David Howarth

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr David Howarth,
a prisoner at HMP Full Sutton,
on 30 December 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 David Howarth died in hospital of multiple organ failure and heart failure as a
complication of sepsis, caused by infection of the prostate gland, with pneumonia
and empyema on 30 December 2023, while a prisoner at HMP Full Sutton. He was
76 years old. We offer our condolences to Mr Howarth’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Howarth received at Full
Sutton was equivalent to that which he could have expected to receive in the
community. The clinical reviewer made no recommendations.
5. Restraints were used in hospital, without due consideration for Mr Howarth’s
advanced age, long-term health and the circumstances of his admission.
Recommendation
• The Governor 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 and that 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
6. We were notified of Mr Howarth’s death on 30 December 2023.
7. The investigator issued notices to staff and prisoners at HMP Full Sutton informing
them of the investigation and asking anyone with relevant information to contact
her. A prisoner contacted her. She and the prisoner spoke by telephone on 29
January to gather some of the information in this report.
8. The investigator obtained copies of relevant extracts from Mr Howarth’s prison and
medical records.
9. NHS England commissioned an independent clinical reviewer to review Mr
Howarth’s clinical care at the prison.
10. We informed HM Coroner for Hull of the investigation. We have sent the Coroner a
copy of this report.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Full Sutton
12. Mr Howarth was the sixth prisoner to die at Full Sutton since December 2020. Of
the previous deaths, four were from natural causes, and one was self-inflicted. To
the end of April 2024, there have been two further deaths at Full Sutton, both from
natural causes. There are no similarities between our findings in the investigation
into Mr Howarth’s death and our investigation findings for the previous deaths.
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Key Events
13. On 25 July 2018, Mr David Howarth was remanded in custody to HMP Leeds for
rape, attempted rape and other sexual offences. At his reception health screening
no immediate issues were raised.
14. On 3 August, Mr Howarth appeared in court and was sentenced to 24 years in
prison, later reduced on appeal to 23 years.
15. On 13 September, Mr Howarth was transferred to HMP Full Sutton.
16. On 25 November 2022, Mr Howarth was reviewed by a hospital urologist and
diagnosed with high pressure chronic urinary retention (inability to pass urine
associated with a tense bladder and renal impairment due to hydronephrosis -
dilatation of the kidney) and a benign prostate (an enlarged prostate which is not
cancerous).
17. On 31 January 2023, Mr Howarth became unwell and was admitted to York
Hospital with urinary retention (unable to pass urine). He had a long-term catheter
inserted and remained in hospital overnight before being discharged back to Full
Sutton.
18. On 30 November, Mr Howarth reported feeling unwell. Healthcare staff
recommended that he move to the prison’s inpatient unit for overnight observation.
19. On 1 December, a GP at Full Sutton attended Mr Howarth’s cell and found him on
the floor and slightly confused. Mr Howarth had a raised temperature and was
unable to sit or stand unaided. He was admitted to hospital where he was found to
have urosepsis (a life-threatening reaction to an infection in the urinary system).
This was initially treated with intravenous antibiotics.
20. Before he went to hospital, a supervising officer completed the escort risk
assessment and noted that Mr Howarth was a medium risk to the public, a low risk
to hospital staff and a low risk of escape. A GP at the prison completed the medical
section. They did not object to the use of restraints and did not request that they be
removed for treatment or a consultation.
21. We asked the prison the reasons for restraining Mr Howarth. An acting Deputy
Governor told us that all escorts are risk assessed at the time, taking into account
relevant information around risk. The starting point for most escorts within a high
security prison is two pairs of ‘D’ cuffs (one which cuffs the prisoners’ two hands to
each other and the second which handcuffs the prisoner to the officer – known as
double cuffing). Relevant information will be considered at the time of the escort
and where there is a reduced level of risk the restraints may be reduced to a single
cuff between the prisoner and the officer or an escort cable. The latter is generally
used where the individual has limited mobility or would require the use of walking
aids. He said that, on this occasion, there was no medical information to suggest
restraints should not be used and therefore based on age/mobility an escort cable
was deemed proportionate.
