Brian Kemp

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Independent investigation into
the death of Mr Brian Kemp,
a prisoner at HMP Fosse Way,
on 26 January 2025
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, 2025
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Summary
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. Mr Brian Kemp died in hospital of cardiac tamponade (blood or fluid collects in the
sac surrounding the heart preventing the heart ventricles from expanding fully)
caused by metastatic squamous cell carcinoma of the lung (lung cancer) on 26
January 2025, while a prisoner at HMP Fosse Way. He was 58 years old. We offer
our condolences to his family and friends.
4. Around the time of his cancer diagnosis, prison staff cancelled four investigative
hospital appointments due to a shortage of escort staff. It is likely that these
cancellations delayed Mr Kemp’s diagnosis and the start of his treatment. Fosse
Way has since introduced a new process to ensure that appointments for cancer
patients are given the highest priority for external escorts.
5. Mr Kemp later missed two chemotherapy appointments, as prison healthcare staff
were seemingly not informed of the dates by hospital staff.
6. Restraints were inappropriately used when Mr Kemp visited hospital in the last
weeks of his life, with little consideration for his mobility, diagnosis and deteriorating
health.
7. Prison staff appropriately applied for early release on compassionate grounds for
Mr Kemp, although a consultant report submitted in support of the application was
several months out of date. The application was therefore rejected, and Mr Kemp
died before an up-to-date report was obtained.
Recommendations
• The Head of Healthcare should discuss with Leicester Royal Infirmary the process
for obtaining chemotherapy appointment letters, to ensure that patients do not miss
important treatments.
• The Director and Head of Healthcare should ensure that all staff undertaking risk
assessments for prisoners taken to hospital understand the legal position on the
use of restraints, including that:
• Healthcare staff complete the healthcare section of the escort risk
assessment fully and accurately, including giving appropriate consideration
to whether the prisoner’s health and mobility means that restraints are not
required.
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• Managers responsible for authorising restraints consider the healthcare input
into the escort risk assessment and base their decision on the actual risk the
prisoner poses at the time.
• A robust quality assurance process is implemented to check that these
measures are in place and effective.
• The Director and Head of Healthcare should ensure that applications for early
release on compassionate grounds contain an up-to-date letter from the relevant
hospital consultant, including all of the information required by the Early Release on
Compassionate Grounds Policy Framework.
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The Investigation Process
8. We were notified of Mr Kemp’s death on 26 January 2025.
9. NHS England commissioned an independent clinical reviewer, to review Mr Kemp’s
clinical care at HMP Fosse Way.
10. The PPO investigator investigated the non-clinical issues relating to Mr Kemp’s
care. She found an area of concern with restraints and availability of prison staff to
escort Mr Kemp to hospital appointments.
11. The Ombudsman’s office contacted Mr Kemp’s next of kin and arranged for them to
be provided with copies of our report. They did not make any comments.
12. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and we have amended this report
accordingly. The action plan is an additional annex to this report.
Previous deaths at HMP Fosse Way
13. Mr Kemp was the eighth prisoner to die at HMP Fosse Way since it opened in May
2023. Of the previous deaths, three were from natural causes, two were self-
inflicted, one was as a result of drugs toxicity and one was a homicide.
14. Our investigation into the death of a man in July 2024 found that staff completing
escort risk assessments did not properly consider his health and mobility, and that
they inappropriately applied restraints until he was very close to death. In December
2024, we recommended that the Director ensure that staff undertaking risk
assessments understand the legal position on the use of restraints and that
authorising managers show that they have taken this into account when assessing
the prisoner’s current level of risk.
15. In response to our recommendation, Fosse Way said that risk assessments were
completed with input from healthcare colleagues. They said that management
checks completed for hospital inpatients would ensure that the level of risk was
reviewed when circumstances changed, decisions were documented, and that
cuffing arrangements reflected this.
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Key Events
16. On 17 November 2022, Mr Brian Kemp was remanded to HMP Leicester for threats
to kill. On 17 March 2023, he was sentenced to three years in prison. On 1 June, Mr
Kemp was transferred to HMP Stocken.
17. On 8 August, Mr Kemp was transferred to HMP Fosse Way. At his reception health
screening, Mr Kemp did not report any significant physical health symptoms or
diagnoses.
18. On 23 March 2024, Mr Kemp told prison staff he had had a cough for the past year,
and that for the past month had been intermittently coughing up specks of blood.
