Charleston Cullen

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Independent investigation into
the death of Mr Charleston
Cullen, a prisoner at HMP
Nottingham, on 25 May 2022
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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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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Charleston Cullen died in hospital on 25 May 2022, of ischaemic heart disease
(reduced blood supply to the heart) while a prisoner at HMP Nottingham. He was
54 years old. We offer our condolences to Mr Cullen’s family and friends.
4. The clinical reviewer found that the physical health care Mr Cullen received was not
of a reasonable standard and partially equivalent to that which he would expect to
receive in the wider community. Mr Cullen was not assessed by healthcare staff
when he discharged himself from an emergency hospital admission, and poor
communication with the hospital meant that changes to his medication were not
identified. The clinical reviewer made four recommendations which the Head of
Healthcare will need to address.
5. We are concerned that Mr Cullen was restrained when he went to hospital on 13
May, even though he had poor mobility and had been provided with a Zimmer frame
by the prison. He remained restrained until 25 May, when hospital staff started
cardiopulmonary resuscitation (CPR).
6. We were also concerned that Nottingham did not provide the investigator with all
requested documentation about the use of restraints when Mr Cullen went to
hospital, which meant that we could not fully determine whether the decision-
making process was appropriate. However, the evidence we have seen strongly
indicates that restraints were not appropriate.
Recommendations
• The Head of Healthcare should ensure that all prisoners returning from inpatient
stays in outside hospital are treated in line with expected standards, including that:
• all prisoners returning via Reception are seen and assessed by healthcare staff;
and
• hospital discharge summaries are received and any changes in treatment and
medication are actioned.
• The Governor should ensure that all evidence relevant to a death in custody is
retained and that the evidence is made available to the Prisons and Probation
Ombudsman, in line with PSI 58/2010.
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• The Governor and the 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 and that in all cases:
• healthcare staff complete the medical information section of the escort risk
assessment to say whether the prisoner’s current medical condition affects their
mobility and risk of escape; and
• authorising managers show that they have taken this information into account
when assessing a prisoner’s current level of risk.
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The Investigation Process
7. NHS England commissioned an independent clinical reviewer, to review Mr Cullen’s
clinical care at HMP Nottingham. The clinical reviewer’s report is annexed to this
report.
8. The PPO investigator investigated the non-clinical issues relating to Mr Cullen’s
care, including Mr Cullen’s location, the security arrangements for his hospital
escorts, liaison with his family and whether compassionate release was considered.
9. The investigator and the clinical reviewer interviewed two members of staff on 20
July and 10 August 2022.
10. The PPO family liaison officer wrote to Mr Cullen’s next of kin, his brother, to
explain the investigation and to ask if he had any matters they wanted us to
consider. He did not respond to our letter.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
Previous deaths at HMP Nottingham
12. Mr Cullen was the seventh prisoner to die at HMP Nottingham since May 2020. Of
the previous deaths, five were from natural causes and one was self-inflicted.
There are no similarities between our findings in the investigation into Mr Cullen’s
death and our investigation findings for the previous deaths.
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Key Events
13. On 9 February 2004, Mr Charleston Cullen was sentenced to life imprisonment for
murder and arson, with a minimum term of 11 years and 7 months.
14. On the 20 September 2019, Mr Cullen was released on licence. This was
subsequently revoked on 26 April 2022, and Mr Cullen was sent to HMP
Nottingham on 27 April.
15. On 27 April, a nurse and a prison GP, assessed Mr Cullen as part of his reception
health screen. They referred him to the mental health team and added him to the
complex care caseload due to his complex medical history. Mr Cullen’s medical
conditions included but were not limited to; ischaemic heart disease, heart failure,
Chronic Obstructive Pulmonary Disease (COPD, the term for a group of serious
lung diseases) and chronic kidney disease stage 4 (severe kidney failure).
16. At 5.00pm on 9 May, Mr Cullen collapsed and complained of chest pain. Prison
staff called an ambulance and paramedics took Mr Cullen to hospital.
17. We cannot say if Mr Cullen was restrained during the hospital escort as Nottingham
did not provide these records.
18. On 11 May, Mr Cullen returned to Nottingham after discharging himself from
hospital. Healthcare staff noted that Mr Cullen had appeared at the medicine hatch
to collect his medications, however there was no discharge summary or information
relating to any changes in his medication. There is no evidence that he was
assessed on his return to prison.
