David Baxter

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr David Baxter,
a prisoner at HMP Wealstun,
on 26 May 2024
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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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 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.
Mr David Baxter died of acute pyelonephritis (inflammation of the kidney) and cystitis
(bladder infection) on 26 May 2024 at HMP Wealstun. He was 64 years old. I offer my
condolences to Mr Baxter’s family and friends.
The clinical reviewer concluded that the care Mr Baxter received at Wealstun was not of
the required standard and was not equivalent to what he could have expected to receive in
the community. She made recommendations relating to clinical assessments and clear
plans for future care.
My investigation found that the officers who found Mr Baxter unresponsive on 26 May, did
not commence cardiopulmonary resuscitation immediately.
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 January 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. On 31 May 2023, Mr David Baxter was sentenced to 21 months imprisonment for
making threats to kill. On 6 February 2024, he was released from HMP Wealstun on
licence.
2. On 24 February, Mr Baxter was recalled to prison for breaching his licence. He was
also charged with a new offence. He was sent to HMP Nottingham.
3. On 18 March, Mr Baxter was sentenced to 12 months imprisonment for offences
against a person. On 27 March, Mr Baxter was transferred to Wealstun.
4. Mr Baxter had type 2 diabetes and had a stroke in 2020. Healthcare staff gave him
his prescribed medication which he was allowed to keep in his cell.
5. On 16 April, healthcare staff saw Mr Baxter after he reported issues with bladder
control. On 26 April, a GP at the prison saw Mr Baxter, conducted some tests and
referred him to hospital for further review.
6. On 15 May, a nurse saw Mr Baxter after he reported struggling to pass urine. On 17
May, the GP saw Mr Baxter and sent him to hospital for further care and treatment.
Mr Baxter started using a catheter (a thin, flexible tube that carries fluids into or out
of the body). He remained in hospital until 20 May. Mr Baxter discharged himself
against hospital advice.
7. On 25 May, Mr Baxter told an officer that he had fallen in his cell overnight. A nurse
attended Mr Baxter’s cell later that day to check on him. Mr Baxter told the nurse
that he had lost consciousness but did not know for how long. The nurse arranged
for him to see the GP on 27 May.
8. At 8.47am on 26 May, an officer went to unlock Mr Baxter’s cell. He found Mr
Baxter unresponsive on the toilet in his cell. He checked for signs of life but there
were none. At 8.48am, an officer radioed a medical emergency code. Two officers
responded immediately and the three officers waited for healthcare staff to arrive.
9. After seeking clarification from the officers, control room staff called an ambulance
at 8.50am.
10. Two Supervising Officers (SO) attended Mr Baxter’s cell. They immediately moved
Mr Baxter onto the floor and commenced cardiopulmonary resuscitation (CPR).
Staff attached a defibrillator to Mr Baxter’s chest.
11. At 8.51am, nursing staff attended and provided additional healthcare support.
12. At 9.10am, paramedics arrived at the prison and took over Mr Baxter’s care. At
9.29am, the paramedics confirmed that Mr Baxter had died.
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Findings
13. The clinical reviewer concluded that the care Mr Baxter received at Wealstun was
not of the required standard and not equivalent to what he could have expected to
receive in the community. She was concerned that there were missed opportunities
to recognise Mr Baxter’s deteriorating health, a lack of professional curiosity and
detailed record keeping.
14. We found that there was a delay in staff commencing CPR when Mr Baxter was
found unresponsive in his cell. We do not consider that the outcome would have
been different in this instance, however it could be critical in future emergencies.
Recommendations
• The Head of Healthcare must ensure that all healthcare staff are trained and
competent in the use of the NEWS2 assessment.
• The Head of Healthcare should ensure that a clear plan is documented within
the patients SystmOne records following self–discharge from the hospital to
ensure that all outstanding care/treatment is re-initiated as soon as possible.
• The Head of Healthcare should ensure that care plans are created to support in
the management of incontinence as per NICE ‘When should I suspect a urinary
tract infection in a man’ (2024).
• The Governor should conduct regular emergency response drills to allow staff to
practice response requirements, including when to commence CPR.
• The Governor should ensure that staff in the control room request an ambulance
immediately when a medical emergency code is called.
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The Investigation Process
15. HMPPS notified us of Mr Baxter’s death on 29 May 2024.
16. The investigator issued notices to staff and prisoners at HMP Wealstun informing
them of the investigation and asking anyone with relevant information to contact
her. One officer contacted the investigator by email.
17. The investigator obtained copies of relevant extracts from Mr Baxter’s prison and
medical records, CCTV, body worn video camera (BWVC) footage, and recordings
of radio communications.