Healthcare staff examined him and booked an electrocardiogram (ECG) for the next
day due to Mr Kemp’s shortness of breath. Staff advised Mr Kemp to contact them if
he had new or worsening symptoms. (The result of the ECG was not recorded in Mr
Kemp’s medical record.)
19. On 26 April, healthcare staff referred Mr Kemp under the two-week referral scheme
for suspected cancer, due to his persistent haemoptysis (coughing up blood from
lungs or airways).
20. On 1 May, hospital staff discussed Mr Kemp’s referral with prison healthcare staff.
They said that Mr Kemp could not be accepted without a chest X-ray or CT scan
and said that they would cancel the referral. Hospital staff advised healthcare staff
to book a chest X-ray and CT scan for Mr Kemp. (The nurse who referred Mr Kemp
recorded that they felt this pathway was obstructive and sent an email to the
hospital to express their concerns.) Mr Kemp’s CT scan was subsequently booked
for 7 June.
21. On 7 June, prison staff cancelled Mr Kemp’s scheduled CT scan appointment as
there were not enough staff available to escort him to hospital.
22. On 11 June, healthcare staff called the hospital to ask if they could rebook Mr
Kemp’s appointment that was missed on 7 June. Hospital staff said that Mr Kemp
had been discharged due to his non-attendance and that they would need to send a
new referral. They said that because the appointment was originally urgent it would
need to be resent as urgent so it was fast tracked.
23. On 24 June, the radiology department at Leicester Royal Infirmary called prison
healthcare staff to arrange a CT scan appointment for Mr Kemp. Healthcare staff
said the earliest appointment they could do was 1 August. The radiology
department said the appointment was urgent and would be upgraded to a two week
wait. Healthcare staff said 28 June was the earliest they could possibly facilitate an
appointment, which was then booked for Mr Kemp.
24. At 3.50pm on 28 June, prison healthcare staff called the hospital CT radiology team
to inform them Mr Kemp would be late for his CT scan due to a shortage of staff to
provide the escort. Hospital staff told them that Mr Kemp would be seen as long as
he was there by 5.00pm. At 4.50pm, healthcare staff told the hospital that they were
unable to facilitate Mr Kemp’s appointment due to the staffing issue. Healthcare
staff explained to Mr Kemp why he was unable to attend his appointment and
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updated him on the next course of action. The appointment was rescheduled for 2
July.
25. On 2 July, prison healthcare staff called the hospital CT team to explain that Mr
Kemp would again not attend his appointment that morning as scheduled because
of a shortage of staff to facilitate the escort. Hospital staff raised their concerns with
healthcare staff at the numerous appointments Mr Kemp had now missed.
Healthcare staff explained that it was out of their control as it was prison staff who
said they could not escort Mr Kemp to the hospital. Healthcare staff asked the CT
team if they had any availability the next day. They confirmed they would
reschedule Mr Kemp’s appointment for 3 July.
26. On 3 July, Mr Kemp attended the hospital appointment. He underwent a CT scan of
his thorax which showed a right upper lobe lung malignancy (a cancerous tumour
located in the top portion of the right lung). Referral to the lung cancer
multidisciplinary team (MDT) was advised. A biopsy of the lung mass was arranged
for 5 August.
27. On 10 July, healthcare staff received the results of Mr Kemp’s scan. Staff requested
an urgent referral to the prison’s lung cancer MDT. They met with Mr Kemp the next
day to inform him of the diagnosis.
28. On 1 August, Mr Kemp attended a hospital appointment for a CT scan of his
abdomen and pelvis, and a blood test.
29. On 2 August, hospital staff informed the prison healthcare team that Mr Kemp
required an additional blood test. They arranged the blood test for 5 August, with
the biopsy now to follow on 8 August.
30. On 5 August, hospital staff contacted Fosse Way to cancel Mr Kemp’s blood test
appointment and reschedule to 12 August, due to changes in other appointments.
(Mr Kemp was already en-route to the hospital at the time.) Mr Kemp’s appointment
was later rebooked for 20 August.
31. On 8 August, Mr Kemp attended his biopsy appointment and afterwards returned to
prison.
32. On 20 August, Mr Kemp did not attend his blood test hospital appointment, due to
there being no prison escort staff available. Healthcare staff made an urgent
request to the hospital to rearrange the appointment. It was rescheduled to 22
August.
