Edward Hands

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Edward Hands,
a prisoner at HMP Bedford,
on 16 February 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
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 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 Edward Hands died in his cell at HMP Bedford on 16 February 2024 from aspiration
pneumonitis (an infection caused by material from the mouth entering the lungs) after
taking unprescribed methadone. Mr Hands was 42 years old. I offer my condolences to his
family and friends.
Mr Hands had no recorded history of drug misuse while at Bedford and it was clear from
his telephone calls that he was optimistic about his prospects of being released at his next
court hearing.
Unfortunately, Mr Hands was able to obtain methadone and the staff response to finding
him under the influence was poor. In addition, the clinical reviewer found that his GP
records were not obtained when he arrived at Bedford meaning that staff were unaware he
had a heart condition. Furthermore, the nurse did not use a suction device during the
emergency response which the clinical reviewer concluded may have contributed to Mr
Hands’ death.
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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 7
Findings ......................................................................................................................... 12
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 25 November 2023, Mr Edward Hands was remanded to HMP Bedford charged
with controlling and coercive behaviour in an intimate relationship.
2. During reception screening, Mr Hands said that he used cocaine daily in the
community. He also said that he had taken an overdose of prescribed Mirtazapine
(an antidepressant) and Risperidone (an antipsychotic) three weeks ago, but he
had no present thoughts of suicide or self-harm.
3. In telephone calls to family and friends, Mr Hands spoke about his impending court
appearance, and he seemed optimistic that he would be released from custody.
4. On the morning of 16 February 2024, an officer unlocked Mr Hands’ cell. Around 30
minutes later, a prisoner went into Mr Hands’ cell for 24 seconds. At 9.15am,
another officer went into Mr Hands’ cell and believed that he was under the
influence of drugs. Mr Hands was able to talk and get to his feet, so the officer
followed protocol and radioed the emergency response nurse directly for her to
come and check Mr Hands. The nurse checked Mr Hands at around 10.00am and
noted that she instructed officers to check him every 30 minutes for the next four
hours and to complete an under the influence monitoring form.
5. Officers checked Mr Hands intermittently for the next two hours. The final check
was a routine check at 11.49am immediately before the lunch time patrol period.
6. At 2.13pm, an officer unlocked Mr Hands’ cell and a DHL courier placed three bags
of canteen (prison shop items) just inside the cell. At 2.44pm, another officer briefly
let another prisoner into Mr Hands’ cell to retrieve one of the bags of canteen as it
belonged to him. The officer and the prisoner noticed that Mr Hands was snoring
loudly.
7. At 4.36pm, an officer unlocked Mr Hands’ cell for him to collect his evening meal
and noticed a smell of vomit. After checking Mr Hands, they found he was
unresponsive and radioed an emergency code. Another officer arrived 40 seconds
later, and further officers arrived at 4.38pm. The officers moved Mr Hands to the
floor and started cardiopulmonary resuscitation (CPR).
8. A nurse arrived a minute later. Officers told the nurse that Mr Hands had vomit in
his mouth, but she did not clear the vomit. Staff continued resuscitation efforts.
Ambulance paramedics arrived at 4.51pm and took charge of Mr Hands’ care. At
5.24pm, the paramedics pronounced that Mr Hands was dead.
9. The post-mortem examination found that Mr Hands had died from aspiration
pneumonitis after taking methadone.
Findings
10. Mr Hands obtained methadone illicitly, most likely from another prisoner who was
being prescribed that medicine.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
11. When Mr Hands was found under the influence on 16 February, neither the
emergency response nurse nor the officers followed the under the influence
protocol.
12. The officer who noticed Mr Hands snoring loudly at 2.44pm, did not understand that
this was a possible sign of a medical emergency.
13. When Mr Hands was found unresponsive the nurse did not suction vomit from his
mouth. Healthcare staff also did not obtain Mr Hands’ GP records, so they were
unaware that he had a heart condition.
Recommendations
• The Governor and Head of Healthcare should review whether the current
medication administration process is sufficiently robust and identify any
weaknesses to minimise the risk of diversion.
