Carl Bennett

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Independent investigation into
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the death of Mr Carl Bennett,
a prisoner at HMP Oakwood,
on 25 August 2023
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 Carl Bennett died of heart failure caused by ischaemic cardiomyopathy (a
decrease in the ability of the heart to pump blood) on 25 August 2023, while a
prisoner at HMP Oakwood. He was 54 years old. We offer our condolences to his
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Bennett received at
Oakwood was equivalent to that which he could have expected to receive in the
community.
5. The clinical reviewer made five recommendations not directly related to Mr
Bennett’s death which the Head of Healthcare will wish to address. She identified
areas of good practice, including additional safeguards that were put in place during
Mr Bennet’s final days at Oakwood, when he initially refused to attend hospital for
potentially life-saving treatment.
6. When Mr Bennett was admitted to hospital in June and July 2023, he was
inappropriately restrained. His advanced heart failure and failing health was not
properly considered.
Recommendation
• The Operational Security Group Director at HMPPS should monitor compliance with
policy on the use of restraints during hospital escorts (for inpatient and outpatient
appointments), including at HMP Oakwood, and discuss the findings with the
Ombudsman.
• NHS England and the Welsh Government should develop national guidance for
establishments to develop local standard operating procedures for healthcare input
in the use of force/restraints risk assessments. This guidance should also include
roles & responsibilities of healthcare during and post planned and unplanned use of
force/restraints.
Prisons and Probation Ombudsman 1
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The Investigation Process
7. HMPPS notified us of Mr Bennett’s death on 26 August 2023.
8. NHS England commissioned an independent clinical reviewer to review Mr
Bennett’s clinical care at HMP Oakwood.
9. The PPO investigator investigated the non-clinical issues relating to Mr Bennett’s
care.
10. The PPO family liaison officer wrote to Mr Bennett’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
11. We shared the initial report with the Prison Service. There were two factual
inaccuracies in the initial report and four factual inaccuracies in the clinical review.
Previous deaths at HMP Oakwood
13. There were ten deaths from natural causes at Oakwood in the three years before
Mr Bennett’s death, three of which were as a result of COVID-19. There was also a
drug related death and a death following a cell fire. Up to March 2024, there have
been three further deaths due to natural causes. Our investigation into the death of
a man in January 2022 found that restraints were inappropriately used on an older
prisoner who was in poor health.
2 Prisons and Probation Ombudsman
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Key Events
14. On 10 February 2016, Mr Carl Bennett was remanded to HMP Hewell for assault.
On 17 November, he was sentenced to 13 years in prison.
15. On 17 January 2020, Mr Bennett was transferred to HMP Oakwood.
16. Mr Bennett had decompensated (severe) heart failure and a history of heart attack,
a stroke, and a collapsed lung.
17. On 23 January 2023, a GP at Oakwood carried out Mr Bennett’s annual heart
failure review. After reviewing his blood tests, a GP at Oakwood concluded that the
results were satisfactory and as expected and that no further action was needed.
18. At 3.10am on 18 June, prison staff radioed a medical emergency code blue (which
indicates that a prisoner is unconscious or not breathing) because Mr Bennett said
that he had chest pain. A nurse sent Mr Bennett to hospital because he was
struggling to breathe and had a productive cough. In hospital, Mr Bennett declined
to have blood tests. Hospital staff thought that he had left ventricular failure (left
sided heart failure). Hospital staff recommended that he be prescribed furosemide
(diuretic medication used to remove a build-up of fluid). Prison staff completed an
escort risk assessment before Mr Bennett left for hospital and concluded that Mr
Bennett should be restrained using single handcuffs. (When ‘single handcuffs’ are
used on an escort, this means that a standard pair of handcuffs are used to
handcuff the prisoner to an escorting officer.) The medical section of the risk
assessment was not completed. On 19 June, Mr Bennett went back to Oakwood.
19. That same morning, a Healthcare Assistant (HCA) saw Mr Bennett and noted that
he was clammy, disorientated and had a sore throat. A prison paramedic and a GP
at Oakwood reviewed Mr Bennett and suspected that he had a chest infection. Mr
Bennett refused to go back to hospital, despite the GP explaining that he might die
if he did not accept treatment for his heart failure.
20. On 26 June, a GP at Oakwood saw Mr Bennett, who had shortness of breath and a
wheeze when breathing. Mr Bennett agreed to go to hospital to stabilise his
worsening heart failure, and the GP called a medical emergency code blue. While
waiting for the ambulance healthcare staff gave Mr Bennett oxygen.
21. Before Mr Bennett went to hospital, prison staff completed an escort risk
assessment. A First Line Manager (FLM) noted that Mr Bennett was a medium risk
to the public, a low risk to hospital staff and a low risk of escape. A paramedic
completed the medical section and did not object to the use of restraints. A senior
manager authorised that two officers escort Mr Bennett and that he be restrained
with single cuffs.