33. On 22 August, hospital staff called healthcare staff to ensure Mr Kemp would attend
his appointment and reminded them of the urgency of Mr Kemp attending. Mr Kemp
attended his appointment and received confirmation of his diagnosis of stage four
terminal lung cancer.
34. On 4 September, Mr Kemp was reviewed by the hospital oncology team to discuss
management options, including potential chemotherapy. He returned to prison
afterwards.
35. On 18 September, prison staff reported that Mr Kemp was making regular hospital
visits for his cancer treatment, which he said was going well. They asked Mr Kemp
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if he had decided to tell his family about the treatment. Mr Kemp said he did not
want to involve them until he was released from prison.
36. On 23 September, prison staff recorded that Mr Kemp told them he had been
collapsing recently, and reached a point where he was too nervous to leave his bed
in case he injured himself. They arranged for Mr Kemp move to an adapted cell. As
Mr Kemp also raised concerns about leaving his cell due to collapsing, prison staff
suggested to healthcare staff that Mr Kemp had a prison buddy to help him with
daily tasks (which was later arranged, along with a hospital bed for his cell).
37. On 2 October, Mr Kemp commenced chemotherapy treatment. Healthcare staff
began an application for early release on compassionate grounds (ERCG) for Mr
Kemp. (In early November, prison staff told Mr Kemp that he did not currently meet
the criteria for early release. This was due to a variety of reasons, including that he
was being treated through chemotherapy and did not yet require hospital or hospice
treatment.)
38. On 4 October, healthcare staff conducted a routine review and care planning
session with Mr Kemp, who now used a wheelchair. He told them he felt he had
declined a lot in the past few weeks. They discussed the ERCG application and
how long the process would take. Mr Kemp said he would prefer to die in a hospice,
if that was possible. Staff said they saw a clear deterioration in Mr Kemp, who
looked frail and had lost weight. Mr Kemp had agreed a DNACPR (do not attempt
cardiopulmonary resuscitation) and was on a gold standards palliative care
framework.
39. On 6 October, healthcare staff discussed Mr Kemp’s deterioration with hospital staff
and requested his admission. Oncology staff told them that they had no beds
available. They advised that Mr Kemp be admitted to Leicester Royal Infirmary
emergency department, where he was escorted by prison staff. Mr Kemp was
restrained using an escort chain (a length of chain with a handcuff at either end;
one worn by the prisoner and the other an officer) throughout his stay in hospital.
40. Over the following days, Mr Kemp’s condition gradually deteriorated with worsening
shortness of breath.
41. On 9 October, a repeat CT scan demonstrated significant progression of Mr Kemp’s
right upper lobe lung cancer. The scan reported bilateral pleural effusions (fluid
within the lining of the lungs), and the presence of a moderate pericardial effusion
(fluid around the heart). It was also noted that Mr Kemp had a blood clot in the
upper chest. Doctors felt that these radiological findings significantly shortened Mr
Kemp’s estimated prognosis to under 12 months. Mr Kemp was referred to the
Marie Curie palliative care service.
42. On 17 October, Mr Kemp returned to prison from hospital. He told prison staff he
felt a lot better due to his treatment in hospital. Staff reported that he looked and
seemed much healthier and happier. However, hospital staff had informed Mr Kemp
his prognosis had reduced and he was now predicted to only have a year left to live.
43. On 22 October, Mr Kemp told prison staff he had been struggling with a lot of
sickness due to his chemotherapy. (Healthcare staff later prescribed anti-sickness
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tablets for this.) Staff said Mr Kemp had put on some weight recently and was
beginning to look slightly healthier despite his current struggles.
44. On 5 November, Mr Kemp was escorted to hospital for chemotherapy. Before
transfer, healthcare and prison staff completed an escort risk assessment.
Healthcare have indicated on the risk assessment by highlighting ‘No’ that they
have no medical objection to the use of restraints. However, they confirmed that Mr
Kemp was a wheelchair user. In the assessment, prison staff gave no indication of
Mr Kemp’s risk of escape and risk to the public. He was taken to hospital restrained
by an escort chain and two prison officers.
45. On 19 November, Mr Kemp attended another appointment. Before his transfer,
healthcare and prison staff completed a risk assessment. Healthcare staff recorded
that Mr Kemp was receiving treatment for lung cancer and might need mobility
support. Healthcare have indicated on the risk assessment by highlighting ‘No’ that
they have no medical objection to the use of restraints. Prison staff completed a
points assessment with a security assessment section that allocated points to his
risk of escape and risk to public. It also states within his PER in the risk indicator
section that he is a risk to the public community. He was taken to hospital restrained
by an escort chain and two prison officers.