• The Governor and Head of Healthcare should introduce a robust audit process to
ensure that when a prisoner is suspected to be under the influence staff understand
and follow the protocol.
• The Governor and Head of Healthcare should ensure that staff are aware of the
potential significance of a prisoner being in an apparent deep sleep and snoring
loudly.
• The Head of Healthcare should ensure that prisoners’ GP records are obtained.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
14. HMPPS notified us of Mr Edward Hands’ death on 19 February 2024.
15. The investigator issued notices to staff and prisoners at HMP Bedford informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
16. The investigator obtained copies of relevant extracts from Mr Hands’ prison and
medical records.
17. The investigator interviewed six members of staff at Bedford on 2 and 3 May 2024.
He interviewed one prisoner by MS Teams on 13 May 2024. He interviewed three
further members of staff by MS Teams in May and June, and he interviewed one
more prisoner by telephone in August.
18. NHS England commissioned a clinical reviewer to review Mr Hands’ clinical care at
the prison. The investigator and clinical reviewer conducted joint interviews with
clinical staff.
19. We informed HM Coroner for Bedfordshire and Luton of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
20. We contacted Mr Hands’ mother to explain the investigation and to ask if she had
any matters she wanted us to consider. Mr Hands’ mother responded with several
questions, and we later received a letter from the family’s legal representative
asking further questions. Their questions and concerns were:
• Why was Mr Hands’ mother not allowed to bring a monitor into the prison that
connected with the ‘Reveal’ heart monitor (a small device inserted under the
skin) that he had had fitted to check his heart activity.
• Mr Hands complained to his mother that he was receiving all of his
medication together at 4.30pm, including a sleeping tablet that should have
been given at night.
• Mr Hands’ asthma inhaler ran out and he waited three to four weeks for a
replacement.
• Mr Hands complained to his mother about the condition of his cell, including
that the window was broken and there was an infestation of cockroaches. He
also complained that there were rats in the prison kitchen.
• Mr Hands complained to his mother about being cold, but he was not allowed
access to a parcel of warm clothing she had sent to him: she was told that his
request had been denied as the prison had mislaid paperwork.
• Was Mr Hands under the care of the mental health team at Bedford?
• Was Mr Hands being supported through prison service suicide and self-harm
monitoring procedures (known as ACCT)?
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• Was Mr Hands prescribed methadone and, if not, how did he acquire
methadone?
• What other medication was prescribed to Mr Hands?
• What time was the last roll check prior to Mr Hands’ death and at what time
was he last seen alive?
• Was Mr Hands sharing a cell at the time of his death?
21. We have answered these questions in this report, the clinical review and in
separate correspondence.
22. We shared our initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
23. Mr Hands’ family also received a copy of the initial report. They did not make any
comments.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Bedford
24. HMP Bedford is a small, local, inner-city Victorian prison. Northants Healthcare
NHS Foundation Trust provides all healthcare services. Bedford also has a small
inpatient unit. There is 24-hour healthcare provision.
HM Inspectorate of Prisons
25. The most recent inspection of HMP Bedford was in October and November 2023.
The Chief Inspector wrote that standards had fallen badly since the last inspection
in 2022.
26. Inspectors found that while the majority of prisoners said that staff treated them with
respect, the interactions they observed were mostly transactional to support the
delivery of the regime. Inspectors noted that the key worker scheme had ceased
and been substituted with a telephone call to the cell, which was inappropriate as
most prisoners were sharing cells so could not speak in confidence. Inspectors
noted that in the cases they reviewed, key work contact levels and quality were
poor and many prisoners had been in Bedford for several months with no contact.
27. Inspectors found that too many cells were in a poor condition with mould and
broken windows. Inspectors also found that there was widespread infestation of
rats, cockroaches and other vermin.
28. Inspectors noted that pharmacy services had been subcontracted and this had
caused considerable disruption, particularly with the management of medicines and
which had affected continuity of care and resulted in gaps in patients receiving their
medication.
