Anne-Marie Roberts

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Independent investigation into the
death of Ms Anne-Marie Roberts,
a prisoner at HMP Eastwood Park,
on 24 July 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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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 Anne-Marie Roberts died from diabetic ketoacidosis (a serious complication of
diabetes or chronic alcoholism when there is a severe lack of insulin in the body which
leads to an excess of ketones) on 24 July 2021 while a prisoner at HMP Eastwood Park.
She was 52 years old. I offer my condolences to her family and friends.
However, the clinical reviewer identified that the management and monitoring of Ms
Roberts’ alcohol withdrawal could be improved.
I am concerned that despite frequent checks on the morning of 24 July, it was only when
another prisoner raised concerns about Ms Roberts that staff identified that she had died.
While we do not know whether the delay in finding Ms Roberts affected the outcome for
her, it is critical that prison staff carry out welfare checks appropriately as early intervention
can save lives.
I am also concerned that when Ms Roberts was found, staff did not immediately call an
emergency code. This is an issue we have raised in two previous recent investigations
into deaths at Eastwood Park, and we now escalate our concerns to the Prison Group
Director for the Women’s Estate.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman October 2022
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Contents
Summary ......................................................................................................................... 3
The Investigation Process ................................................................................................ 5
Background Information ................................................................................................... 6
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 11
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Summary
Events
1. On 12 July 2021, Ms Anne-Marie Roberts was remanded to HMP Eastwood Park,
charged with arson.
2. At an initial health screen, staff identified that Ms Roberts had Type 2 diabetes,
drank heavily and had a history of mental health concerns. Healthcare staff
prescribed relevant medications and referred her to the prison’s mental health and
substance misuse teams.
3. On 14 July, a prison GP reviewed Ms Roberts’ blood test results which showed
slightly high blood glucose levels. The GP arranged for her to be reviewed on 27
July and recommended that she should repeat the blood tests in three months.
4. At around 9.23am on 24 July, a prisoner raised concerns with staff about Ms
Roberts’ welfare. Officers unlocked her cell and found her unresponsive. They
called for medical assistance and nurses tried to resuscitate her. However, they
stopped attempts after seeking external advice.
Findings
5. The clinical reviewer concluded that the care that Ms Roberts received at Eastwood
Park was of a standard reasonably expected and was generally equivalent to that
which she could have expected to receive in the community.
6. However, the clinical reviewer made a number of recommendations which the Head
of Healthcare will need to address.
7. Despite frequent checks on the morning of 24 July, we are concerned that it was
not until another prisoner raised concerns about Ms Roberts’ welfare that staff
identified that she had died. We are also concerned that staff did not call an
emergency code when Ms Roberts was found unresponsive.
8. The clinical reviewer also concluded that emergency response nurses should be
trained to recognise when it is inappropriate to attempt resuscitation.
Recommendations
• The Head of Healthcare should ensure that all patients undertaking alcohol
withdrawal are clinically monitored in line with local procedures.
• The Head of Healthcare should ensure that when the procedures for when
not to perform CPR is published, all healthcare staff have the opportunity
to attend additional training.
• The Governor should ensure that staff are aware that when a prisoner is
not due to be unlocked until later in the morning, staff satisfy themselves
of the prisoner’s safety, if there are concerns about the prisoner’s
wellbeing, by obtaining a response during the morning roll check.
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• The Governor should ensure that subject to a dynamic risk assessment,
staff enter a cell as quickly as possible, where there is a risk to life or
concerns about a prisoner’s welfare.
• The Governor should ensure that all staff understand their responsibilities
during medical emergencies, including calling an immediate emergency
code when there is a threat to life, in line with PSI 03/2013.
• The Prison Group Director for the Women’s Estate should satisfy herself
that staff at Eastwood Park understand their responsibilities during
medical emergencies, including the use of emergency codes, and should
write to the Ombudsman when she has done this.
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The Investigation Process
9. The investigator issued notices to staff and prisoners at HMP Eastwood Park
informing them of the investigation and asking anyone with relevant information to
contact him. No one responded.
10. The investigator obtained copies of relevant extracts from Ms Roberts’ prison and
medical records.
11. NHS England commissioned a clinical reviewer to review Ms Roberts’ clinical care
at the prison.
12. The investigator interviewed eight members of prison staff and one prisoner at
Eastwood Park. The clinical reviewer also interviewed healthcare staff at the
prison.
