Curtis Cadman

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Curtis Cadman,
a prisoner at HMP Lincoln,
on 21 November 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
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
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.
If my office is to best assist HM Prisons 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.
Mr Curtis Cadman died of heart disease at HMP Lincoln, on 21 November. He was 50
years old. I offer my condolences to Mr Cadman’s family and friends.
The investigation found that Mr Cadman’s clinical care was equivalent to that which he
could have expected to receive in the community.
The welfare check on the morning of Mr Cadman’s death fell short of the required
standards, but I am satisfied that the Governor has since taken steps to increase staff
awareness of their responsibilities when conducting such checks.
I consider that Lincoln’s policy on managing medical emergencies should be strengthened,
to clarify that control room staff should not wait for authorisation to request an ambulance
when a medical emergency code is called.
I am concerned that the Early Learning Review of Mr Cadman’s death did not explore the
fundamental issues highlighted in this report, relating to staff actions before and
immediately after Mr Cadman was found dead.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman November 2023
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. Mr Curtis Cadman was remanded to HMP Lincoln on 10 November 2022. He had a
history of substance misuse and was placed on methadone maintenance and
benzodiazepine detoxification. Healthcare staff monitored him closely and reviewed
medical problems unrelated to his cause of death.
2. At around 7.50am on 21 November, a prison officer conducted a welfare check. He
thought Mr Cadman was asleep but spoke to his cell mate. At around 8.10am, Mr
Cadman’s cell mate tried to wake him up, but found that he was cold. He alerted an
officer, who called a code blue medical emergency.
3. Healthcare and operational staff went to Mr Cadman’s cell. Rigor mortis in his face
and arms indicated that he was dead, so they did not try to resuscitate him. A
paramedic employed at the prison confirmed Mr Cadman’s death and that an
ambulance was not required.
Findings
4. Mr Cadman’s clinical care was equivalent to that which he could have expected in
the community.
5. The morning welfare check was inadequate and did not comply with the expectation
that a response should be obtained from each prisoner. The Governor has issued
fresh guidance, reminding staff of the requirement to do so.
6. Control room staff did not adhere to the mandatory requirement to request an
ambulance when the code blue was called. They consulted the custodial manager,
who advised several minutes later that an ambulance was not needed. The
sequence of events documented on the incident log suggests a poor understanding
of the medical emergency procedures, rather than individual error.
7. The Early Learning Review found no learning points. Given that wellbeing is one of
the aspects considered, it is disappointing that there was no reference to the
welfare check that took place around 20 minutes before Mr Cadman was found, or
an examination of whether it was appropriately handled. In addition, the review did
not address the failure to automatically request an ambulance in response to the
code blue.
Recommendations
• The Governor should review Lincoln’s local guidance on medical emergency
response codes to remind control room staff that, in the event of a medical
emergency code, they should not wait for authorisation to request an
ambulance.
• The Prison Group Director for East Midlands should share the Ombudsman’s
report with the regional safety lead.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
8. HMPPS notified us of Mr Cadman’s death on 21 November 2022.
9. The investigator issued notices to staff and prisoners at HMP Lincoln informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Cadman’s prison and
medical records.
11. NHS England commissioned a clinical reviewer to review Mr Cadman’s clinical care
at the prison. The investigator and clinical reviewer jointly interviewed two
healthcare staff on 31 January 2023. The interviews were conducting using
Microsoft Teams video conferencing. Additionally, they conducted individual
interviews with a prisoner, a paramedic employed at the prison and a member of
the substance misuse team.
12. We informed HM Coroner for Northeast Lincolnshire and Grimsby of the
investigation. He gave us the results of the post-mortem examination. We have sent
the Coroner a copy of this report.
13. The Ombudsman’s family liaison officer contacted Mr Cadman’s partner to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not reply.
14. The initial report was shared with HMPPS. They found no factual inaccuracies.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Lincoln
15. HMP Lincoln holds up to 729 remanded and convicted men, in four residential
wings. It serves the courts of Lincolnshire, Nottinghamshire, and Humberside.