19. On 12 May, a prison paramedic, saw Mr Cullen because he had complained of
numbness in his legs and hands in the early hours of the morning. He arranged for
Mr Cullen to have an electrocardiogram (ECG) the next day.
20. The ECG was carried out the following morning. The prison paramedic noted that
the results were abnormal. He carried out a welfare check and, at 12.09pm,
requested an ambulance. Ambulance paramedics arrived and took Mr Cullen to
hospital.
21. HOT debrief minutes provided by Nottingham state that Mr Cullen was handcuffed
by a single cuff while a hospital inpatient, which was removed when
cardiopulmonary resuscitation (CPR) was administered at the end of his life.
Nottingham did not provide the escort risk assessment document and we have not
therefore seen the evidence used to justify this decision.
22. On 17 May, healthcare staff received the hospital discharge summary, which
related to Mr Cullen’s earlier stay in hospital. This showed that there had been an
increase in his furosemide medication (used to treat heart failure).
23. On 25 May, Mr Cullen died in hospital.
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Post-mortem report
24. A post-mortem examination established that Mr Cullen died of ischaemic heart
disease (reduced blood supply to the heart).
Inquest into Mr Cullen’s death
25. The inquest into Mr Cullen’s death was held on 24 June 2024 and a verdict of
natural causes was recorded. The coroner concluded that Mr Cullen’s death was
due to ischaemic heart disease.
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Findings
Clinical Findings
26. The clinical reviewer concluded that the physical care that Mr Cullen received at
HMP Nottingham was not of a reasonable standard and only partially equivalent to
that which he could have expected to receive in the community.
27. The clinical reviewer was concerned that Mr Cullen was not reviewed by healthcare
staff when he returned to Nottingham on 11 May, having discharged himself from
hospital. She noted that Mr Cullen had left hospital without being medically
discharged, therefore there was a possibility that he was still unwell and healthcare
should have undertaken an assessment on his return.
28. The clinical reviewer was also concerned that Mr Cullen returned to prison without
any discharge paperwork or information about changes to his medication. This
meant that healthcare staff were not aware that one of his medications had
increased. The discharge summary was not received by healthcare until 17 May.
We make the following recommendation:
The Head of Healthcare should ensure that all prisoners returning from
inpatient stays in outside hospital are treated in line with expected standards,
including that:
• all prisoners returning via Reception are seen and assessed by healthcare
staff; and
• hospital discharge summaries are received and any changes to treatment
or medications are actioned.
Providing evidence to the Prisons and Probation Ombudsman
29. PSI 58/2010 requires prisons to provide evidence to the Ombudsman’s office for the
purpose of our investigation. Nottingham did not supply all the escort risk
assessment documentation. This adversely affected our investigation and meant
that we could not determine whether the decision-making process when Mr Cullen
was escorted to hospital on 9 May and 13 May was appropriate. We make the
following recommendation:
The Governor should ensure that all evidence relevant to a death in custody
is retained and that the evidence is made available to the PPO, in line with PSI
58/2010.
Restraints, security and escorts
30. 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
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of escape, the risk to the public and takes into account the prisoner’s health and
mobility.
31. 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.
32. On 9 May, Mr Cullen was taken to hospital after he had collapsed and had chest
pain. He remained an inpatient for two days. Mr Cullen was admitted to hospital
again on 13 May, following an abnormal ECG, and resided in hospital for the rest of
his life.
33. We were not provided with the prisoner escort records or risk assessments for
either hospital admission. However, other information provided by the prison details
that Mr Cullen was restrained by a single cuff on his final admission. The handcuff
was only removed when it was clear that CPR was needed.
34. It is documented within the medical records that Mr Cullen had mobility issues and,
on 28 April, he was provided with a Zimmer frame. On 8 May, Mr Cullen collected
his medications from the medical hatch in a wheelchair and, on 9 May, he was
moved to a different cell which was closer to where the medication hatch was
located. We have seen no evidence to indicate that Mr Cullen was a high risk of
violence or of attempting to escape. Our ability to full consider this matter has been
hampered by a lack of information. However, based on the information that we have
seen we do not think that it was appropriate that Mr Cullen was restrained given his
limited mobility and his general poor health. We therefore make the following
recommendation:
The Governor and the 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 and that, in all cases:
• healthcare staff complete the medical information section of the escort
risk assessment to say whether the prisoner’s current medical
condition affects their mobility and risk of escape; and
• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk.
Mark Judd
Acting Assistant Prisons and Probation Ombudsman May 2023
Prisons and Probation Ombudsman 7
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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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