22. On 4 December, Mr Howarth was discharged from hospital back to Full Sutton with
his indwelling catheter remaining and on oral antibiotics.
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23. On 8 December, at a wellbeing check, staff reported that Mr Howarth was in poor
health and had to give him a carer to assist him in day-to-day things, such as
cleaning his cell and collecting his meals. Mr Howarth, although in poor health, said
that he was “okay” in himself. Over the following two weeks, prison and healthcare
staff made additional welfare checks on Mr Howarth and provided food that he
found easier to digest, such as soup and additional milk.
24. On 21 December, prison staff reported that Mr Howarth looked much more like his
usual self. Mr Howarth told staff he had been drinking and managed to eat and
keep down some food over the past couple of days but was still in a lot of
discomfort in his stomach/bowel area.
25. At around 12.00pm on 28 December, Mr Howarth fell out of bed. Healthcare staff
arranged for his admission to the inpatient unit. As Mr Howarth was being
transferred from the wing to the healthcare unit, he lost consciousness. Prison staff
telephoned for an ambulance and Mr Howarth was admitted to hospital. Before he
was transferred to hospital, a supervising officer completed the escort risk
assessment and noted that Mr Howarth was a medium risk to the public, a low risk
to hospital staff and a low risk of escape. A GP at the prison completed the medical
section and did not object to the use of restraints, but said their removal was
required for treatment or a consultation. No details of Mr Howarth’s age, mobility or
medical condition were included. Staff authorised that Mr Howarth be double cuffed
with an escort chain on the escort and in hospital.
26. Later, on 28 December, Mr Howarth experienced a cardiac arrest and had to be
resuscitated. The duty operational manager authorised that the restraints be
removed. They were not reapplied.
27. We asked the prison the reasons for restraining Mr Howarth. The acting Deputy
Governor told us that outcome of the risk assessment indicated that use of an
escort chain at that time was proportionate and no concerns about its use were
raised when Mr Howarth left the prison.
28. On 30 December, at 1.10am, Mr Howarth died in hospital.
Contact with Mr Howarth’s family
29. Mr Howarth did not name a next of kin and prison staff were unable to identify one.
Post-mortem report
30. The post-mortem report concluded that Mr Howarth died of multiple organ failure
and bilateral arterial popliteal artery occlusion, arising as a complication of sepsis,
and prostatic abscesses and cystitis arising in the context of long term
catheterisation for high pressure urinary retention, and pneumonia and empyema
arising from a sternal fracture resulting from a fall.
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Findings
31. 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.
32. Mr Howarth was 76 years old and in poor health. On two occasions in the month
before he died, Mr Howarth attended hospital on unplanned admissions. He was
restrained throughout the first visit and initially on his second visit, until he needed
to be resuscitated. On the first occasion he could not stand unaided and on the
second occasion he was admitted after losing consciousness. On both occasions
he was assessed as a low risk of escape. In these circumstances, the decision to
restrain him was not proportionate to his risk, and the presence of two escorting
officers by themselves should have been sufficient to manage any risk he might
have presented.
33. We are not satisfied that staff complied with the High Court judgement or that they
fully considered Mr Howarth’s risk in light of his physical health. The medical
sections of the escort risk assessment contained no consideration for Mr Howarth’s
age, long-term health or his current circumstances and reason for the admission.
34. 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
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. This work is
planned for completion by October 2024.
35. In the meantime, it is important that Full Sutton properly considers the prisoner’s
age, health and mobility when determining the appropriate level of restraints. We
make the following recommendation:
The Governor 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 and that authorising managers show that
they have taken this information into account when assessing a prisoner’s
current level of risk.
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Inquest
36. The inquest into Mr Howarth’s death concluded on the 30 October 2024. The
coroner confirmed that Mr Howarth died from natural causes.
Adrian Usher
Prisons and Probation Ombudsman June 2025
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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