29. Following the inspection HM Chief Inspector of Prisons invoked the Urgent
Notification process because he was so concerned about conditions at Bedford (the
Urgent Notification process allows HM Chief Inspector of Prisons to directly alert the
Lord Chancellor and Secretary of State for Justice if he has an urgent and
significant concern about the performance of a prison). The Chief Inspector noted
that the Urgent Notification process had also been invoked after an inspection of
Bedford in 2018 when many similar concerns were highlighted. The Chief Inspector
noted that he had reported more favourably in 2022, showing that progress was
possible despite the many challenges face by the prison.
Independent Monitoring Board
30. 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 June 2023, the IMB reported that
the key worker scheme had stopped during the Covid-19 pandemic and had not
since been fully reinstated. The IMB noted that in their prisoner survey, 21 out of 72
responses were positive about officers, but 22 responses said that officers were not
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
helpful. As with HMIP, the IMB referred to the poor standard of the physical
infrastructure of the prison and the abundance of vermin.
Previous deaths at HMP Bedford
31. Mr Hands was the eighth prisoner to die at Bedford since July 2020. Of the previous
deaths, three were self-inflicted and four were from natural causes. There were no
similarities between Mr Hands’ death and any of the previous deaths.
Key worker scheme
32. The key worker scheme is a key part of HMPPS’s response to self-inflicted deaths,
self-harm, and violence in prisons. It is intended to improve safety by engaging with
people, building better relationships between staff and prisoners, and helping
people settle into life in prison. Details of how the scheme should work are set out in
HMPPS’s Manage the Custodial Sentence Policy Framework. This says:
• All prisoners in the male closed estate must be allocated a key worker whose
responsibility is to engage, motivate and support them through the custodial
period.
• Key workers must have completed the required training.
• Governors in the male closed estate must ensure that time is made available
for an average of 45 minutes per prisoner per week for delivery of the key
worker role, which includes individual time with each prisoner.
33. Within this allocated time, key workers can vary individual sessions to provide a
responsive service, reflecting individual need and stage in the sentence. A key
worker session can consist of a structured interview or a range of activities such as
attending an ACCT review, meeting family during a visit or engaging in conversation
during an activity to build relationships.
34. In 2023/24, due to exceptional staffing and capacity pressures in parts of the estate,
some prisons are delivering adapted versions of the key work scheme while they
work towards full implementation. Any adaptations, and steps being taken to
increase delivery, should be set out in the prison’s overarching Regime Progression
Plan which is agreed locally by Prison Group Directors and Executive Directors and
updated in line with resource availability.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
35. On 25 November 2023, Mr Edward Hands was remanded into prison at HMP
Bedford charged with controlling and coercive behaviour in an intimate relationship.
It was Mr Hands’ first time in prison.
36. A nurse saw Mr Hands for a reception health screen. Mr Hands said that he had a
history of mental health problems, including a psychotic disorder and was in receipt
of medication. He said that he had had asthma since he was a child and also said
that he had suspected epilepsy, potentially diagnosed the year before. Mr Hands
reported daily use of cocaine. Mr Hands said that he had taken an overdose of
prescribed Mirtazapine and Risperidone three weeks earlier, but he had no present
thoughts of suicide or self-harm. Mr Hands did not mention any other concerns and
did not mention heart monitoring. (His mother told us he had been fitted with a heart
monitor which had a separate bedside monitor to check his heart activity.) The
nurse referred Mr Hands to the mental health team.
37. A reception GP prescribed Mr Hands a number of medicines, including Lamotrigine
(for epilepsy), Mirtazapine and Risperidone. He was not allowed to hold these
medicines in possession and had to collect them daily.
38. On 27 November, an officer had a key worker session with Mr Hands via his in-cell
telephone. Mr Hands asked for clarity on his next court date and after checking, the
officer telephoned Mr Hands the next day to confirm he would appear at court on 29
November.
39. On 28 November, a substance misuse worker gave Mr Hands harm minimisation
advice and an intervention service self-referral form. If Mr Hands wanted to engage
with the service, he needed to fill this in.