22. In hospital, Mr Bennett had an ECG and blood tests. When Mr Bennett had a chest
X-ray the officers who were with him obtained permission from a senior manager to
remove the restraint. The manager authorised that the restraint could be removed
for any further treatment. On 28 June, the officers replaced the single cuff with an
escort chain (a long chain with a handcuff at each end, one of which is attached to
the prisoner and the other to an officer), following authorisation from a manager. On
11 July, Mr Bennett discharged himself from hospital.
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23. Healthcare staff tried to persuade Mr Bennett to go back to hospital where he was
being treated for decompensated heart failure (a worsening of heart failure
symptoms).
24. On 26 July, a nurse saw Mr Bennett and noted that he had swelling to both of his
legs and below the waist. That afternoon a nurse noted that Mr Bennett had
considerable swelling on his legs and genital area. The nurse noted that Mr
Bennett’s National Early Warning Score (NEWS, a tool to detect and respond to
clinical deterioration) was 7 (which indicated a high clinical risk) and sent him to
hospital by ambulance.
25. Before he went to hospital, prison staff completed an escort risk assessment. A
security manager completed the escort risk assessment and noted that Mr Bennett
was a medium risk to the public, a low risk to hospital staff and a low risk of escape.
A paramedic completed the medical section, did not object to the use of restraints
and noted that Mr Bennett was mobile and independent. The duty director
authorised that Mr Bennett be restrained with an escort chain. In hospital Mr
Bennett continued to be restrained with an escort chain.
26. On 10 August, despite hospital staff advising him to remain in hospital, Mr Bennett
discharged himself and he went back to Oakwood. A prison paramedic saw Mr
Bennett and noted that he had a NEWS score of 10 and was extremely clinically
unwell.
27. On 12 August, after Mr Bennett’s health deteriorated further, healthcare staff
successfully persuaded him to go to hospital. When he went to hospital he was not
restrained. On 25 August, Mr Bennett died in hospital.
28. There was no post-mortem examination. A hospital doctor concluded that Mr
Bennett died of heart failure caused by ischaemic cardiomyopathy (a decrease in
the ability of the heart to pump blood).
4 Prisons and Probation Ombudsman
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Findings
Restraints, security and escorts
29. 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. 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.
30. Mr Bennett was a 54-year-old man, who had a history of poor health including heart
and lung conditions. By June 2023, hospital staff said that he had heart failure.
31. In June 2023, Mr Bennett was twice sent to hospital in a medical emergency. On
both occasions he was restrained with a single cuff. On the first occasion, the
medical section of the escort risk assessment was not completed, and there is not
therefore any evidence that his condition, including struggling to breathe, was
considered when judging whether to use restraints. On the second occasion, a
nurse completed the medical section but did not object to the use of restraints
despite him having shortness of breath that required oxygen. In hospital, prison staff
were given permission to remove the restraints for tests, but they were reapplied
despite his ongoing periods of breathlessness.
32. On 26 July, when Mr Bennett was sent back to hospital, he was restrained with an
escort chain. The same nurse again completed the medical section of the escort
risk assessment and did not object to the use of restraints and noted that he was
mobile and independent. That morning, before he went to hospital, the medical
records show that Mr Bennett had swelling to both of his legs and below the waist
and later in the day that he had considerable swelling of his legs and his genital
area and that his clinical observations showed that he was a high clinical risk.
33. Mr Bennett’s symptoms and medical history on each of these occasions, in line with
the High Court judgement, meant that his risk could have been effectively managed
by the officers accompanying him without the use of restraints.
34. Following the death of a prisoner in January 2022, we recommended that the
Director write to the Ombudsman to explain what further steps he would take to
ensure that ill prisoners were not inappropriately restrained. The Director wrote that
he and the Head of Healthcare had briefed all managers undertaking the
completion of risk assessments to remind them that all relevant information,
including health information, should be considered. Nevertheless, Mr Bennett was
restrained despite being subject to emergency hospital admissions. We make the
following recommendation:
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The Operational Security Group Director at HMPPS should monitor
compliance with policy on the use of restraints during hospital escorts (for
inpatient and outpatient appointments), including at HMP Oakwood, and
discuss the findings with the Ombudsman.
35. 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. We make the following recommendation:
NHS England and the Welsh Government should develop national guidance
for establishments to develop local standard operating procedures for
healthcare input in the use of force/restraints risk assessments. This
guidance should also include roles & responsibilities of healthcare during
and post planned and unplanned use of force/restraints.
Adrian Usher
Prisons and Probation Ombudsman May 2024
Inquest
36. The inquest into Mr Bennett’s death was held on 1 July 2024 and a verdict of
natural causes was recorded.
6 Prisons and Probation Ombudsman
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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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