’s family liaison officer confirmed with the prison that Ms Pyle did
not identify a next of kin.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not identify any factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Drake Hall
16. HMP/YOI Drake Hall is a prison in Staffordshire, holding approximately 320 adult
and young adult women who are on remand or sentenced. Drake Hall is a closed
prison with an open regime, which means that women are never locked in their
rooms and have free access around the site during the day. At night, they are
locked in their houseblocks, but able to move around these units freely. Care UK
provides health services from 7.15am to 6.30pm weekdays and 7.30am to 5.00pm
at weekends.
Her Majesty’s Inspectorate of Prisons (HMIP)
17. The most recent inspection of Drake Hall was in February 2020. Inspectors
reported that the prison remained a safe place to live, with minimal instances of
serious violence. They found that prisoners were positive about the community
ethos.
18. Healthcare provision had improved since the last inspection and was considered to
be good. Prisoners had good access to a range of primary care services which
includes a female GP and specialist counselling. The level of missed appointments
remained high. However, overall waiting times for appointments were within
acceptable time frames.
Independent Monitoring Board
19. 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 October 2020, the IMB reported
that that HMP Drake Hall provided a safe and secure environment for prisoners,
and that the prison is managed effectively.
20. Overall, the Board were satisfied with the standard of healthcare at the prison.
They suggested that missed medical appointments decreased during the COVID-19
pandemic as prisoners were escorted to all appointments.
Previous deaths at HMP Drake Hall
21. The last death at HMP Drake Hall took place in 2018. There are no similarities in
our findings across these investigations.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
22. On 15 July 2002, Ms Ann-Marie Pyle was sentenced to life imprisonment for
manslaughter. She served time in a number of prisons and was transferred to HMP
Drake Hall on 29 June 2018. On arrival at Drake Hall, healthcare staff identified
and recorded Ms Pyle’s long-term health conditions, including high cholesterol and
joint pain. These conditions were managed by prescribed medication, which was
provided, and required regular monitoring.
23. On 30 July 2018, during a routine mental health assessment, Ms Pyle told a nurse
that she was not happy consulting male professionals, including prison doctors.
The healthcare team reflected this in Ms Pyle’s care plan.
24. In 2019, Ms Pyle was diagnosed with an underactive thyroid gland.
25. In February 2021, Ms Pyle’s blood sugar was identified as raised and she was
diagnosed with Type 2 diabetes. She was referred to the community diabetes
service but declined the two telephone consultations that were offered. She asked
to be discharged from the service.
26. On 24 July, Ms Pyle’s medication was reviewed by the prison pharmacist. She
asked for the prison GP to review Ms Pyle, following blood tests taken to review
thyroid function.
27. On 2 August, a prison GP recorded that Ms Pyle’s blood test results were normal
and that her average blood sugar level was slightly above the normal range. She
noted that no further action was required. A review appointment was organised
with a female GP on 17 August 2021. Ms Pyle declined to attend.
28. On 13 September 2021, Ms Pyle told staff that she felt unwell and had cold
symptoms. A nurse reviewed Ms Pyle on 13 and 14 September and recorded that
her temperature, pulse and blood oxygen levels were within the normal range on
both days. However, on 14 September, the nurse recorded that Ms Pyle’s blood
pressure was raised.
29. At around 1.00pm on 29 September, two officers saw Ms Pyle during lunch. Both
officers said that there was nothing unusual about her presentation. They said that
she was excited about her temporary release the next day.
30. At 7.00pm, an officer conducted roll checks. He counted Ms Pyle, who was in her
room. At interview, he did not recall anything unusual or concerning and was not
informed of any concerns about Ms Pyle during his shift, which finished at 9.00pm.
31. Night staff conducted further roll checks at approximately 10.00pm. Roll checks did
not involve any verbal interaction with prisoners unless they were subject to welfare
or monitoring checks, which Ms Pyle was not. She did not ring her room bell for
assistance during the night.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Events of 30 September 2021
32. At around 7.00am on 30 September, an officer completed the morning roll check.
She observed that Ms Pyle was sleeping in her bed.