40. On 5 December, a mental health nurse reviewed Mr Hands. She noted that Mr
Hands was stable on his current medication, and he said that he had no thoughts of
deliberate self-harm. The nurse added Mr Hands to the psychiatrist’s waiting list.
41. On 6 December, a substance misuse worker gave Mr Hands a replacement self-
referral form as he had lost the form previously given to him.
42. On 14 December, another substance misuse worker noted that Mr Hands had still
not completed a self-referral form. The worker sent Mr Hands a letter to say that he
would not be seen again, but he would be able to apply for help in the future if he
wished. Mr Hands did not request help.
43. On 23 January 2024, Invisible Walls (an organisation that supports prisoners’
families), emailed one of Bedford’s managers who they previously had contact with,
to say that Mr Hands’ mother was trying to bring his heart monitor into the prison,
but she needed authority from the prison to do so. The manager was on leave at
the time, but on 31 January she replied to say that she had emailed healthcare to
check that Mr Hands required the device and said that once she had this
confirmation, she would agree the request. The investigator understood that the
monitor that Mr Hands’ mother was trying to bring into the prison connected
electronically to a device inserted in Mr Hands’ body to give ongoing data about his
heart function. There is no reference in Mr Hands’ medical records about any such
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
device or of Mr Hands telling prison staff that he used a monitor in the community
and that his mother was trying to bring the monitor into the prison. She did not
receive agreement to bring the monitor into the prison. We incidentally note that
there is no reference in Mr Hands’ post-mortem examination report to say that any
internally fitted device was discovered.
44. Also on 23 January, an officer noted that he spoke to Mr Hands for a welfare check
and that Mr Hands raised no concerns.
45. On 1 February, a GP saw Mr Hands and noted that he was taking his medication,
and his mental health was stable. The GP also prescribed an asthma inhaler, which
he noted had last been prescribed in January 2023.
46. The investigator listened to Mr Hands’ telephone calls during the last month of his
life. The majority of his calls were to his mother, along with several calls to two
friends. Mr Hands was generally positive in conversation, and he spoke frequently
about his court appearances and his belief that he would soon be granted bail.
47. Mr Hands’ final telephone call was a call to his mother in the early afternoon of 15
February. She said that she was unable to book a visit to see him the next day as
the visiting list was full. (She had regularly visited him over his time at Bedford.) Mr
Hands told his mother that he would telephone her again in two days’ time.
48. Staff the investigator spoke to said that Mr Hands was a quiet, polite and well-
behaved prisoner. However, Mr Hands did not have a key worker and none of the
entries in his record indicate detailed interaction with him.
Events of 16 February
49. The investigator watched CCTV and body worn video camera (BWVC) footage,
listened to the staff radio communications, and obtained information from the East
of England Ambulance Service. He studied staff response statements and records
and interviewed key staff. The account below is based on all these sources of
information.
50. On 16 February at 7.34am, Officer A carried out a routine check on A wing,
including Mr Hands’ cell. She did not note anything of concern. At 8.05am, another
officer unlocked cells on A wing for prisoners to use the showers. The officer did not
check on the welfare of the prisoners while unlocking cells.
51. At 8.31am, another prisoner went into Mr Hands’ cell and came out again 24
seconds later. The prisoner was transferred to HMP Peterborough shortly after Mr
Hands’ death and was then released from prison. The investigator wrote to his
home address to arrange to speak with him, but he did not respond. The prison told
the investigator that the prisoner was prescribed methadone.
52. It seems that Mr Hands’ cell was re-locked sometime after this but, from speaking to
staff and watching CCTV, the investigator could not establish when this happened.
53. At 9.15am, Officer B unlocked Mr Hands’ cell for him to socialise with other
prisoners. The officer said that Mr Hands was in bed, and he did not return his
greeting as he usually did. He said that he went into the cell and as Mr Hands
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
began to stand, he saw that he was unsteady his feet. He called for help from
Officer A and then radioed Hotel Two (the emergency response nurse). Officer B
said that as Mr Hands was conscious, it was not standard practice to radio an
emergency code that all staff could hear, and instead he radioed the nurse directly
and told her that Mr Hands seemed under the influence of an illicit substance.