46. On 17 December, Mr Kemp was again escorted to hospital, for a consultant review.
Before his transfer, healthcare and prison staff completed a risk assessment. A
healthcare nurse ticked a box to indicate they had no medical objections to the use
of restraints. Prison staff said that Mr Kemp was low risk for escape and of low risk
to the public but did not object to the use of restraints. A senior officer authorised an
escort chain and two officers.
47. On 20 December, prison staff asked Mr Kemp about his cancer treatment. He told
them that at his last treatment session he had seen a consultant and had tests to
check if the treatment was working. Hospital staff informed Mr Kemp he might also
have a heart condition, so they planned to conduct tests over the next few weeks.
Prison staff spoke with Mr Kemp about the sort of tests they might be.
48. On 30 December, Mr Kemp attended a routine hospital appointment. Before he was
transferred, healthcare and prison staff completed a risk assessment. Healthcare
staff said in the assessment that they did not object to the use of restraints. Prison
staff indicated in the risk assessment that Mr Kemp was low risk for escape and of
low risk to the public, but also did not object to the use of restraints. A senior officer
authorised an escort chain and two officer escort.
49. Mr Kemp requested to return to prison on the same day, even though clinical staff
advised that he needed to have a pericardial drain (thin tube inserted into the sac
surrounding the heart to drain excess fluid). Mr Kemp was aware of the risks
involved and had signed a disclaimer stating he did not want to stay in hospital. He
had an appointment the following day (31 December) which he agreed to attend.
Prison staff conducted hourly checks on Mr Kemp throughout the night and were to
call an ambulance if there was any sign of deterioration or health concerns.
50. On 31 December, Mr Kemp was admitted to Glenfield Hospital due to worsening
breathlessness. Before transfer, healthcare and prison staff completed an escort
risk assessment. Healthcare staff did not object to the use of restraints. Prison staff
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indicated in the risk assessment that Mr Kemp was low risk for escape and of low
risk to the public, and also did not object to the use of restraints. A senior officer
authorised an escort chain and two officer escort.
51. In hospital, Mr Kemp underwent pericardiocentesis (procedure to drain fluid from
the pericardial sac, the space surrounding the heart). Mr Kemp remained in
restraints throughout this procedure.
52. Mr Kemp remained in hospital for the rest of his life. On 2 January 2025, he was
placed on a formalised palliative care plan. On several occasions in January, a
prison family liaison officer asked Mr Kemp if he would like him to contact his family
on his behalf. Mr Kemp always declined.
53. Also on 2 January, healthcare staff called Leicester Royal Infirmary after they
received an email from them regarding Mr Kemp not attending two chemotherapy
appointments on 7 November and 26 December. Healthcare staff said they were
not informed about these appointments at the time. They queried why the two
missed appointments were not raised when Mr Kemp attended a consultant
appointment on 17 December.
54. On 8 January, a prison manager authorised that Mr Kemp’s restraints should be
removed.
55. On 17 January, a palliative care MDT took place to discuss Mr Kemp’s care plan
going forward. Mr Kemp remained on oxygen and presented as weak.
56. On 22 January, the Head of Offender Management Services submitted an
application for ERCG to the Public Protection Casework Unit (PPCS). The
application included a line in the GP section that said that Mr Kemp’s prognosis (as
of 17 January) was “days to weeks at present” and that this may change rapidly. It
is unclear in the form whether this prognosis was the GP’s opinion or whether it had
been obtained from the consultant. A letter from the consultant to support the
application was dated September 2024.
57. The following day, PPCS staff replied that the consultant oncologist’s report was
several months out of date and did not include a prognosis. They requested that an
up-to-date report be obtained and submitted. (The ERCG policy framework requires
a report from the consultant involved in the care of the prisoner, to include
information about diagnosis and prognosis, including a clear indication of life
expectancy.)
58. On 23 January, an officer recorded in Mr Kemp’s prison record that a consultant’s
letter had confirmed that he would not return to the prison soon due to his health
conditions. (We have not seen a copy of this letter and it is unclear whether it
included updated information about Mr Kemp’s prognosis. The letter was not
submitted to PPCS to support the application for early release.)
