Anthony Kimmins

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Anthony
Kimmins, a prisoner at HMP
Littlehey, on 27 March 2020
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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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.
Mr Anthony Kimmins died in hospital on 27 March 2020 from COVID-19 while a prisoner at
HMP Littlehey. He was 77 years old. I offer my condolences to Mr Kimmins’ family and
friends.
Mr Kimmins had advanced Parkinson’s disease and in the last six months of his life he
regularly fell in his cell overnight. Early on 20 March, prison staff found Mr Kimmins on the
floor of his cell. It appears that he had been there for several hours following a fall. He
was taken to hospital with suspected aspiration pneumonia and died a week later.
The investigation found that Mr Kimmins’ clinical care was equivalent to that which he
could have expected to receive in the community. He did not display any symptoms of
COVID-19 in prison and tested negative for the virus when he first went to hospital on 20
March. It, therefore, appears likely that he contracted COVID-19 in hospital and not in
prison, although we cannot be certain.
However, I am very concerned that such a frail elderly man lay on the floor of his cell
overnight without being found by prison staff. I have recommended that the Governor
commissions a fresh investigation into how this happened.
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 January 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. Mr Anthony Kimmins was serving a sentence of 11 years and six months for sexual
offences and had been at HMP Littlehey since September 2018.
2. Mr Kimmins had several long-term health conditions, including Parkinson’s disease.
He often experienced ‘freezing’ (a symptom of Parkinson’s), which prevented him
from being able to move and he regularly fell over in his cell during the night.
3. In September 2019, Mr Kimmins said his ‘freezing’ episodes had increased and
prison staff were finding it difficult to support him during the night. Mr Kimmins told
a prison GP that he did not want to move to a prison with 24 hour healthcare.
4. On 3 March 2020, healthcare staff provided Mr Kimmins with a commode and a
personal emergency alarm. A prison manager noted in the wing observation book
that prison staff should monitor Mr Kimmins hourly overnight.
5. On 19 March, Mr Kimmins fell over in his cell at about 10.00pm and was not found
by prison staff until 5.20am the next day, 20 March. Healthcare staff were not
informed of the fall until around 10.00am. They examined Mr Kimmins and
arranged for him to be admitted to hospital with suspected aspiration pneumonia.
6. Healthcare staff subsequently completed a safeguarding incident form and recorded
information about a lack of overnight observations and the failure to report to
healthcare staff the injuries Mr Kimmins had sustained when he fell.
7. A routine test for COVID-19 in hospital on 20 March was negative. On 26 March, Mr
Kimmins tested positive for COVID-19. He died on 27 March.
8. The Coroner accepted Mr Kimmins’ cause of death as COVID-19, with advanced
Parkinson’s disease and frailty of old age as contributing factors.
Findings
9. The clinical reviewer concluded that the clinical care Mr Kimmins received in prison
was of a good standard and equivalent to that which he could have expected to
receive in the community.
10. Mr Kimmins did not display any symptoms of COVID-19 at Littlehey. He tested
positive for COVID-19 six days after his admission to hospital. Although we cannot
say for certain where or when he contracted the virus, it seems likely that it was in
hospital.
11. We are, however, very concerned that it was possible for Mr Kimmins to lie on the
floor of his cell for several hours overnight without being found by prison staff,
despite being known to be at high risk of falls and despite a prison manager having
said he should be monitored at hourly intervals at night. We are also concerned
that prison staff did not inform healthcare staff about Mr Kimmins’ fall until more
than three and a half hours after Mr Kimmins was found.
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12. We consider that the prison’s internal investigation into these failings was
inadequate and that the Governor needs to conduct a further investigation into what
happened.
13. We are satisfied that since Mr Kimmins’ death, the prison has introduced measures
to ensure that prisoners who are at an increased risk of falling are identified and
appropriately monitored.
Recommendations
• The Governor should commission an investigation into the failure to put hourly
observations in place for Mr Kimmins during the night and the failure to contact
healthcare staff promptly on 20 March, with a view to considering whether
disciplinary action is appropriate.
• The Head of Healthcare should ensure that healthcare staff are aware of
Northamptonshire Healthcare NHS Foundation Trust’s policy for safeguarding
responsible adults and that staff adhere to the policies, procedures and guidelines.
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The Investigation Process
14. The investigator issued notices to staff and prisoners at HMP Littlehey informing
them of the investigation and asking anyone with relevant information to contact
her.
15. The investigator obtained copies of relevant extracts from Mr Kimmins’ prison and
medical records.
16. NHS England commissioned a clinical reviewer to review Mr Kimmins’ clinical care
at the prison.