54. The morning emergency response nurse told the investigator that she was issuing
controlled medicines when she received the call from Officer B. She said that if she
had received an emergency call, she would have responded immediately, but as
she did not, she decided that completing the controlled medication round was the
more pressing task at that time.
55. Officer B said that he made a further call to the nurse due to the time it was taking
for her to attend.
56. The nurse went to Mr Hands’ cell at 9.53am. She noted that Mr Hands was lying in
bed and breathing normally. She noted that he was talking in full sentences, but his
speech was slurred, and his responses were slow. She also noted that his gait was
unsteady when he tried to walk. She told officers to observe Mr Hands twice an
hour for the next four hours and to contact healthcare if they had any further
concerns. She told the investigator that she went to the wing office and asked
officers to start an under the influence (UTI) monitoring form detailing their checks.
She said that staff seemed reluctant to start a UTI form, but she insisted that they
should do so (officers did not complete a UTI monitoring form). She told the
investigator that she was an agency nurse and had only just started working at
Bedford.
57. Officers searched Mr Hands’ cell and found a rolled-up piece of paper with traces of
a white substance. They also found a container holding cigarette butts and a dark
powder that smelled of tobacco. Results of the tests on these items were still
unavailable when we issued this report.
58. CCTV shows that officers relocked Mr Hands’ cell at 10.18am.
59. At 11.04am, Officer B went into Mr Hands’ cell to check him. He said that he asked
Mr Hands if he was okay, and he said that he was. He told us that he understood
that healthcare staff and not officers were responsible for checking Mr Hands until
he fully recovered.
60. CCTV shows that officers looked into Mr Hands’ cell three more times that morning:
at 11.21am, 11.48am and 11.49am. Staff did not carry out any checks on Mr Hands
between midday and 2.13pm.
61. In the afternoon, prisoners’ canteen (prison shop) orders were delivered to the wing.
At 2.13pm, Officer C unlocked Mr Hands’ cell and he saw Mr Hands in bed,
apparently asleep. A DHL operative carried in Mr Hands’ canteen items. He told the
investigator that DHL visited Bedford every Friday to deliver prisoners’ canteen
orders. He said that DHL staff delivered the orders and remained in the prison for a
time to allow prisoners time to check that their orders were correct. He said that
most of the time prisoners would stand at their cell doors ready to take their canteen
orders. However, if the prisoner was asleep, he would place the canteen order just
inside the cell and the officer would then relock the door. He said that he did not
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
fully step into cells, and he had no recollection of Mr Hands that day. (CCTV shows
that he stepped fully across the threshold of Mr Hands’ cell entrance, although he
did not walk further into the cell.)
62. At 2.39pm, a group of prisoners returned to the wing following the Friday Muslim
service. One of the prisoners stood in front of Mr Hands’ cell door. Officer C asked
him if that was his cell and he said that it was. The officer unlocked the door, and
the prisoner went in. Another prisoner then called from the upper landing to say that
that was not his cell, so Officer C and Officer A unlocked the cell again and brought
him out. He had remained alone in the cell with Mr Hands for 14 seconds. Officer C
did not normally work on that wing and said the photos of prisoners on cell doors
were often not clear, hence his mistake. The prisoner told the officers that one of
the bags of canteen had been bought by a previous occupant of the cell and
belonged to him in repayment of a debt. The officers told him that they needed to
lock away all of the other prisoners first and they would then deal with the bag of
canteen.
63. The prisoner told the investigator that he had tried to wake Mr Hands, but he
seemed to be in a deep sleep and was snoring loudly. He told the investigator that
the prison later published a notice to say that loud snoring could be a sign of a drug
overdose, but he did not realise that at the time. Officer C also said that Mr Hands
was snoring loudly, but he again did not recognise the significance.
64. At 2.44pm, having established that one of the bags of canteen did not belong to Mr
Hands, Officer A briefly let the prisoner back into Mr Hands’ cell to collect his
canteen. The officer said that he noticed Mr Hands snoring loudly and he just
thought that he was having ‘a good sleep’.