59. On 24 January, Mr Kemp was transferred to a hospice. On the same day, he said
that he would like to see his children before he died. Prison staff tried to arrange
this, but Mr Kemp died before they were able to complete arrangements.
60. At 12.06pm on 26 January, Mr Kemp died. The prison family liaison officer informed
Mr Kemp’s children.
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Post-mortem report
61. The post-mortem report concluded that Mr Kemp died of cardiac tamponade (blood
or fluid collects in the sac surrounding the heart preventing the heart ventricles from
expanding fully) caused by metastatic squamous cell carcinoma of the lung (lung
cancer).
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Findings
Clinical findings
62. The clinical reviewer found areas of good practice by healthcare staff.
Documentation of Mr Kemp’s palliative care and nursing and medical care plans
were good, providing clear guidance on appropriate management and escalation of
treatment in the face of Mr Kemp’s ongoing clinical deterioration. Also, a duty of
candour letter was written to Mr Kemp acknowledging the delay in his treatment due
to miscommunication.
63. However, the clinical reviewer concluded that the clinical care Mr Kemp received at
Fosse Way was only partially equivalent to that which he could have expected to
receive in the community. He identified issues pertaining to delays in diagnosis and
treatment of Mr Kemp’s lung cancer, in relation to a number of hospital
appointments that were cancelled. In addition, miscommunication and poor
information sharing between the hospital and prison healthcare team meant that Mr
Kemp missed two chemotherapy appointments. The clinical reviewer found the
logistical management of Mr Kemp’s diagnostic and therapeutic care for his lung
cancer was not equivalent to that which would have been received in the wider
community.
64. We make the following recommendation:
The Head of Healthcare should discuss with Leicester Royal Infirmary the
process for obtaining chemotherapy appointment letters, to ensure that
patients do not miss important treatments.
Prison escort staffing issues
65. Due to prison staffing issues, Mr Kemp could not be escorted to hospital for some
appointments. He missed at least four appointments from June to August, including
for important tests that might have led to an earlier diagnosis and, potentially, an
earlier start to treatment.
66. We asked Fosse Way why they had been unable to transfer Mr Kemp to hospital on
these dates. They said that the number of prisoners already hospital inpatients,
other planned hospital escorts, and staffing required for prison security, meant staff
were not available for Mr Kemp’s transfer to hospital.
67. In support of this, the prison provided evidence of the total numbers of prison staff
required to carry out all the functions on the dates specified. Some of the numbers
of staff required for escorts are stark. On 7 June, for example, there were seven
prisoners staying in hospital as inpatients (which requires 14 officers at a time on
12-hour shifts, so 28 officers in total per day). Including Mr Kemp, there were also
six scheduled hospital outpatient appointments (which require two officers per
escort, so 12 in total if all had gone ahead). Fosse Way told us that this meant that
40 officers would be required on that day to manage hospital escorts (had all of the
outpatient escorts gone ahead), which is enough staff to manage four of their
houseblocks. As a result, two planned outpatient appointments were cancelled by
the healthcare department and four were cancelled by the prison.
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68. On other dates on which Mr Kemp’s appointments were cancelled, fewer escort
staff were needed. On 28 June, there were four prisoners in hospital as inpatients
and six scheduled outpatient escorts, of which two went ahead. On 20 August,
there was one hospital inpatient, two emergency escorts and six planned escorts of
which one went ahead.
69. The clinical reviewer found that prison staffing issues significantly hindered Mr
Kemp’s access to time critical diagnostic evaluation.
70. The Deputy Director, told us that from September 2024, Fosse Way introduced a
clinically-led triage process where any urgent or critical appointments (such as
cancer referrals) are identified as not suitable to cancel. They are treated as the
highest priority in daily operational arrangements to prevent prisoners from missing
appointments.
71. We note that Mr Kemp did not have any appointments cancelled due to a shortage
of escorting staff from September 2024. As prison staff have introduced these new
procedures to prioritise cancer patients, we do not make a recommendation.
Use of restraints
72. 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. 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. The judgment indicated 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.
73. Mr Kemp was 58 years old and in poor health. He had a terminal cancer diagnosis,
for which he was undergoing chemotherapy, and used a wheelchair. On 5 and 19
November, and 17, 30 and 31 December he attended hospital and was restrained
by an escort chain on each occasion. During his final inpatient stay, restraints were
applied for eight days before being removed.
