Brian Johncock

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Brian Johncock,
a prisoner at HMP Lewes,
on 15 February 2022
A report by the Prisons and Probation Ombudsman
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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 Brian Johncock died in hospital on 15 February 2022, while a prisoner at HMP Lewes.
He died after an operation to remove a tumour in his bowel. He was 82 years old. I offer
my condolences to Mr Johncock’s family and friends.
The clinical reviewer concluded that aspects of the care that Mr Johncock received at
Lewes were not equivalent to that which he could have expected to receive in the
community.
The clinical reviewer found that staff failed to recognise the deterioration in Mr Johncock’s
condition leading up to his admission to hospital on 4 February. She also considered that
staff missed an opportunity to refer Mr Johncock under the suspected cancer pathway
when he showed symptoms of possible cancer in November 2021.
Staff restrained Mr Johncock using an escort chain when he was taken to hospital on 4
February. I am concerned that the decision to restrain Mr Johncock, who was an elderly,
unwell man, was not proportionate to the risk he posed.
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 April 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 7
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Summary
Events
1. Mr Brian Johncock arrived at HMP Lewes on 15 August 2019. He had several
health conditions, including heart disease and diabetes, and he used a walking stick
to get around as he had hip and back problems.
2. In November 2021, Mr Johncock told staff that he had blood in his stools. Mr
Johncock provided a stool sample, but it was never analysed as the specimen
container was overfilled. Staff ordered another test, but it did not arrive. It was not
followed up.
3. By mid-January 2022, Mr Johncock was complaining of severe abdominal pain,
vomiting and diarrhoea. Healthcare staff arranged blood tests and a stool sample
to check for blood. The blood tests showed signs of infection and abnormal liver
function, but the stool test was normal.
4. On 30 January, staff found Mr Johncock bent double in pain. He said he had
vomited a bile-like substance and found eating painful. On 2 February, staff
admitted Mr Johncock to the prison’s inpatient unit for closer monitoring.
5. On 3 February, staff discharged Mr Johncock from the inpatient unit and moved him
back to his cell. This was despite his blood pressure being very low.
6. The next day, a nurse reviewed Mr Johncock and recorded that his blood pressure
was still low, his pulse rate was high, and his blood oxygen level was at the low end
of the normal range. He asked a GP to see Mr Johncock. The GP found a lump in
Mr Johncock’s abdomen and sent him to hospital. Two officers accompanied him
and restrained him using an escort chain (a long chain with a handcuff at each end,
one of which is attached to the prisoner’s wrist and the other to an officer’s wrist).
7. The next morning, a prison manager authorised the removal of the escort chain due
to Mr Johncock’s age and poor mobility.
8. Mr Johncock underwent surgery to remove part of his large intestine as doctors
suspected a cancerous tumour. His condition subsequently deteriorated, and he
died in hospital on 15 February.
Findings
9. The clinical reviewer found that aspects of the care Mr Johncock received at Lewes
were not equivalent to that which he could have expected to receive in the
community.
10. The clinical reviewer noted that in November 2021, Mr Johncock displayed some
symptoms of possible cancer, and she considered it would have been prudent to
refer him under the two-week cancer pathway at that point. She also noted that
there had been a long delay in stool sample testing.
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11. The clinical reviewer found that staff did not recognise Mr Johncock’s clinical
deterioration when he was in the prison’s inpatient unit. She was concerned that he
was discharged and returned to a standard wing when his blood pressure was very
low. She considered that this was a poor decision. She also considered that use of
the Multi-Professional Complex Case Clinic (MPCCC) might have enabled better
management of Mr Johncock’s declining health.
12. We consider that the use of an escort chain on Mr Johncock when he was taken to
hospital on 4 February was inappropriate. Mr Johncock was 82 years old, was
unwell and used a walking stick. The use of restraints on Mr Johncock was
disproportionate to the risk he posed.
Recommendations
• The Head of Healthcare should remind staff how to order supplies.
• The Head of Healthcare should ensure that staff understand when they should
make referrals under the suspected cancer pathway.
• The Head of Healthcare should ensure that staff understand how to assess clinical
deterioration including use of the NEWS2 tool.
• The Head of Healthcare should ensure that staff are aware of the Multi-Professional
Complex Case Clinic (MPCCC) criteria and consider its early use for a patient who
is deteriorating.
• The Governor should ensure that authorising managers understand the legal
position on the use of restraints and that assessments fully take into account the
health of a prisoner and are based on the actual risk the prisoner presents at the
time.
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Lewes informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
14. The investigator obtained copies of relevant extracts from Mr Johncock’s prison and
medical records.