13. We informed HM Coroner for Avon of the investigation. She provided us with a
copy of the post-mortem and toxicology reports. We have sent her a copy of this
report.
14. The Ombudsman’s family liaison officer wrote to Ms Roberts family to explain our
investigation and to ask if they had any matters they wanted us to consider. They
asked what medication Ms Roberts was prescribed, what the medication was for
and if Ms Roberts was taking it. They also asked what mental health support Ms
Roberts received at Eastwood Park.
15. Ms Roberts’ family received a copy of the initial report. They raised a number of
issues/questions that do not impact on the factual accuracy of this report and have
been addressed through separate correspondence.
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Background Information
HMP Eastwood Park
16. HMP Eastwood Park is a closed prison in Gloucestershire which holds up to 442
women. It has ten residential wings, two of which specialise in addressing
substance misuse. Healthcare services at Eastwood Park are provided by Inspire
Better Health (part of Avon and Wiltshire Mental Health Partnership NHS Trust),
and they provide an integrated health services, including the delivery of primary
care, mental health, and substance misuse services. Healthcare is provided 24
hours a day.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Eastwood Park was in May 2019. Inspectors
reported that relationships between staff and prisoners remained a strength, and
prisoners reported that staff were supportive.
18. Inspectors noted that healthcare services were well-led, supported by skilled clinical
leads, and they observed conscientious staff who knew their patients well.
Inspectors reported that new prisoners received a comprehensive initial health
screen which focused on risks and immediate needs, including those relating to
substance use withdrawal, mental health and self-harm and that secondary health
screens were booked promptly. Inspectors noted good liaison with community
healthcare services which helped to ensure continuity of care.
19. Inspectors reported that healthcare staff responded to all emergencies, had
received life support training, officers were familiar with the emergency codes
protocol and emergency ambulances were called promptly.
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 October 2020, the IMB reported
that staff worked with prisoners in a highly professional and caring way. They
reported that healthcare provided a range of both clinical and non-clinical
interventions and in general, prisoners’ health needs were well met.
Previous deaths at HMP Eastwood Park
21. Since January 2018, there have been two deaths from natural causes and two
drug-related deaths at Eastwood Park. In our investigations into the deaths of
women at the prison in October 2018 and November 2019, we identified that staff
did not immediately call an emergency code when they found the prisoners
unresponsive.
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Key Events
22. On 12 July 2021, Ms Anne-Marie Roberts was remanded to HMP Eastwood Park,
charged with arson.
23. A nurse carried out an initial health screen. She identified that Ms Roberts had
Type 2 diabetes, which Ms Roberts told her was well-controlled. The nurse did not
take a blood glucose reading but noted that Ms Roberts’ clinical observations were
stable. She also noted Ms Roberts’ history of mental health concerns and that she
drank heavily.
24. Ms Roberts brought to the prison her prescribed medications, including diabetic
medication, antipsychotics and antidepressants. The nurse assessed that nurses
should administer Ms Roberts’ medication.
25. Ms Roberts told the nurse that she felt depressed and suicidal but denied thoughts
of self-harm. (Ms Roberts had previously tried to take her life by taking an overdose
around eighteen months earlier.) Staff started suicide and self-harm monitoring
procedures, known as ACCT, and referred Ms Roberts to the mental health team.
26. A prison GP reviewed Ms Roberts and noted her significant mental health history
and that she was vague about her alcohol use. The GP competed an alcohol
withdrawal assessment, which indicated that Ms Roberts had minimal withdrawal
symptoms but that her possible alcohol withdrawal should be monitored.
27. Ms Roberts lived in the prison’s substance misuse and detoxification unit.
28. On 13 July, Ms Roberts declined to attend her first ACCT case review, and it was
therefore agreed that the mental health team would continue to monitor her.
29. On 14 July, a prison GP noted that Ms Roberts’ blood glucose levels were slightly
high. He arranged to review her on 27 July and for the blood tests to be repeated in
three months.
30. Ms Roberts declined to participate in her secondary health screen on 16 July, and it
was rearranged for 19 July.
31. On 16 July, two mental health support assistants assessed Ms Roberts. They
noted that it was difficult to hold a conversation with her and that she was unable to
give an accurate picture of her mental health. It was decided that Ms Roberts
would be given further support through mental health keywork.
32. On 19 July, Ms Roberts again declined to take part in her secondary health screen.
33. That day, Ms Roberts attended an ACCT case review and told an officer that she
could not keep her medication down. There is no evidence that this information
was passed to healthcare staff.