Nottinghamshire Healthcare NHS Trust provides health services, with 24-hour
nursing cover.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Lincoln was in December 2019 and January
2020. Inspectors reported that Lincoln was a much safer prison since the previous
inspection in 2017.
17. Inspectors noted that there had been an increase in healthcare staff, with regular
clinical supervision and training, as well as a systemic approach to learning lessons.
New prisoners received a comprehensive health screen and appropriate specialist
referrals. There was integrated clinical and psychosocial substance misuse
treatment, which met individual needs and was reviewed regularly. The substance
misuse team’s location in the healthcare department enabled good communication
with the primary care and mental health teams.
Independent Monitoring Board
18. 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 2022, the IMB reported
that the prison had made an ‘extraordinary’ effort to keep the prison running during
the COVID-19 pandemic and continued to provide all healthcare services. There
had been improvements to stop the diversion of medication.
Previous deaths at HMP Lincoln
19. Mr Cadman was the eleventh prisoner at Lincoln to die since November 2019. Six
of the previous deaths were from natural causes and four were self-inflicted. We
have highlighted deficiencies in welfare checks at Lincoln in previous investigations,
as well as the need to comply with the medical emergency response procedures.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
20. Mr Curtis Cadman was remanded to HMP Lincoln on 10 November 2022, charged
with burglary. It was not his first time in prison.
21. At his initial health screen, a nurse recorded that Mr Cadman had a history of
substance misuse, notably cocaine, benzodiazepines, zopiclone (sleeping pills) and
methadone. He had engaged with We Are With You (WAWY), a provider of
substance misuse services in the community and at the prison. A local pharmacy
confirmed that his prescription was 80ml of methadone, collected three times a
week. Mr Cadman had also been diagnosed with deep vein thrombosis, nerve pain
from an accident and depression. (Mr Cadman’s secondary health screen was
completed on 13 November.)
22. A GP at the prison then reviewed Mr Cadman. She prescribed methadone (taking
into account that he had not had a dose for two days), benzodiazepine
detoxification and medication to relieve withdrawal symptoms. The methadone was
to be increased gradually to his community dose. Substance misuse reviews were
scheduled for 5 days and 13 weeks. Mr Cadman was closely monitored for the next
five days, and the GP reviewed him on 15 November.
23. On 18 November, Mr Cadman had injuries to his face and shoulder that he
attributed to dozing off and falling from the toilet. He was sent to hospital for
assessment and returned the same day. (After his death, intelligence reports
suggested that the injuries were due to assault.)
24. On 19 and 20 November, Mr Cadman’s leg was swollen, hot and red. There were
no signs of infection and a nurse provisionally diagnosed cellulitis, arranging for him
to attend the wound care clinic on 21 November.
Events of 20/21 November 2022
25. At interview, Mr Cadman’s cell mate said that during the evening of 20 November,
Mr Cadman felt as though he was ‘rattling’ (withdrawing from drugs) and had gone
to bed on the top bunk, at around 6.00pm or 7.00pm. This was unusually early for
Mr Cadman, as his normal pattern was to stay awake for most of the night. The cell
mate had not heard him snore before, but he was snoring noisily. He was lying on
his front, and when he tried to wake him up, he acknowledged him but put his head
down straight away.
26. On 21 November, Officer A signed to confirm that he had completed the welfare
check for Mr Cadman’s cell between 7.50am and 7.52am. He said in a statement
that he and the cell mate had said good morning to each other, but Mr Cadman was
always asleep during the morning checks. Using the light from the television, he
looked into the cell and thought Mr Cadman was breathing. The cell mate said that
the officer had shouted Mr Cadman’s name but did not check him.
