Anthony Matthews
Natural causes
Report published
HMP Hollesley Bay (Prison)
Recommendations (2)
2 Accepted
Recommendation 1
The Head of Healthcare should ensure all staff comply with national guidance regarding the diagnosis and management of hypertension.
Response
Further training implemented to ensure the wider primary care team are aware of NICE & Clinical Lead Guidelines. We take learning from other incidents, other sites and from all alerts which come via our national comms. The Clinical Lead is auditing long term condition reviews and all learning from these audits is then fed into scenario-based training, one to one feedback and daily handovers. Long Term Condition Nurse has been recruited, and we are awaiting vetting clearance, once this key role is in place it will further reinforce our processes. To ensure follow ups are being booked from the return of home blood pressure monitoring we now book the follow up appointment with the GP for 7 days from the date of the dairy being handed out to ensure the patient knows when their next appointment is in relation to this concern.
Recommendation 2
The Head of Healthcare should ensure all staff comply with national guidance around the risk management and reduction of cardiovascular disease.
Response
Further training implemented to ensure the wider primary care team are aware of NICE and Clinical Lead Guidelines. We take learning from other incidents, other sites and from all alerts which come via our national comms. The Clinical Lead is auditing long term condition reviews and all learning from these audits is then fed into scenario-based training, one to one feedback and daily handovers. Long Term Condition Nurse has been recruited, and we are awaiting vetting clearance, once this key role is in place it will further reinforce our processes. We also have a nurse prescriber from a GP surgery that comes in on a as required basis to help with our patients with long term conditions and medication reviews linked to their conditions. This has improved wait times for patients with complex long-term conditions to be seen in a timely manner with reviews in place.
Full Report Text
OFFICIAL - FOR PUBLIC RELEASE Independent investigation into the death of Mr Anthony Matthews, a prisoner at HMP Hollesley Bay, on 13 June 2024 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 1. The Prisons and Probation Ombudsman aims to make a significant contribution to safer, fairer custody and community supervision. One of the most important ways in which we work towards that aim is by carrying out independent investigations into deaths, due to any cause, of prisoners, young people in detention, residents of approved premises and detainees in immigration centres. 2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in ensuring the standard of care received by those within service remit is appropriate, our recommendations should be focused, evidenced and viable. This is especially the case if there is evidence of systemic failure. 3. In February 2023, Mr Anthony Matthews was sentenced to five years and 10 months in prison for firearms offences. He died of cardiomegaly (an abnormal enlargement of the heart) on 13 June 2024, while a prisoner at HMP Hollesley Bay. He was 59 years old. We offer our condolences to Mr Matthews’ family and friends. 4. The Ombudsman office wrote to Mr Matthews’ next of kin, his father, to explain the investigation and to ask if he had any matters he wanted us to consider. He did not respond to our letter. 5. NHS England commissioned an independent clinical reviewer to review Mr Matthews’ clinical care at HMP Hollesley Bay. 6. The clinical reviewer concluded that the clinical care Mr Matthews received at Hollesley Bay was of a reasonable standard and was partially equivalent to that which he could have expected to receive in the community. She found that Mr Matthews received individualised support for his needs and the medical records described compassionate interactions with him. However, she was not satisfied that Mr Matthews’ care was equivalent in relation to his raised blood pressure and cardiovascular risk score. We make the following recommendations: The Head of Healthcare should ensure all staff comply with national guidance regarding the diagnosis and management of hypertension. The Head of Healthcare should ensure all staff comply with national guidance around the risk management and reduction of cardiovascular disease. 7. The PPO investigator investigated the non-clinical issues relating to Mr Matthews’ care. We did not find any non-clinical issues of concern. 8. The initial report was shared with HM Prison and Probation Service (HMPPS) and Practice Plus Group. They did not find any factual inaccuracies. 9. At an inquest held on 28 March 2025, the Coroner concluded that Mr Matthews died of natural causes. Adrian Usher November 2024 Prisons and Probation Ombudsman Prisons and Probation Ombudsman 1 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
Case Details
Date of Death
13 June 2024
Report Published
11 April 2025
Age
51-60
Gender
Responsible Body
HMP Hollesley Bay
Recommendations
2
Inquest Date
28 March 2025
Recommendation Themes
healthcare (2)