34. Ms Roberts was compliant with her prescribed medication, apart from on 20 July
when she refused to take her diabetic medication but did not provide a reason why.
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35. On 21 July, a substance misuse worker tried to assess Ms Roberts’ alcohol
dependence and to explain the support available from the substance misuse team.
Ms Roberts declined to be assessed. The mental health team confirmed that Ms
Roberts had mental capacity and the substance misuse worker therefore
discharged her.
36. On 22 July, it was noted in Ms Roberts’ ACCT document that she complained of
stomach pain but did not want paracetamol.
37. On 23 July, a nurse introduced herself to Ms Roberts as her mental health
keyworker and arranged an appointment for the following week.
38. That day, Ms Roberts finished her daily exercise early after she told staff that she
was not feeling well, felt hot and had a headache. Ms Roberts was noted as being
slightly out of breath, but she became more settled after she returned to her cell and
did not complain further of feeling unwell.
39. CCTV footage shows that Ms Roberts was checked regularly throughout the night
as part of her ACCT observations. (We have based our timings on the prison’s
communications room log of events and adapted the recorded CCTV times in this
report accordingly.)
40. Officer A said that she recalled speaking to Ms Roberts at around 10.00pm, when
she was watching television. The officer recalled that Ms Roberts did not engage in
conversation or raise any concerns.
Events of 24 July
41. Officer A said when she checked on Ms Roberts during the night as part of ACCT
monitoring, she could hear her snoring lightly at times. She checked on her at
around 3.30am and tried to engage with her but Ms Roberts did not look up or
speak. Officer B also said that when she checked on Ms Roberts in the early hours
of the morning, she too could hear that Ms Roberts was breathing.
42. Officer A said that when she checked on Ms Roberts at around 6.04am, she
appeared to have changed sleeping position, with her feet on the floor and lying on
her left side. At around 6.08am, she completed the early morning roll check. She
said that Ms Roberts remained in the same position and said that she could hear
and see Ms Roberts breathing. She said that she had no concerns and checked
Ms Roberts again at 6.30am.
43. At around 7.23am, Officer C carried out his roll check. He looked into Ms Roberts’
cell for around forty seconds. He said that he thought that Ms Roberts was sleeping
and believed that she was breathing but that this was quite shallow. He described
her as being in a ‘weird’ position, with her feet on the floor and leaning to her left
side, with her shoulder on the bed. He said that it looked as if Ms Roberts had
fallen asleep, and that it was not unusual for prisoners to sleep in ‘weird’ positions.
44. After the roll check, Officer C returned to the wing office and told Officer B and
Officer A how Ms Roberts was sleeping. They discussed how she had been
sleeping awkwardly all week and how she regularly slept in unusual positions.
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45. Officer C checked on Ms Roberts again at around 7.54am (for 40 seconds) and
7.55am (for 20 seconds) and found her in the same position. He checked on her
again at around 8.05am, and she remained in the same position. He asked Officer
D for a second opinion and the officers checked on her at around 8.07am (for 40
seconds). Officer D agreed with Officer C that Ms Roberts looked as though she
was breathing but that it was shallow. She remained in the same position.
46. At 8.42 am and 9.12am, Officer C checked on Ms Roberts again. He said that Ms
Roberts remained in the same position and that he could see her breathing.
47. At 9.13am, a prisoner who worked as a prison orderly went to Ms Roberts’ cell to
offer her hot water as the wing had not yet been unlocked due to Covid-19
restrictions and as it was the weekend. She looked into Ms Roberts’ cell and saw
her sitting up, with both feet on the floor, but slouched to the side. She tried to get a
response from Ms Roberts but could not. Concerned about her, she told Officer E,
who arrived at the cell around thirty seconds later.
48. Officer E called out to Ms Roberts and asked for Officer C’s help when she could
not get a response. The officers went into the cell and found that Ms Roberts was
unresponsive and not breathing. Officer C, who said that Ms Roberts felt warm to
the touch, checked for a pulse but found none so radioed for healthcare staff to
attend.
49. At around 9.15am, a nurse arrived at the cell, assessed her and called a medical
emergency code blue (used when a prisoner is unresponsive or has breathing
difficulties). The control room called an ambulance. The nurse could not find any
signs of life and noted that rigor mortis was present, that her skin was mottled but
that she was still warm. The nurse started cardiopulmonary resuscitation (CPR).