65. At 2.48pm, Officer B went into Mr Hands cell to check him again. He said that Mr
Hands was asleep and snoring and he thought he was okay. He said that he
understood that some drugs can cause paranoia so he did not try to wake him as
he thought this might have scared him.
66. At 4.36pm, Officer A unlocked Mr Hands’ cell so he could collect his evening meal.
He said that when he unlocked the door, he could smell vomit. He went into the cell
and shook Mr Hands’ shoulder to try to wake him. He said that Mr Hand’s body was
warm. He tried to find a pulse and thought he was doing something wrong as he
could not find one. He radioed a medical emergency code blue (to indicate a
prisoner is unconscious or having breathing difficulties). Control room staff
immediately requested an ambulance. An officer came into the cell and another
officer arrived a few seconds later. Officers moved Mr Hands from his bed to the
cell floor and an officer began CPR.
67. Two nurses arrived at 4.39pm (Nurse A was the afternoon response nurse and
Nurse B was a new nurse who followed Nurse A for experience). As Nurse A began
preparing her equipment, audio captured on the BWVC recording included two of
the officers making repeated comments that Mr Hands’ mouth was full (of vomit)
and asking whether his mouth should be suctioned.
68. Nurse A acknowledged at interview that she saw a black substance coming from Mr
Hands’ mouth, but she did not ask for a suction unit to clear his mouth and could
not fully explain why not. Instead, she took over giving CPR and she and officers
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
then took turns with further CPR. Staff brought a defibrillator but each time they
checked Mr Hands they were instructed that no shock could be given (a defibrillator
will only shock if the heart is in a rhythm that will respond to a shock). The
investigator noted that Nurse B did not take an active part in the attempts to
resuscitate Mr Hands. A nurse who was Hotel One that afternoon (Hotel One
should provide back-up support to the emergency response nurse) said that he was
screening new receptions that afternoon and he did not hear the code blue call.
69. Paramedics reached Mr Hands at 4.51pm and took over his care. Efforts to try to
resuscitate him proved unsuccessful and, at 5.24pm, they declared that he was
dead.
Contact with Mr Hands’ family
70. Bedford appointed a family liaison officer (FLO). He and a colleague drove to Mr
Hands’ mother’s home. Due to heavy traffic, they did not arrive until 9.55pm. The
FLO informed Mr Hands’ mother of her son’s death and offered her condolences.
71. Bedford contributed to the cost of Mr Hands’ funeral in line with national
instructions.
Support for prisoners and staff
72. After Mr Hands’ death, the Duty Governor debriefed prison staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. Staff were also offered support from the care team and
officer specific trauma support. The healthcare team held a separate debrief
meeting.
73. The prison posted notices informing other prisoners of Mr Hands’ 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 Hands’ death.
Post-mortem report
74. Toxicological investigation found that Mr Hands’ blood was positive for his
prescribed medicines at a therapeutic level (therapeutic level refers to the level
prescribed to treat an illness). Investigation also found that he had taken
methadone, which he was not prescribed. His post-mortem report explained that
while the blood methadone concentration was within the range encountered in
therapy, the concentration may be associated with fatalities in those not prescribed
methadone. Examination found gross aspiration of gastric contents in Mr Hands’
airways (when a significant amount of food or liquid enters the airway) and
established aspiration pneumonitis (an infection caused by a relatively large amount
of material from the mouth entering the lungs). The pathologist gave Mr Hands’
cause of death as aspiration pneumonitis with methadone use having contributed to
but not caused his death.
Prisons and Probation Ombudsman 11
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Mr Hands’ reported substance misuse
75. When Mr Hands arrived in Bedford in November 2023, he reported daily use of
cocaine. He was seen several times by the substance misuse team who gave him
information leaflets and self-referral forms. Mr Hands did not complete a self-referral
form so he was told he would not be seen again, although he could request support
in the future if he wished. He did not request support.
76. There is no record that Mr Hands used illicit substances or took any medication not
prescribed to him until 16 February.
77. We are satisfied that Mr Hands was offered appropriate support for any substance
misuse issues he might have had.