74. We are not satisfied that staff complied with the High Court judgement or that they
fully considered Mr Kemp’s risk in light of his physical health. The medical sections,
when completed, of the escort risk assessments contained no consideration for Mr
Kemp’s long-term health or his current circumstances and the reason for the
hospital admissions. Mr Kemp’s wheelchair use was sometimes, but not always,
included on the escort risk assessment, and healthcare staff never objected to the
use of restraints.
75. We frequently raise concerns about how well healthcare staff understand, or feel
empowered, to make a meaningful contribution to the risk assessment process,
such as in this case. In March 2024, we recommended that NHS England develop
national guidance for establishments to develop local standard operating
procedures for healthcare input into restraints risk assessments. This
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recommendation was accepted, and NHS England told us that they are working
with HMPPS to review the Prevention of Escapes – External Escorts Policy
Framework, with particular focus on the escort risk assessment. We also welcome
the work that the Operational Security Group Director has undertaken to review and
amend the national risk assessment form, mandate its use and provide additional
guidance to staff responsible for making decisions about the use of restraints.
76. Our investigation into the death of a man at Fosse Way in July 2024 found that staff
completing escort risk assessments did not properly consider his health and
mobility, and that they inappropriately applied restraints until he was very close to
death. In December 2024, we recommended that the Director ensure that staff
undertaking risk assessments understand the legal position on the use of restraints
and that authorising managers show that they have taken this into account when
assessing the prisoner’s current level of risk.
77. While Fosse Way accepted this recommendation, their response did not indicate
that any work had been done to inform healthcare staff of their responsibilities in
completing the health section of the escort risk assessment, or to further train
managers who consider the risk assessment and decide on the level of restraints to
apply. It is important that Fosse Way properly considers the prisoner’s age, health
and mobility when determining the appropriate level of restraints.
78. We make the following recommendation:
The Director and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners taken to hospital understand the legal
position on the use of restraints, including that:
• Healthcare staff complete the healthcare section of the escort risk
assessment fully and accurately, including giving appropriate
consideration to whether the prisoner’s health and mobility means that
restraints are not required.
• Managers responsible for authorising restraints consider the
healthcare input into the escort risk assessment and base their
decision on the actual risk the prisoner poses at the time.
• A robust quality assurance process is implemented to check that these
measures are in place and effective.
Early Release on Compassionate Grounds
79. Release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from prison before their sentence has expired. A clear
medical opinion of life expectancy is required. The criteria for early release are set
out in the Early Release on Compassionate Grounds Policy Framework. Among the
criteria is that the risk of reoffending is expected to be minimal, further imprisonment
would reduce life expectancy, there are adequate arrangements for the prisoner’s
care and treatment outside prison, and release would benefit the prisoner and his
family. The policy framework says that the application must include a report from
the medical specialist (usually a consultant) involved in the care of the prisoner, to
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include factors such as diagnosis, prognosis, treatment plan and a clear indication
of life expectancy. An application for early release on compassionate grounds must
be submitted to the Public Protection Casework Section (PPCS) of HM Prison and
Probation Service (HMPPS).
80. On 22 January, Fosse Way submitted an application for early release on
compassionate grounds. It contained an up-to-date line of prognosis in the GP
section of the form (which was not marked as being from the consultant and unclear
whose opinion it represented), giving a prognosis of days to weeks. However, the
consultant letter submitted with the application was dated September 2024, and
was therefore around four months out of date. PPCS subsequently rejected the
application and asked for an updated report from the consultant, which was not
provided before Mr Kemp died.
81. We appreciate that cancer patients’ condition can sometimes change rapidly,
particularly towards the end of their life, and it can therefore be difficult to obtain a
timely and accurate prognosis. Nevertheless, it is important that up-to-date
information from a consultant is submitted with an application for early release, in
line with the expectations of the policy framework. Any application that does not
contain a contemporaneous supporting letter is unlikely to succeed.
82. We make the following recommendation:
The Director and Head of Healthcare should ensure that applications for early
release on compassionate grounds contain an up-to-date letter from the
relevant hospital consultant, including all of the information required by the
Early Release on Compassionate Grounds Policy Framework.
Inquest
83. The inquest into Mr Kemp’s death concluded on the 14 April 2025. The coroner
confirmed that Mr Kemp died of natural causes.
Adrian Usher
Prisons and Probation Ombudsman November 2025
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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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