27. At around 8.10am, the cell mate tried to wake Mr Cadman so that he could get his
methadone at 8.15am. His arm felt “dead cold”, so he went onto the landing and
told Officer B that Mr Cadman seemed to be dead.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
28. Officer B called a code blue medical emergency, which indicates that a prisoner has
breathing difficulties or is unresponsive. Two nurses went to the cell, followed by
other officers, healthcare staff and a Custodial Manager (CM). They did not attempt
resuscitation, as there were clear signs of rigor mortis in Mr Cadman’s jaw and
arms. A paramedic at the prison confirmed Mr Cadman’s death.
Contact with Mr Cadman’s Family
29. At 9.55am, the family liaison officer (FLO) and the prison chaplain broke the news
of Mr Cadman’s death to his partner, at her home. They gave her information about
the processes to be followed and offered support. The FLO telephoned several
times in the following days and they both visited again on 30 November.
30. The prison contributed to the costs of Mr Cadman’s funeral, which was held on 19
January.
Support for prisoners and staff
31. A CM debriefed the staff involved in the emergency response to ensure they had
the opportunity to discuss any issues arising, and to offer support.
32. Mr Cadman’s cell mate was moved to a cell in the first night centre for the next few
days. He received support from the safer custody, mental health and prison
chaplaincy teams and was referred to the trauma nurse.
33. The prison posted notices informing other staff and prisoners of Mr Cadman’s death
and offering support.
Post-mortem report
34. The post-mortem report concluded that the cause of Mr Cadman’s death was
ischaemic heart disease. The use of methadone and cocaine contributed to but did
not cause Mr Cadman’s death.
35. HM Coroner noted that, “Methadone was detected at a concentration within its
quoted potentially toxic to lethal ranges which overlap due to the development of
tolerance. Diazepam and Pregabalin at therapeutic levels and a low level of
Quetiapine were also detected. There was also evidence of previous Cocaine use.
The combined use of Methadone and Cocaine may increase the risk of cardiac
arrythmia or other adverse cardiac events…” (Mr Cadman had been prescribed
diazepam and pregabalin, but not quetiapine.)
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Clinical care
36. The clinical reviewer concluded that Mr Cadman’s care at Lincoln was of a good
standard and equivalent to that which he could have expected to receive in the
community. However, she made a recommendation about the need for clinical
observations when a patient presents with signs of an infection. As this was
unrelated to the cause of Mr Cadman’s death, we do not repeat it in this report, but
the Head of Healthcare will need to consider it.
Morning welfare checks
37. Prison Service Instruction (PSI) 75/2011, Residential Services, says:
“Reports from the Prisons and Probation Ombudsman on deaths in custody
have identified cases in which a prisoner has died overnight … but staff
unlocking them have not noticed that the prisoner had died. This is not
acceptable.
“The appropriate arrangements will depend on the local regime, but there
need to be clearly understood systems in place for staff to assure
themselves of the well-being of prisoners during or shortly after unlock ...
Where prisoners are not necessarily expected to leave their cell, staff will
need to check on their well-being, for example by obtaining a response
during the unlock process.”
38. Officer A and the cell mate both thought that Mr Cadman was asleep when the
welfare checks were completed on 21 November. The officer said that he was
familiar with the normal behaviour of prisoners on his wing and Mr Cadman was
always asleep during the morning checks. He thought he saw Mr Cadman
breathing. The cell mate said that officers would normally say good morning if a
prisoner was awake. If they were asleep, they would check but not disturb them.
39. Rigor mortis appears in the face around two hours after death, progressing to the
limbs over the next few hours, completing in six to eight hours. Given that it was
found in Mr Cadman’s face and arms, he had been dead for at least two hours at
the time of the welfare check. It is therefore clear that the check was not compliant
with instructions to obtain a response to ensure a prisoner is alive and well.
40. The Governor issued a staff information notice on 16 May 2023, Welfare Checks of
Prisoners – Gaining a Response. It states, “welfare checks MUST be carried out on
ALL prisoners … All staff must satisfy themselves that when unlocking a cell door,
the prisoner in question is alive and well … This can take the form of a verbal or
physical acknowledgement, positive signs of breathing, the prisoner moving in the
cell or in bed, or any other indication that the man in question is alive.”