50. More healthcare staff arrived, and staff continued resuscitation efforts. The
defibrillator was attached but advised that there was no shockable rhythm. At
around 9.28am, an on-call GP was contacted for advice and CPR was stopped at
9.32am. The ambulance was stood down and a prison GP confirmed Ms Roberts’
death at 12.45pm.
Contact with Ms Roberts’ family
51. On 24 July, a custodial manager was appointed as the family liaison officer. In line
with national instructions on managing the risk of COVID-19 in prisons, she
telephoned Ms Roberts’ brother, her next of kin, to tell him that Ms Roberts had died
and offer her condolences. The prison contributed to the funeral costs in line with
national instructions.
Support for prisoners and staff
52. After Ms Roberts’ death, the Head of Residential Services and Safeguarding
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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53. The prison posted notices informing other prisoners of Ms Roberts’ 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 her death.
Post-mortem report
54. A post-mortem examination established that Ms Roberts died of diabetic
ketoacidosis which can occur as a result of diabetes or chronic alcoholism. The
report noted that it can be difficult to differentiate between the two causes if a
person has both diabetes and alcoholism. The post-mortem examination was
unable to identify an underlying condition, such as infection. However, the
pathologist reported that because ketoacidosis in alcoholics is poorly understood, it
could not be excluded that alcohol withdrawal could have contributed to Ms
Roberts’ diabetes ketoacidosis as she had diabetes. The post-mortem report noted
that Ms Roberts’ history of alcohol use was not well documented, and as she had
no firm clinical diagnosis, the pathologist did not include chronic alcohol excess in
the cause of death.
55. Toxicology tests confirmed the presence of prescribed medications, consistent with
therapeutic use. There was no evidence of illicit drug or alcohol use.
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Findings
Clinical care
56. The clinical reviewer found that the care that Ms Roberts received at Eastwood
Park was of a standard reasonably expected and was generally equivalent to that
which she could have been expected to receive in the community.
57. However, the clinical reviewer found areas of non-equivalence regarding the
management and monitoring of Ms Roberts’ alcohol withdrawal period as it did not
follow NICE guidance.
58. The clinical reviewer made two recommendations which are not relevant to Ms
Roberts’ death but which the Governor and Head of Healthcare will need to
address.
Alcohol detoxification
59. The GP who assessed Miss Roberts at reception assessed that she needed to be
monitored for symptoms of alcohol withdrawal. The clinical reviewer reported that
in line with Eastwood Park’s local healthcare policy, healthcare staff should have
monitored her for five days, initially every two hours,
60. The clinical reviewer identified that Ms Roberts was not monitored in line with the
local policy because the GP did not send a task to the nurses to explain that she
needed these observations, and the nurses did not read the GP’s notes which said
that she needed alcohol withdrawal monitoring. We make the following
recommendation:
The Head of Healthcare should ensure that all patients undertaking alcohol
withdrawal are clinically monitored in line with local procedures.
Type 2 diabetes
61. The clinical reviewer reported that the GP’s plans were in line with NICE guidelines
for managing diabetes. The clinical reviewer noted that there would not have been
a requirement for Ms Roberts’ blood glucose levels to be monitored outside of these
routine tests.
62. The clinical reviewer concluded, and the Head of Healthcare agreed that, while Ms
Roberts’ diabetes management at Eastwood Park was in line with NICE guidance,
the expectations on how to monitor patients with Type 2 diabetes at Eastwood Park
were not clear. It would be helpful for Eastwood Park to develop a pathway to
manage and monitor Type 2 diabetes, including an additional pathway for those
also undertaking an alcohol withdrawal regime.
Resuscitation
63. When the nurse arrived at Ms Roberts’ cell, she found that she did not appear to be
breathing, rigor mortis was present in her arms, she had widespread mottled skin
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but was still warm. She immediately started CPR. After further advice was sought,
the decision was taken to stop CPR.
64. The clinical reviewer noted that the College of Nursing guidance for when not to
perform CPR in prison settings (March 2016) includes guidance for when CPR
might be futile, such as when rigor mortis is present. The clinical reviewer noted
that healthcare professionals faced a difficult decision when deciding not to perform
CPR, as they are taught to preserve life. Although not critical of the decision to start
CPR, the clinical reviewer concluded that staff needed to feel more confident in
making such decisions while taking into account the patient’s dignity.