18. The investigator interviewed nine members of staff, including the officer who
emailed the investigator, at Wealstun between 18 July and 22 August.
19. NHS England commissioned a clinical reviewer to review Mr Baxter’s clinical care at
the prison. The clinical reviewer conducted joint interviews with the investigator.
20. We informed HM Coroner for Wakefield of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
21. The Ombudsman’s office contacted Mr Baxter’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Baxter’s family
had no questions but asked for a copy of our report.
22. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
23. Mr Baxter’s family received copies of the draft report. They pointed out some factual
inaccuracies and/or omissions. This report has been amended accordingly. Mr
Baxter’s family also raised a number of issues/questions that do not impact on the
factual accuracy of this report and have been addressed through separate
correspondence.
24. At the inquest held on 3 September 2024, the Coroner concluded that Mr Baxter
died of acute pyelonephritis (inflammation of the kidney) and cystitis (bladder
infection). Ischaemic heart disease, enlarged prostate gland and diabetes mellitus
contributed to, but did not cause, his death.
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Background Information
HMP Wealstun
25. Wealstun is a category C adult training and resettlement prison for men. Practice
Plus Group provides physical and mental health care services.
HM Inspectorate of Prisons
26. The most recent inspection of Wealstun was in October 2022. Inspectors reported
that healthcare staff were well trained and had access to appropriate, regularly
checked equipment, and arrangements to respond to medical emergencies were
robust when the health care team was on duty.
Independent Monitoring Board
27. 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 May 2023, the IMB reported that
there appeared to be a number of instances where communications between
healthcare staff and prison staff had potential gaps, and where wing staff were not
aware of treatment plans (including GP advice) suggested for prisoners by the
healthcare team.
Previous deaths at HMP Wealstun
28. Mr Baxter was the third prisoner to die at Wealstun since May 2021. Of the previous
deaths, one was from natural causes and one was self-inflicted. Since Mr Baxter’s
death, there have been no further deaths at Wealstun.
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Key Events
29. On 31 May 2023, Mr David Baxter was sentenced to 21 months imprisonment for
making threats to kill.
30. On 6 February 2024, Mr Baxter was released from Wealstun on licence.
31. On 24 February, Mr Baxter was recalled to prison for breaching his licence and was
charged with breach of a restraining order. He was transferred to Nottingham.
32. At his first reception health screen, nurses noted that Mr Baxter had type 2
diabetes. Healthcare staff created an older persons care plan.
33. On 14 March, Mr Baxter was transferred to Leeds, as he had a court hearing. On 18
March, Mr Baxter was sentenced to 12 months imprisonment for offences against a
person.
34. On 27 March, Mr Baxter was transferred to Wealstun.
35. During his first reception health screen, nurses noted that Mr Baxter had type 2
diabetes and that he had a stroke in 2020. Nurses gave Mr Baxter his prescribed
medication which he was allowed to keep in his cell.
36. On 2 April, Mr Baxter was moved from the induction wing to a standard residential
wing.
37. On 16 April, healthcare staff saw Mr Baxter as he reported issues with bladder
control. He said that he was getting up every hour in the night to urinate, and
sometimes he was incontinent when he could not wake up. Nurses gave Mr Baxter
incontinence pads and booked an appointment for him to see the GP.
38. On 26 April, the GP at the prison saw Mr Baxter to conduct some tests and a further
examination. He referred Mr Baxter to hospital for an ultrasound.
39. On 1 May, healthcare staff conducted a diabetic review with Mr Baxter. As Mr
Baxter’s urine test came back abnormal, a new appointment was booked for him to
see the GP.
40. On 3 May, the GP saw Mr Baxter to follow up on his blood test results, which were
taken on 30 April. The results showed a slightly raised prostate-specific antigen,
which indicated possible prostate cancer. The GP requested repeat blood tests.
41. On 9 May, the GP saw Mr Baxter to discuss the results of his recent tests. Mr
Baxter reported that he felt well but was slightly constipated. The GP prescribed Mr
Baxter laxatives and healthcare staff completed a fast track hospital referral to the
urology department for suspected cancer the next day.
42. On 15 May, a nurse saw Mr Baxter after he reported he was struggling to pass
urine. The nurse noted that he may need to attend A&E for catheterisation. She
noted that Mr Baxter had an arranged appointment with the GP and considered this
could be discussed then. On 17 May, the GP saw Mr Baxter and sent him to
hospital. He remained in hospital until 20 May during which time he was
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catheterised (meaning he passed urine through a thin tube inserted into his bladder
and into a bag).