17. We informed HM Coroner for Cambridgeshire and Peterborough of the
investigation. The coroner gave us the cause of death. A post-mortem examination
was not carried out. We have sent the coroner a copy of this report.
18. We wrote to Mr Kimmins’ son, his nominated next of kin, to explain the investigation
and to ask if he had any matters he wanted the investigation to consider. He did
not have any specific issues for the investigation to consider.
19. We shared our initial report with HM Prison and Probation Service. They did not
find any factual inaccuracies. They provided an action plan which is annexed to this
report.
20. We sent a copy of our initial report to Mr Kimmins’ son. He did not notify us of any
factual inaccuracies.
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Background Information
HMP Littlehey
21. HMP Littlehey in Cambridgeshire is a medium security prison holding approximately
1,200 men convicted of sexual offences.
22. Northamptonshire Healthcare NHS Foundation Trust (NHFT) commissions
healthcare services at Littlehey. The prison healthcare centre is open from 7.30am
to 7.30pm Monday to Friday, and from 8.00am to 5.30pm at weekends. A local
practice provides GP services and there is a range of nurse-led clinics. There are
no inpatient beds at the prison.
HM Inspectorate of Prisons
23. The last inspection of HMP Littlehey took place in August 2019. Inspectors found
that prisoners were generally positive about health services and there was a wide
range of good and responsive primary care clinics and services. The prison
responded proactively to the needs of the large population of prisoners aged over
50.
24. HMIP conducted a scrutiny visit to Littlehey in June 2020 (in line with its COVID-19
methodology) and reported that the prison had adopted clear plans to manage the
COVID-19 pandemic at the start of the lockdown. Littlehey had been declared an
official outbreak site in March. HMIP reported that the prison, in conjunction with
Public Health England (PHE), took swift action to control the spread of the virus and
managed to bring infection rates down to a manageable level.
Independent Monitoring Board
25. 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 January 2019, the IMB reported
that the opportunities and facilities for older prisoners had decreased. Prisoners
with poor mobility were unable to access the healthcare unit because it was located
on the first floor. The Board noted that external healthcare appointments were
capped, and no routine appointments were kept for prisoners. They concluded that
this was not equivalent to healthcare in the community.
Previous deaths at HMP Littlehey
26. Mr Kimmins was the 15th prisoner to die at Littlehey since March 2018. Of the
previous deaths, 13 were from natural causes (including one from COVID-19) and
one was self-inflicted. There have been eight deaths from natural causes since,
including one COVID-19 related death, and one self-inflicted death.
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COVID-19 (Coronavirus)
27. COVID-19 is an infectious disease that affects the lungs and airways. On 11
March, the World Health Organisation declared COVID-19 as a worldwide
pandemic.
28. COVID-19 can make anyone seriously ill, but the risk is higher for some
people. People at high risk include those who have a severe lung condition; are
having certain types of treatment for cancer; or have a condition with a very high
risk of getting infections. Those at moderate risk include people over 70; people
with a lung condition or a chronic medical condition, such as diabetes, heart, liver,
or chronic kidney disease; or those who are very obese (this list is not exhaustive).
29. To reduce the spread of the virus, the Government introduced voluntary and
mandatory actions, such as ‘social distancing’ and ‘lockdown’ (on 16 and 23 March,
respectively). Public Health England (PHE), HM Prison & Probation Service
(HMPPS) and NHS England worked together to devise measures to contain the
outbreak, achieve social distancing, reduce the risk to the most vulnerable in
prisons in England and protect the NHS (by reducing the number of people
requiring specialist care in community-based hospitals).
30. On 13 March, PHE’s National Health and Justice team issued an interim notice
providing advice on preventing and controlling outbreaks of COVID-19 in prisons.
HMPPS issued further instructions over the following weeks with guidance on the
appropriate use of personal protective equipment (PPE), hygiene, cleaning
schedules and stock checks. The guidance set out the importance of effective
preventative measures and that methodical cleaning would help prevent infection
spread.
31. On 24 March, HMPPS issued an instruction to all prisons to implement a restricted
regime and to enforce social distancing of two metres for staff and prisoners
wherever possible. The most vulnerable prisoners were to be identified and put into
protective isolation.
32. On 31 March, HMPPS, in consultation with PHE, issued an order to significantly
reduce transfers between prisons. Other measures, known as
‘compartmentalisation’ were also announced. These measures were designed to
be implemented at local level, depending on the needs of each individual
establishment, and included protective isolation units to accommodate known
COVID-19 cases and shielding units to protect the most clinically vulnerable
prisoners.