65. The clinical reviewer noted that Inspire Better Health have drafted their own
Standard Operating Procedure (SOP) about when not to perform CPR, which is due
to be published soon. She concluded that when it is published, staff should receive
supplementary training so that they feel supported in making difficult decisions
about CPR. We therefore make the following recommendation:
The Head of Healthcare should ensure that when the procedures for when not
to perform CPR is published, all healthcare staff have the opportunity to
attend additional training.
Discovering Ms Roberts
66. Although staff checked on Ms Roberts hourly throughout the night, it was only when
another prisoner could not get a response from her at 9.13am that staff intervened
and discovered that she had likely died. Staff told us that when they carried out
checks during the night and morning, they could see Ms Roberts breathing, albeit
shallowly.
67. However, we are concerned that when staff saw that Ms Roberts was sleeping in an
unusual position (she changed from a lying position to a sitting position in the early
hours of 24 July), staff did not consider making further efforts to check on her
welfare, for example, by calling out her name, shining a torch or by entering the cell.
We are also concerned that the staff we interviewed considered it normal for
women on the detoxification unit to sleep in unusual positions.
68. We are also concerned that although Officer A, Officer N and Officer C discussed
among themselves the ‘weird’ way that Ms Roberts was sleeping, they did not
consider or take further action to check on her. Because it was the weekend and
COVID-19 restrictions were in place, Ms Roberts was not expected to have been
unlocked from her cell until later that morning.
69. We note that Officer C checked on Ms Roberts a further five times after his first
check at around 7.23am, with some checks taking up to 40 seconds. He also
sought clarification about Ms Roberts’ welfare from Officer D.
70. We accept that the primary purpose of a roll check is to confirm that all prisoners
are present and correctly accounted for. However, roll checks are also an
opportunity to check on prisoners’ wellbeing and to identify any obvious signs that a
prisoner may be ill or dead. We accept that roll checks may be carried out very
early in the morning and, where that is the case, we do not consider that it is
reasonable for staff to wake prisoners up and obtain a response from them to
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confirm that they are alive. For example, if a prisoner is in bed covered by bedding
during a roll check, we consider that it is reasonable for staff to assume that she is
asleep, unless she is lying in an obviously awkward position, which Ms Roberts
evidently was.
71. Prison Service Instruction 75/2011 on residential services says that:
“Reports from the Prisons and Probation Ombudsman on deaths in custody
have identified cases in which a prisoner has died overnight … but staff
unlocking them have not noticed that the prisoner had died. This is not
acceptable...
“…there needs to be clearly understood systems in place for staff to
assure themselves of the wellbeing of prisoners during or shortly after
unlock ...Where prisoners are not necessarily expected to leave their cell,
staff will need to check on their wellbeing, for example, by obtaining a
response during the unlock process.”
72. We cannot know whether earlier intervention would have affected the outcome for
Ms Roberts, but we do know that a delay of even a few minutes can make a critical
difference in a medical emergency, and there were a number of missed
opportunities to identify her condition earlier. We make the following
recommendations:
The Governor should ensure that staff are aware that when a prisoner is not
due to be unlocked until later in the morning, staff satisfy themselves of the
prisoner’s safety, if there are concerns about the prisoner’s wellbeing, by
obtaining a response during the morning roll check.
The Governor should ensure that subject to a dynamic risk assessment, staff
enter a cell as quickly as possible, where there is a risk to life or concerns
about a prisoner’s welfare
Emergency response
73. PSI 03/2013 on medical emergency response codes requires staff to radio a code
blue when a prisoner is unconscious or having breathing difficulties and for the
control room then to call an ambulance immediately.
74. When Officers E and Officer C found Ms Roberts, they called for healthcare
assistance but did not immediately call a code blue. We recognise that it can be
difficult for prison staff to make instant decisions in such distressing circumstances.
However, when there is a potentially life-threatening situation, it is essential for
them to act quickly and exercise good judgement. However, we are satisfied that
they were aware of the emergency code procedures and that they should have a
called a code blue immediately. We raised similar concerns about the use of
emergency codes into the deaths of women at Eastwood Park in October 2018 and
November 2019. We make the following recommendation:
The Governor should ensure that all staff understand their responsibilities
during medical emergencies, including calling an immediate emergency code
when there is a threat to life, in line with PSI 03/2013.
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The Prison Group Director for the Women’s Estate should satisfy herself that
staff at Eastwood Park understand their responsibilities during medical
emergencies, including the use of emergency codes, and should write to the
Ombudsman when she has done this.
Inquest
The inquest, held on 27 February 2024 concluded that Ms Anne-Marie Roberts died from
natural causes.
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