43. On 20 May, Mr Baxter discharged himself from hospital against clinical advice. Two
officers escorted Mr Baxter back to the prison. At interview, they said that hospital
staff did not want to discharge Mr Baxter but he was insistent on returning to the
prison as he had a visit with his sister the following day, and he agreed he would
return to the hospital following his visit. Both officers said that Mr Baxter had been
given another appointment to attend the hospital later that week. There is no record
that the appointment had been arranged.
44. A nurse saw Mr Baxter upon his return from hospital to conduct a post-hospital
review. She explained to Mr Baxter how to use his catheter, and how to fit the night
bags. Mr Baxter declined any further support from healthcare. Following advice
from the hospital, she booked a blood test for Mr Baxter.
45. On 23 May, Mr Baxter was due to attend the healthcare clinic for his blood test, but
failed to attend. An officer on Mr Baxter’s wing called the healthcare unit and asked
them if Mr Baxter could be seen on the wing instead due to issues with his leg.
Healthcare staff re-booked Mr Baxter’s blood test.
46. On 24 May, a nurse saw Mr Baxter on the wing to discuss some problems he was
having with his catheter. Mr Baxter said that his catheter bag had burst overnight
and he needed the nurse to show him how to change it. She showed Mr Baxter how
to use and change the catheter bag. Mr Baxter told her that he was feeling unwell
and was not sleeping. She conducted some clinical observations but did not
complete a National Early Warning Score (NEWS2 - a tool to facilitate the early
detection of clinical deterioration). She arranged for Mr Baxter to see the GP the
following day.
47. On 25 May, Mr Baxter told an officer that he had fallen in his cell overnight. The
officer called healthcare, and a nurse attended Mr Baxter’s cell later that day to
check on him. Mr Baxter told her that he had lost consciousness but did not know
for how long. She observed a small cut to Mr Baxter’s eyebrow. She took his clinical
observations, including his blood pressure, pulse rate, oxygen saturation, Glasgow
Coma Score (GCS) and temperature. She provided Mr Baxter with solution and a
gauze to clean his wound. She did not check Mr Baxter’s blood glucose levels, his
NEWS2 score or complete a falls risk assessment. She arranged for him to see the
GP on Monday 27 May.
Events of 26 May 2024
48. At 8.47am, Officer A went to Mr Baxter’s cell to unlock him for a religious service.
He found Mr Baxter unresponsive on the toilet in his cell. As he was trying to get a
response from Mr Baxter, Officer B entered the cell. Officer A checked for signs of
life and noted that Mr Baxter did not have a pulse and was not breathing.
49. At 8.48am, Officer B radioed a code blue (indicating a prisoner is unconscious or is
having breathing difficulties). Officer C responded immediately as she was already
on the wing. The officers discussed whether they should commence CPR, but they
decided to wait until healthcare staff arrived.
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50. At 8.50am, control room staff asked if an ambulance was needed. Officer C said
yes and left the cell to access Mr Baxter’s prison record to provide control room
staff with more information.
51. Two Supervising Officers (SOs) attended Mr Baxter’s cell. They immediately lifted
Mr Baxter off the toilet and onto the floor and commenced CPR. Staff got a
defibrillator from the office and attached it to Mr Baxter’s chest.
52. At 8.52am, a nurse arrived at the cell. She worked on Mr Baxter’s airway, while both
SOs continued with CPR. At 8.56am, another nurse arrived and gave additional
healthcare support.
53. At 9.10am, paramedics arrived at the cell and took over Mr Baxter’s care. At
9.15am, more paramedics arrived. The first nurse told them that Mr Baxter had
been in hospital recently. The paramedics asked to see Mr Baxter’s medical
records, which she retrieved for them.
54. At 9.22am, more paramedics arrived. A nurse told them that Mr Baxter had
collapsed the night before and he reported unconsciousness and had a small cut to
his head.
55. At 9.29am, the paramedics confirmed that Mr Baxter had died.
Contact with Mr Baxter’s family
56. Shortly after Mr Baxter’s death, a Custodial Manager (CM) contacted Mr Baxter’s
sister to notify her of Mr Baxter’s death by telephone, as the prison did not have her
address on record. Mr Baxter’s sister and her husband visited the prison. She
shared the news of Mr Baxter’s death with his ex-partner.
57. On 28 May, the prison allocated a family liaison officer (FLO). The FLO continued to
liaise and support Mr Baxter’s sister, ex-partner and daughter.
58. The FLO and a prison chaplain attended the funeral on behalf of the prison. They
arranged a memorial service in the prison for Mr Baxter, which was attended by his
ex-partner, their daughter and 20 prisoners who knew Mr Baxter.