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Key Events
33. On 3 July 2015, Mr Anthony Kimmins was sentenced to 11 years and six months in
prison for sexual offences and sent to HMP Lewes. He spent time in several
prisons before he transferred to HMP Littlehey on 6 September 2018.
34. Mr Kimmins had several long-term health conditions. He was diagnosed with
Parkinson’s disease in 2012 and had a pacemaker fitted in 2013. He also had
hypertension (high blood pressure), thoracic back pain and bladder muscle
dysfunction. In September 2018, Mr Kimmins signed a do not attempt
cardiopulmonary resuscitation (DNACPR) order to say that he did not want to be
resuscitated if his heart stopped beating.
35. Mr Kimmins had poor mobility due to the progression of Parkinson’s disease and
used a wheeled walking frame. He had numerous falls and healthcare staff noted
that he tended to fall over in his cell overnight when he was using the toilet.
36. On 28 August 2019, a prison GP assessed Mr Kimmins. She noted that he lived in
a disability cell and often got up during the night to walk around. She considered
that Mr Kimmins did not need 24 hour healthcare support and that his needs were
related to his social care. Mr Kimmins said that he did not wish to move to a prison
with 24 hour healthcare.
37. On 4 September 2019, Mr Kimmins had a full social care review with a clinical
services manager. Mr Kimmins said that he had started to ‘freeze’ a lot more and
she noted that prison officers were finding it more difficult to support him on the
wing, especially when he was freezing during the night. (Freezing is a common
symptom of Parkinson’s disease and patients describe it as feeling like their feet are
glued to the ground. Freezing can prevent patients being able to move for several
minutes.)
38. A prison GP assessed Mr Kimmins on 19 September. He noted that Mr Kimmins
was freezing at night at least three times a week and he was often unable to use
the toilet. The prison GP discussed Mr Kimmins with a specialist Parkinson’s nurse
who advised changes to his medication. Prison staff arranged for a prisoner carer
to help Mr Kimmins with his daily living.
2020
39. On 29 February 2020, a nurse saw Mr Kimmins after he fell twice in his cell during
the night.
40. On 1 March, a prison manager and the clinical services manager assessed him in
his cell to see if there were any additional aids that would reduce his risk of falling.
Mr Kimmins said that he tended to get up and walk around his cell because his
bones were aching. The clinical services manager noted that Mr Kimmins was
wearing appropriate footwear, had a handrail in his cell and used a walking frame.
The prison manager noted in the wing observation book that staff should monitor Mr
Kimmins hourly overnight.
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41. On 3 March, prison staff completed a Social Care Assessment Referral Form
(SCARF) and provided Mr Kimmins with a commode. He was also provided with a
personal emergency alarm to alert his prisoner ’buddy’ when he needed assistance.
Events of 20 March
42. At approximately 5.20am on 20 March, prison staff found Mr Kimmins slumped
against his chair on the floor of his cell. He was not wearing his personal
emergency alarm. Staff did not know how long Mr Kimmins had been in that
position.
43. A Custodial Manager (CM) who was the night orderly manager, was called and he
checked Mr Kimmins over. He was apparently able to have “a reasonably normal
conversation” with him. Mr Kimmins had liquid draining from his nose and he told
prison staff that he had experienced a ‘freezing’ episode. He said that he was not in
pain. The CM concluded that it was not necessary to call an ambulance because
there was no immediate risk to Mr Kimmins, and he had no visible injuries and was
not in pain. Prison staff washed and dressed him and helped him into bed. A note
in the wing observation book said that staff should monitor Mr Kimmins every thirty
minutes until he was assessed by healthcare staff.
44. The prisoner who was appointed as Mr Kimmins’ buddy (to help him with everyday
care) later told the prison’s internal investigation that Mr Kimmins had pressed his
personal alarm during the early hours to alert him that he needed help of some kind,
and he had then pressed his cell bell and alerted the night staff. However, the
investigation report went on to say, “This has been checked with the night OSG
[operational support grade] and the cell bell call outs and there is no evidence that
the cell bell was activated.”
45. At 7.42am, a CM recorded that healthcare staff had cancelled Mr Kimmins hospital
appointment that day because of his ill health. At 2.13pm, a nurse made a
retrospective entry in Mr Kimmins’ medical record saying that that prison staff had
initially asked healthcare staff to see Mr Kimmins because he was feeling unwell
and had vomited in the night and had made no mention of a fall. The Head of
Healthcare told the clinical reviewer that prison staff did not ask healthcare staff to
see Mr Kimmins’ until 10.00am on 20 March and that there was no formal handover
between prison night staff and healthcare staff.