15. NHS England commissioned an independent clinical reviewer to review Mr
Johncock’s clinical care at the prison.
16. We informed HM Coroner for East Sussex of the investigation. The coroner gave
us the cause of death. We have sent the coroner a copy of this report.
17. The Ombudsman’s family liaison officer contacted Mr Johncock’s next of kin, a
friend, to explain the investigation and to ask if he had any matters he wanted us to
consider. Mr Johncock’s friend raised concerns about the health care that Mr
Johncock had received. These issues have been addressed in this report and in
the clinical review.
18. We shared our initial report with HM Prison and Probation Service (HMPPS). They
pointed out one minor factual inaccuracy which has been amended in this report.
19. We sent a copy of our initial report to Mr Johncock’s next of kin. They did not notify
us of any factual inaccuracies.
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Background Information
HMP Lewes
20. HMP Lewes is a local prison serving the courts of East and West Sussex. Practice
Plus Group provides primary care services. The prison has a healthcare centre
with a full time senior medical officer. Healthcare is provided on a 24-hour basis.
There is also a 9-bed inpatient unit, an outpatient facility, a pharmacy and a range
of clinics.
HM Inspectorate of Prisons
21. The most recent inspection of HMP Lewes was in May 2022. Inspectors reported
that around half of healthcare staff were agency or bank staff, which created risk
and instability. However, dedicated staff demonstrated a commitment to the
service, and the provider was taking all available steps to recruit substantive staff.
22. Inspectors reported that the inpatient unit provided good quality care to prisoners
residing there, but staff shortages led to a restricted regime, with limited activities to
support their well-being. The inpatient environment was inadequate, and some
cells were in a poor condition, even though this had been highlighted at the
previous inspection.
Independent Monitoring Board
23. 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 2021, the IMB noted
that Practice Plus Group took over the provision of healthcare from Sussex
Partnership Foundation Trust in April 2020 and had had a hugely beneficial impact
on the healthcare provided at Lewes.
24. The healthcare provider had kept residents informed and clinics running throughout
the pandemic, with waiting list times which the IMB considered to be no longer than
those in the general community. There had been improved healthcare coverage
during evenings and weekends and better out of hours prescribing.
Previous deaths at HMP Lewes
25. Mr Johncock was the tenth prisoner to die at Lewes since February 2020. Of the
previous deaths, six were from natural causes and three were self-inflicted. There
have been four deaths since, two from natural causes and two drug-related. In one
of those investigations, we found that staff had not assessed clinical deterioration
using the NEWS2 tool.
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Key Events
26. On 15 August 2019, Mr Brian Johncock was sentenced to 12 years in prison for
sexual offences. He was sent to HMP Lewes.
27. Mr Johncock had several health conditions including heart disease, diabetes and
high blood pressure. He used a walking stick to get around as he had hip and back
problems.
28. In November 2021, Mr Johncock said he had blood in his stools. Staff ordered a
faecal immunochemical test (FIT) and asked him to collect a stool sample, which he
did. However, the sample was never analysed as the specimen container was
overfilled. Staff ordered another test, but it never arrived and was not followed up.
29. At the end of December, Mr Johncock told staff that he was having abdominal
cramps and there was blood in his stools. He said that he was anxious about
eating as it caused cramps. Healthcare staff said they would arrange another FIT
test.
30. By mid-January 2022, Mr Johncock was complaining of severe abdominal pain. On
13 January, a nurse saw him and referred him for an urgent GP appointment.
However, the GP could not see him the next day as the wing was in lockdown due
to COVID-19. A nurse saw him on 15 January, and Mr Johncock complained of
vomiting and diarrhoea. The nurse thought he might have gastroenteritis. The
nurse gave Mr Johncock medication to treat diarrhoea and noted that Mr Johncock
needed blood tests and a FIT test to check for blood in his stools. Healthcare staff
checked on Mr Johncock daily. His condition improved but he said he had no
appetite.
31. On 19 January, Mr Johncock complained of abdominal pain again. Staff took blood
samples and realised that his FIT test had not been sent off (it was sent the next
day). The blood test results were abnormal. They showed signs of infection and
abnormal liver function. However, the FIT test result was normal.
32. On 30 January, staff found Mr Johncock bent double in pain. He told them he had
vomited a bile-like substance, was off his food and found eating painful. Healthcare
staff checked on him and found his vital signs were stable, but his blood pressure
was low. They informed the GP.
33. On 1 February, healthcare staff decided that Mr Johncock should be admitted to the
prison’s inpatient unit for closer monitoring. He was admitted the next day. Staff
carried out a range of tests, including another FIT test, and closely monitored his
food and fluid intake.