59. The prison contributed towards the cost of Mr Baxter’s funeral in line with national
guidance.
Support for prisoners and staff
60. After Mr Baxter’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
61. The prison posted notices informing other prisoners of Mr Baxter’s death, and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Baxter’s death.
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Post-mortem report
62. The post-mortem gave Mr Baxter’s cause of death as acute pyelonephritis
(inflammation of the kidney) and cystitis (bladder infection). Ischaemic heart
disease, an enlarged prostate gland and diabetes mellitus also contributed to his
death.
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Findings
Clinical care
63. The clinical reviewer concluded that the care Mr Baxter received at Wealstun was
not of the required standard and was not equivalent to what he could have expected
to receive in the community.
64. The clinical reviewer was concerned that healthcare staff missed opportunities to
recognise Mr Baxter’s deteriorating health. There was also a lack of professional
curiosity and detailed record keeping. She was concerned that when Mr Baxter
returned to the prison from hospital on 20 May, there was insufficient information
recorded about the plan for follow-up care. There were also missed opportunities to
recognise Mr Baxter’s deteriorating health between 20 May and 26 May.
65. The clinical reviewer found that a nurse did not complete a falls risk assessment for
Mr Baxter following his fall on the night of 24 to 25 May, and a falls care plan was
not created for him as it should have been. She was also concerned that there was
no hypertension or urinary incontinence care plan in place.
66. Despite healthcare staff being notified that Mr Baxter self-discharged from hospital
on 20 May, no arrangements to return him to hospital were made and there was no
evidence that healthcare staff who interacted with Mr Baxter after his return to the
prison discussed his self-discharge with him. We recommend:
The Head of Healthcare must ensure that all healthcare staff are trained and
competent in the use of the NEWS2 assessment.
The Head of Healthcare should ensure that a clear plan is documented within
the patients SystmOne records following self–discharge from the hospital
acute Trust to ensure that all outstanding care/treatment is re-initiated as
soon as possible.
The Head of Healthcare should ensure that care plans are created to support
in the management of incontinence as per NICE ‘When should I suspect a
urinary tract infection in a man’ (2024).
Emergency response
67. The local guidance, Wealstun Safety Awareness Guide, says that if someone is
discovered unresponsive and not breathing, CPR should be commenced
immediately.
68. When Officer A found Mr Baxter unresponsive on 26 May, he called a medical
emergency code. Officers B and C responded immediately. There was some
discussion among the officers as to whether they should commence CPR, but they
decided to wait until healthcare arrived.
69. Officer A told us that he was surprised when he found Mr Baxter unresponsive on
the toilet. He was worried about preserving his decency considering he was with
two female officers. He said that this was his first experience of a medical
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emergency of this nature and he felt like it would have been disrespectful to move
Mr Baxter from the toilet on the floor and begin chest compressions. Officer A
received first aid training in October 2022.
70. Officer B told the investigator that she did not commence CPR immediately
because she panicked. She said she had never dealt with something like this
before, and she felt commencing chest compressions would have been indecent as
it was clear to her that resuscitation attempts would have been futile. She also said
that she was with Officer A, a more experienced officer, from whom she was taking
lead. Officer B received first aid training in July 2023.
71. Officer C told us she did suggest to Officers A and B that they should commence
CPR, but she could not pinpoint why exactly CPR was not started. She said it may
have been the shock of finding a prisoner unresponsive in this way, and said it felt
undignified given that Mr Baxter was on the toilet, in a state of undress. Officer C
received first aid training in September 2023.
72. At interview, all three responding officers recognised that they should have started
CPR immediately, and that in hindsight, they would have commenced CPR sooner.
73. While we recognise that it is difficult for staff to make instant decisions in shocking
situations, it is critical that staff act quickly when there is a potentially life-
threatening situation. We do not consider that the outcome would have been
different in Mr Baxter’s case had CPR commenced earlier, but it could be critical in
future emergencies. We make the following recommendation:
The Governor should conduct regular emergency response drills to allow
staff to practice response requirements, including when to commence CPR.
74. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes set
out the actions staff should take in a medical emergency. It states that if an
emergency code is called over the radio network, an ambulance must be called
immediately.
75. Radio communications evidence shows that the medical emergency code was
called at 8.48am. The control room staff asked if an ambulance was required at
8.50am. Officer C confirmed that an ambulance was needed, then the control room
called for an ambulance. There was a delay of two minutes in requesting an
ambulance. Whilst this did not affect the outcome for Mr Baxter, it could be critical in
future emergencies. We recommend:
The Governor should ensure that staff in the control room request an
ambulance immediately when a medical emergency code is called.
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