46. Two nurses examined Mr Kimmins at about 10.00am. They found that Mr Kimmins
had vomited and been incontinent of urine. He could not respond verbally and
communicated with a thumbs up or down sign. They recorded his oxygen saturation
level as 93-94% (the normal range is 95-100%), his temperature as 36.5°C and
pulse rate as 84 beats per minute. They gave him his medication and asked a
prison GP to see him.
47. At about noon, a prison GP assessed Mr Kimmins, together with three nurses . The
prison GP noted that Mr Kimmins was drooling, had low oxygen saturation and was
unable to stand unaided. He was, however, able to speak as his Parkinson’s
medication had taken effect. He said he had fallen at about 10.00pm and been
unable to get up or call for help. A nurse later recorded that she had asked an un-
named prison officer if Mr Kimmins had been observed over night and was told that
Mr Kimmins “had a bell and should have rung it”.
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48. The prison GP found that Mr Kimmins’ condition and the injuries to his hip were
consistent with having been immobile on the floor for several hours. She diagnosed
him with pressure area wounds and possible rhabdomyolysis (when damaged
muscle breaks down very quickly) and aspiration pneumonia and arranged for him
to be taken to hospital by a non-emergency ambulance (which arrived within 30
minutes). Mr Kimmins left prison by ambulance at about 1.50pm. He was
accompanied by two prison officers and was not restrained.
49. Healthcare staff completed a patient safety incident form about Mr Kimmins’ fall.
They noted his lack of overnight observations, the failure of prison staff to report the
incident at the time and the injuries Mr Kimmins had sustained. The Head of
Healthcare said that he asked the prison to report the incident as a RIDDOR
(Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013).
50. On 20 March, Mr Kimmins was given a routine test for COVID-19 in hospital. The
results were negative. He was treated with high levels of oxygen and hospital staff
decided he was suitable for end of life care. On 26 March, Mr Kimmins tested
positive for COVID-19. He died the next day.
Contact with Mr Kimmins’ family
51. The prison appointed a Reverend as family liaison officer (FLO) and identified Mr
Kimmins’ son as his next of kin. Mr Kinder arranged for Mr Kimmins’ son to visit
him in hospital. In accordance with COVID -19 restrictions, Mr Kinder broke the
news of Mr Kimmins’ death by telephone.
52. The prison contributed to the cost of Mr Kimmins’ funeral in line with national
guidance.
Support for prisoners and staff
53. The prison posted notices informing other prisoners of Mr Kimmins’ 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 Kimmins’ death.
Post-mortem report
54. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Kimmins’ cause of
death as COVID-19, with advanced Parkinson’s disease and frailty of old age as
contributing factors.
The internal investigation
55. After Mr Kimmins’ death, the Governor commissioned a prison manager to carry out
a factfinding investigation. The prison manager investigation report, dated 4 June
2020, concluded that “there is no evidence to suggest staff were negligent in their
duties and commissioning of a Disciplinary investigation is not needed in this
situation”. He said that there had been “some confusion in communication with the
handover between the day staff and the healthcare staff in regards to the healthcare
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staff not understanding that [Mr Kimmins] had fallen in the night” and he made
some recommendations for improvement.
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Findings
Clinical care
56. The clinical reviewer concluded that the clinical care that Mr Kimmins received at
Littlehey was of a good standard and equivalent to that which he could have
expected to receive in the community.
57. He had care plans in place to monitor his long-term health conditions, skin integrity,
pain management and palliative care. He was accommodated in a disability cell
with a hospital bed and a pressure relieving mattress, and he was given the
opportunity to discuss a transfer to another prison if he felt he needed overnight and
enhanced healthcare. When Mr Kimmins’ Parkinson’s disease progressed,
healthcare staff assessed his social care needs and provided him with additional
equipment.
Management of Mr Kimmins’ risk of catching COVID-19
58. At the outbreak of the pandemic, Mr Kimmins was not identified as at high risk of
contracting the COVID-19 virus and he was not required to shield. On 24 March,
Mr Kimmins was identified as high risk, but he was already in hospital by this time.
59. Mr Kimmins was routinely tested when he was admitted to hospital on 20 March
with a negative result. He subsequently tested positive on 26 March. Mr Kimmins
displayed no symptoms of COVID-19 while he was at Littlehey and, although we
cannot be sure, it, therefore, seems likely that Mr Kimmins contracted COVID-19 in
hospital rather than at Littlehey.
Safeguarding
60. Mr Kimmins had regular falls in his cell overnight and on 1 March, a prison manager
noted that prison staff should complete hourly observations on him during the night.