33. At 8.00am on 30 September, Officer A started her shift. That morning, she was
responsible for checking that all prisoners had attended their activities.
34. At approximately 8.30am, a Custodial Manager (CM) told Officer A that three
women, including Ms Pyle, had not attended their workplaces and asked her to
check on them. The officer checked on Ms Pyle first. She arrived at her room at
about 8.45am and looked in her doorway (her door was unlocked because Durham
House, where Ms Pyle lived, operates an open regime). She thought that Ms Pyle
was asleep in her bed, under the covers, but she did not get a response when she
shouted her name repeatedly. She immediately called for assistance. A prison
contractor was near Ms Pyle’s room at the time. She asked him to stand outside
Ms Pyle’s room while she went in. She was concerned that Ms Pyle was not
responding and did not want to wait any longer for assistance before going into her
room.
35. Officer A went into Ms Pyle’s room and tapped her shoulder. There was no
response. She touched Ms Pyle’s forehead which was cold. She noticed that Ms
Pyle was pale, and her lips looked blue and purple. She radioed a code blue (a
medical emergency code indicating that a prisoner is having difficulty breathing) and
asked for staff assistance again at 8.50am. An emergency ambulance was called
immediately at 8.50am.
36. Officer B and a Senior Officer (SO) heard the call for assistance and arrived at Ms
Pyle’s room at approximately 8.54am. Officer B noted that her skin was cold and
confirmed that she could not find a pulse. The SO and Officer B moved Ms Pyle
from her bed to the floor and started cardiopulmonary resuscitation (CPR). Officer
A left the room to find further support.
37. Two nurses arrived at 8.57am in response to the emergency call for assistance.
They took over CPR. The Head of Healthcare arrived at 9.00am. At 9.03am, the
Head of Healthcare told staff to stop CPR because it was clear that Ms Pyle was
dead. This was in line with current UK resuscitation guidelines. The ambulance
arrived at 9.10am and paramedics confirmed at 9.30am that Ms Pyle had died.
Support for prisoners and staff
38. After Ms Pyle’s death, a prison governor 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.
39. The prison posted notices informing other prisoners of Ms Pyle’s 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 Ms Pyle’s death.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Post-mortem report
40. The Coroner concluded that Ms Pyle died from ischaemic heart disease (a heart
problem caused by narrowed heart arteries reducing blood and oxygen flow to the
heart), caused by coronary artery atheroma (a build-up of plaque in the arteries
around the heart).
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
41. The clinical reviewer concluded that, overall, Ms Pyle’s clinical care was not
equivalent to that which she could have expected to receive in the community.
42. Ms Pyle made it clear to staff that she did not want to consult with male
professionals. This was well managed by the healthcare team at Drake Hall, who
were able to provide female-led clinical support. When clinical support was
required outside the prison, at the local hospital, female professionals were always
requested when arranging appointments. When Ms Pyle did not attend arranged
appointments, prison staff consistently followed up and encouraged engagement.
We are satisfied that, in doing so, they made every effort to ensure that Ms Pyle’s
health was appropriately monitored.
43. When Ms Pyle’s cholesterol and blood pressure readings were raised, healthcare
staff did not take action to mitigate the associated risks in line with national
guidelines. We accept that Ms Pyle might have had her cholesterol reviewed if she
attended the diabetic clinic in February 2021 and had not discharged herself from
the service. This may have led to further investigations that might have identified
heart disease.
44. While it is not possible to conclude whether failure to follow up the readings was
linked to Ms Pyle’s death, high cholesterol and high blood pressure can contribute
to ischemic heart disease. We are concerned that this practice might impact on
outcomes for future patients, and we make the following recommendation:
The Head of Healthcare at HMP Drake Hall should ensure that healthcare staff
take appropriate action in response to abnormal readings for blood pressure
and cholesterol, in line with the National Institute for Health and Care
Excellence (NICE) guidelines.
45. The clinical reviewer identified a number of issues which were not directly linked to
Ms Pyle’s death, but which the Head of Healthcare will need to address.
Inquest
46. The inquest, held on 9 September 2024, concluded that Ms Pyle died from natural
causes.
Prisons and Probation Ombudsman 7
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