Methadone distribution
78. As noted, Mr Hands was found to have taken methadone in the hours before his
death. Methadone is a liquid medicine used to treat heroin dependence. Mr Hands
was not prescribed methadone so he would have obtained the medicine from
another prisoner. CCTV shows that another prisoner went into Mr Hands’ cell at
8.31am, where he remained for 24 seconds. The investigator was told that the
prisoner was being prescribed methadone. As already indicated, we were unable to
interview him. However, we consider it more likely than not that he diverted his
methadone and sold or gave it to Mr Hands that morning.
79. The acting Head of Healthcare told us that prisoners at Bedford who are prescribed
methadone are required to first swallow the methadone and then drink 200 millilitres
of water in front of the nurse to prevent them from saving or passing the methadone
to another prisoner. She said that good practice would be for prisoners to also be
asked to open their mouths, although she was unsure if this was always the
practice. In addition to the presence of nurses involved in the distribution of the
methadone, officers are responsible for supervising the methadone queue. It is
clear that the processes broke down in this instance leading to Mr Hands’ death.
We make the following recommendation:
The Governor and Head of Healthcare should review whether the current
medication administration process is sufficiently robust and identify any
weaknesses to minimise the risk of diversion.
Response on 16 February to Mr Hands being found under the influence
80. Bedford’s protocol for non-emergency responses to prisoners found under the
influence is for staff to telephone either Hotel Two or Hotel One. Officer B correctly
followed protocol by telephoning Hotel Two (the emergency response nurse).
However, he was concerned about the time it took for the nurse to respond, which
indicates that he did not properly understand the principle of a non-emergency
response.
12 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
81. After the nurse assessed Mr Hands, she told officers that they should check him
twice an hour for the following four hours and to contact healthcare again if they had
concerns. She asked them to complete a UTI monitoring form, but said officers
seemed reluctant to do so. None of the officers with whom the investigator spoke
could recall being asked to complete UTI monitoring (and no one started a UTI
monitoring form).
82. The investigator spoke to Bedford’s temporary Drug Strategy Lead. She said that
she had taken up post in mid-March. She acknowledged that there were apparent
problems at the time with officers completing UTI monitoring forms. She said that
there had been 15 recorded UTI incidents at Bedford in February, and she had not
been able to locate a completed UTI monitoring form for any of the incidents. She
said that on taking up post she began to re-write policy documents and had in place
a programme for training staff on their responsibilities. She said that around June
2024, the Prison Officers’ Association (POA; the officers’ trade union) had raised
concerns that UTI monitoring forms were a healthcare document and should not be
completed by officers. She said that this was a national concern to the POA, not a
local one. She said that while the issue was still under discussion, it had been
agreed that officers would record UTI observations in the wing diary.
83. The Lead agreed with the investigator that Officer B had apparently misunderstood
that telephoning Hotel Two meant that there might be a delay in the response
depending on what Hotel Two was doing at the time. She said that the instruction to
staff included the need to also inform the Orderly Officer (the officer in charge) who
would be able to follow-up if there were any problems with the response from
healthcare. (There is no record that Officer B called the Orderly Officer). She also
acknowledged that the healthcare team at Bedford used a lot of bank nurses and
that there was room for improvement in the relationships between prison and
healthcare staff.
84. We also note that the protocol for ongoing checks on prisoners found under the
influence included that the prisoner should be observed every 10 minutes for the
first hour and reassessed by healthcare after the first hour. At interview, it was clear
that none of the staff understood the protocol. We note that officers maintained a
reasonable level of checks on Mr Hands up to 11.49am, but after that the checks
became intermittent and some of them only occurred because it was canteen
delivery day and not because they understood that he needed to be checked until
he had recovered. We also note with concern that Mr Hands was one of 15
prisoners found under the influence in February with no UTI forms completed.