34. Mr Johncock was discharged from the inpatient unit and moved back to his cell on 3
February. Healthcare staff noted that his blood pressure was low and should be
monitored.
35. On the morning of 4 February, wing staff asked for a nurse to check on Mr
Johncock as he seemed unwell. The nurse recorded that Mr Johncock appeared
well and that the GP was aware of his low blood pressure.
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36. Another nurse checked on Mr Johncock a few hours later. The nurse recorded that
Mr Johncock’s blood pressure was still low, his pulse rate was high, and his blood
oxygen level was at the low end of the normal range. The nurse asked the GP to
see him. When the GP examined Mr Johncock, he felt a lump in his abdomen. He
sent Mr Johncock to hospital. Two prison officers accompanied Mr Johncock and
they restrained him using an escort chain (a long chain with a handcuff at each end,
one of which is attached to the prisoner’s wrist and the other to an officer’s wrist).
37. The next day, a prison manager agreed to remove the escort chain due to Mr
Johncock’s age and poor mobility.
38. Mr Johncock underwent surgery to remove part of his large intestine as doctors
suspected a cancerous tumour. However, his condition deteriorated in hospital,
and he died on 15 February.
Contact with Mr Johncock’s next of kin
39. On 6 February, when Mr Johncock was placed in a coma, the prison appointed a
family liaison officer (FLO). The FLO contacted Mr Johncock’s next of kin, a friend,
to tell him that Mr Johncock was in hospital and to offer support.
40. The prison contributed to the costs of Mr Johncock’s funeral in line with national
policy.
Support for prisoners and staff
41. After Mr Johncock’s death, a Custodial Manager debriefed the staff that were at the
hospital when Mr Johncock died to ensure they had the opportunity to discuss any
issues arising, and to offer support. The staff care team also offered support.
Cause of death
42. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Johncock’s cause of
death as pneumonia, caused by emergency right hemicolectomy (an operation
removing the right side of the colon and attaching the small intestine to the
remaining portion of the colon) as a result of colorectal cancer with bowel
obstruction.
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Findings
Clinical care
43. The clinical reviewer found that Mr Johncock’s long-term conditions were well-
managed at Lewes, but other aspects of his care were not equivalent to that which
he could have expected to receive in the community.
44. Healthcare staff recognised from their own internal investigation that the delay in
testing the stool sample was not good practice as this may have presented a
missed opportunity for further referrals. We recommend:
The Head of Healthcare should remind staff how to order supplies.
45. The clinical reviewer noted that in November 2021, Mr Johncock displayed some
symptoms outlined in NICE (National Institute for Health and Care Excellence)
guidance [NG12] Suspected cancer: recognition and referral, and that it may have
been prudent to refer him under the two-week cancer pathway at that time. We
recommend:
The Head of Healthcare should ensure that staff understand when they
should make referrals under the suspected cancer pathway.
46. The clinical reviewer found that healthcare staff did not recognise Mr Johncock’s
declining health despite a rising NEWS2 score when he was in the prison’s inpatient
unit. (NEWS2 is a tool used to assess clinical deterioration in adult patients. A
score is calculated based on the readings taken from clinical observations and the
higher the score, the higher the clinical risk.) She was concerned that Mr Johncock
was discharged from the inpatient unit despite his very low blood pressure, and she
considered this was a poor decision given how unwell he was. She also considered
that an earlier multidisciplinary meeting and use of the Multi-Professional Complex
Case Clinic (MPCCC), held weekly to discuss patients who meet the criteria, may
have enabled better management of Mr Johncock’s declining health. We
recommend:
The Head of Healthcare should ensure that staff understand how to assess
clinical deterioration including use of the NEWS2 tool.
The Head of Healthcare should ensure that staff are aware of the Multi-
Professional Complex Case Clinic (MPCCC) criteria and consider its early use
for a patient who is deteriorating.
Restraints, security and escorts
47. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility.
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48. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
49. The escort risk assessment noted that Mr Johncock was in poor health and had low
mobility. Mr Johncock was also assessed as a low risk to staff and a low risk of
escape. We consider that the use of restraints on Mr Johncock when he was taken
to hospital on 4 February was not proportionate to the risk he posed. We
recommend:
The Governor should ensure that authorising managers understand the legal
position on the use of restraints and that assessments fully take into account
the health of a prisoner and are based on the actual risk the prisoner presents
at the time.
Inquest
50. The inquest, held on 19 September 2024, concluded that Mr Johncock died from
natural causes.
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