41. Welfare checks are essential to ensure the safety and wellbeing of all prisoners,
particularly so for those vulnerable to substance misuse. We consider that the
check on Mr Cadman was inadequate. However, as tangible steps have been taken
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
to address the issue of welfare checks since Mr Cadman’s death, we make no
further comment.
Emergency response
42. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes and
Lincoln’s local protocol, Healthcare Assistance & Code Red/Blue set out the actions
staff should take in a medical emergency. Both instructions state that if an
emergency code is transmitted, an ambulance must be called automatically. In
addition, paragraph 5.2 of the PSI notes the mandatory requirement for local
procedures to reflect that staff should not wait for a member of the healthcare team
or a prison manager to attend the incident before an ambulance is called. The
expectation is that an ambulance can be stood down if it is not required.
43. It was recorded on the prison’s incident log that a code blue was called at 8.15am
and that the custodial manager, duty governor and emergency response nurse
acknowledged it. At 8.20am, a member of staff in the communications room radioed
to ask a CM if an ambulance was required. They recorded that an ambulance was
unnecessary and that, at 8.24am, the CM had telephoned the control room to
confirm this and ask for the incident to be stood down. The prison paramedic noted
in Mr Cadman’s medical record that the custodial manager had asked whether an
ambulance was needed and he had said no.
44. East Midlands Ambulance Service have no record of a request for an ambulance for
Mr Cadman on 21 November and the prison’s own records show that an ambulance
was not requested after the code blue.
45. Although the prison’s local guidance explicitly states that an ambulance should be
called immediately in such circumstances, it does not inform staff that authorisation
is unnecessary. The departure from the expected procedure did not affect the
outcome for Mr Cadman and we accept that an ambulance was not needed.
However, the process recorded on the incident log and the interval of 5-9 minutes
between the emergency code and the definitive decision about an ambulance
suggests a systemic problem rather than human error. We recommend:
The Governor should review Lincoln’s local guidance on medical emergency
response codes to remind control room staff that, in the event of a medical
emergency code, they should not wait for authorisation to request an
ambulance.
Early Learning Review
46. The Early Learning Review completed on behalf of the Prison Group Director,
concluded that there were no learning points arising from Mr Cadman’s death.
While we appreciate that such reviews are completed immediately after the incident
and with limited information, we are concerned that this review did not fully explore
the available evidence on two key issues.
47. Mr Cadman was found within 20 minutes of a welfare check. The review
acknowledged that he was cold, and staff had stated that resuscitation had not
been attempted due to rigor mortis. Therefore, under the subheading, ‘health and
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
wellbeing’ it would have been helpful for an examination of, or at the very least,
reference to the welfare check and whether it had been sufficiently thorough. While
we do not expect the reviewers to be aware of the timescales for the development
of rigor mortis, it was clear from accounts of Mr Cadman’s condition that he had
been dead for some time. We believe the question of when a prisoner was last seen
alive is one that should be routinely considered and, in this instance, the failure to
address the welfare check was an obvious omission.
48. Actions around the emergency response would also have benefitted from more
depth. The review noted that there had been a code blue and that an ambulance
was not required but did not address the failure to comply with the mandatory
requirement to request an ambulance. The conversations between the control room
and other staff were documented in detail in the incident log. While there was no
detriment to Mr Cadman, it was a learning point for the future.
49. If early learning reviews are to be of immediate value after prisoners’ deaths, they
need to have more substance than a chronology of events and potential issues
should be examined more critically. We recommend:
The Prison Group Director for East Midlands should share the Ombudsman’s
report with the regional safety lead.
Inquest
50. The inquest was held from 8 to 16 August 2024. The jury concluded that Mr
Cadman died from ischaemic heart disease and that his use of prescribed
methadone and illicit cocaine contributed to his death.
8 Prisons and Probation Ombudsman
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