We are very concerned that these observations had clearly not taken place on the
night of 19/20 March, and that Mr Kimmins may have been on the floor for more
than eight hours before he was found. We do not know if the overnight
observations had ever taken place.
61. We are also concerned that prison staff did not report Mr Kimmins’ fall to healthcare
staff until some time between 9.00 and 10.00am (at least three hours after Mr
Kimmins was found on the floor of his cell), even though healthcare staff were on
duty in the prison from 7.30am. In addition, prison staff did not tell healthcare staff
that Mr Kimmins may have been on the floor for several hours before he was found
and healthcare staff only discovered this when Mr Kimmins told them. The prison’s
internal investigation found that there was “confusion and miscommunication
around this information” and that healthcare staff would have responded more
quickly if they had been aware that Mr Kimmins had fallen and been unable to get
up during the night.
62. Since Mr Kimmins’ death, the prison told us that they have introduced measures to
monitor prisoners who are at risk of falling. Prisoners who are identified as at an
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increased risk are reviewed weekly at the Safety Intervention Meeting and are
provided with a fall detector. Prisoners who need to be monitored overnight are
identified on the daily briefing sheet and observations are recorded in the wing
observation book. The prison has also provided healthcare staff with access to the
daily briefing sheet and has introduced a formal handover between prison night staff
and healthcare staff.
63. We are satisfied that these measures will ensure prisoners who are at risk of falling
are appropriately monitored and healthcare staff are aware of prisoners who have
caused concern during the night.
64. However, we are concerned that the prison’s internal investigation did not address
the key question of why Mr Kimmins was not being observed on an hourly basis
overnight in line with the prison manager’s instructions in the wing observation book
on 1 March. If observations had been taking place, Mr Kimmins would have been
discovered within an hour and would not have been lying on the floor for several
hours. If he had been found earlier, it is possible that his condition would not have
deteriorated to the point where he needed to go to hospital.
65. The prison manager’s recorded in his investigation report that on 1 March he “spoke
to the staff to ask them to keep an hour [sic] eye on [Mr Kimmins] over night which
was recorded in the Observation book but there was nothing formal put in place.”
We consider that the internal investigation should have considered whether this was
an adequate way of communicating such key instructions about the care of a
vulnerable prisoner, and, if it was, why staff were not conducting hourly checks.
66. We are also concerned that the internal investigation did not adequately consider
whether staff should have called an ambulance or spoken to an out of hours doctor
for advice when they found Mr Kimmins on the floor, given his age, medical issues
and the fact that they did not know how long he had been lying on the floor. In
addition, although it was recorded that staff should check Mr Kimmins every 30
minutes until healthcare staff had seen him, we have seen no evidence that such
checks took place or that the deterioration in Mr Kimmins’ condition before
healthcare staff saw him at about 10.00am was noted. We are also concerned that
no one had responsibility for ensuring that healthcare staff were told about the fall
when they came on duty at 7.30am.
67. For these reasons, we do not consider that the internal investigation was an
adequate investigation of what went wrong and why. We recommend:
The Governor should commission an investigation into the failure to put
hourly observations in place for Mr Kimmins during the night, and the failure
to contact healthcare staff promptly on 20 March, with a view to considering
whether disciplinary action is appropriate.
68. The clinical reviewer said that the Head of Healthcare did not know if the prison had
reported the patient safety incident to the Health and Safety Executive (HSE) and
had not investigated healthcare staff’s concerns about Mr Kimmins’ care. The Head
of Healthcare said that safeguarding was a prison responsibility and while
healthcare staff sought advice and support from safeguarding teams, it was the
prison’s responsibility to report safeguarding incidents.
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69. The clinical reviewer said that relying on another party to raise a safeguarding
concern was not in accordance with NHFT’s policy for safeguarding vulnerable
adults which says:
“If an adult has died as the result of abuse or neglect (whether known or
suspected) and there is a concern that partner agencies could have worked
more effectively to protect the adult, then Local Safeguarding Adult Boards
are to commission a Safeguarding Adult Review (SAR).”
70. The clinical reviewer considered that while the application of safeguarding policy will
vary between the community and a custodial setting, it was the responsibility of the
Head of Healthcare to ensure that safeguarding concerns raised by healthcare staff
were actioned and that staff were aware of the outcome of any investigation into
those concerns. We recommend that:
The Head of Healthcare should ensure that healthcare staff are aware of
NHFT’s policy for safeguarding responsible adults and that staff adhere to the
policies, procedures and guidelines.
Inquest
71. The inquest, heard on 2 October 2023, concluded that Mr Kimmins died from
natural causes.
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