85. One of the most important omissions in keeping Mr Hands safe after he was
suspected to be under the influence was the absence of an appropriate healthcare
review of his condition after the first hour. Currently, most prisoners found under the
influence will have used a psychoactive substance (PS) where generally prisoners
recover quite quickly following use. In Mr Hands’ case, he had used methadone that
he presumably obtained from a prisoner prescribed that medicine. With methadone
overdose, individuals recover much more slowly, and unconsciousness and loud
snoring are signs of deteriorating health and signify a medical emergency. Both
officers and a prisoner noticed these signs in the early afternoon, but they did not
recognise the significance.
Prisons and Probation Ombudsman 13
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
86. We recommend that:
The Governor and Head of Healthcare should introduce a robust audit
process to ensure that when a prisoner is suspected to be under the
influence staff understand and follow the protocol.
The Governor and Head of Healthcare should ensure that staff are aware of
the potential significance of a prisoner being in an apparent deep sleep and
snoring loudly.
Clinical care
87. The clinical reviewer found that the care Mr Hands received for his mental health
and substance misuse needs was of a good standard and equivalent to that which
he would have received in the community.
88. However, the clinical reviewer considered that Mr Hands’ physical healthcare was
only partially equivalent to that which he would have received in the community. In
particular, she noted the inadequate recording of information about Mr Hands’
mother’s attempts to bring a heart monitoring device into the prison and whether he
required any such device. She also noted that Bedford had not obtained Mr Hands’
GP records so it would not have been possible to verify that he had been fitted with
the device. We make the following recommendation:
The Head of Healthcare should ensure that prisoners’ GP records are
obtained.
89. The clinical reviewer also noted that Nurse A did not request suction equipment to
clear the vomit from Mr Hands’ mouth. At interview, the nurse said that she had
since reflected on her actions that day and regretted failing to ask for a suction
device. The acting Head of Healthcare reviewed the CCTV/BWVC footage and
spoke with Nurse A about her actions. She also arranged with Northants Healthcare
NHS Foundation Trust provision of bespoke training for staff in use of suction
equipment and maintenance of the patient’s airway. Bedford has also ordered
additional portable suction units to be held on all wings. In view of the actions taken,
we make no recommendation.
Key worker scheme
90. Mr Hands was at Bedford for almost three months and had just one key worker
meeting in that time. The last entry in his records before his death was made on 23
January when he said that he had no concerns. HM Inspectorate of Prisons found
at their last inspection that the key worker scheme had been replaced by telephone
calls to prisoners in their cells which was deemed inappropriate as most prisoners
were sharing cells. Bedford has subsequently reinstated face to face key worker
meetings.
91. Bedford’s Head of Residence told the investigator that in the last three months the
prison had delivered 718 key worker sessions, but he explained that it was difficult
to determine how many sessions were being delivered per prisoner due to prisoner
churn and a fluid population level (the population was 334 at the time of the last
14 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
HMP inspection). He told the investigator that Bedford aimed to deliver one key
worker session each week to the priority group comprising young adults, prisoners
at risk of suicide and self-harm and prisoners in the segregation unit. For other
prisoners the aim was to deliver one key worker session each month. In view of the
apparent improvement since Mr Hands’ time in Bedford we make no
recommendation.
Governor to note
Unlock procedures
92. When Mr Hands’ cell was unlocked at 8.05am on 16 February, the officer did not
check his welfare before moving to the next cell. There is no evidence to suggest
that Mr Hands was unwell at that time, however the Governor will wish to ensure
that officers check prisoners’ welfare when unlocking cells in the morning.
Resuscitation guidance
93. The clinical reviewer noted from reviewing the BWVC that officers were unclear
about how to set up the defibrillator and needed guidance from Nurse A. The
clinical reviewer also noted that some officers were unclear about the rate and
depth when giving CPR, but the nurse did not give guidance on this. The Governor
and Head of Healthcare may wish to consider these issues further.
Inquest
94. An inquest into Mr Hands’ death held between 24 November and 2 December 2025
concluded that his medical cause of death was aspiration pneumonitis following
consumption of methadone. The inquest jury found that Mr Hands’ death was
contributed to by neglect and could have been prevented had prison and healthcare
staff given him appropriate follow up care after he was found under influence on 16
February 2024.
Prisons and Probation Ombudsman 15
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