Eric Stringer

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Independent investigation into
the death of Mr Eric Stringer,
a prisoner at HMP Wormwood
Scrubs, on 23 August 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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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 Eric Stringer died in hospital of lung cancer on 23 August 2024, while a prisoner
at HMP Wormwood Scrubs. He was 78 years old. We offer our condolences to Mr
Stringer’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Stringer received at
Wormwood Scrubs was of a good standard and equivalent to that which he could
have expected to receive in the community. However, she found that Mr Stringer
was not referred to the local authority social care department or the pain clinic, staff
did not create a food or fluid chart to monitor his diet and they did not use the
malnutrition universal screening tool as they should have done. The clinical
reviewer concluded that these concerns did not contribute to Mr Stringer’s death.
5. The clinical reviewer made four recommendations about matters not directly related
to Mr Stringer’s cause of death but which the Head of Healthcare at Wormwood
Scrubs will want to address.
6. Healthcare staff were not involved in the decision to restrain Mr Stringer on 22
June. This is particularly concerning as we found that this is standard practice for all
emergency hospital escorts, and we have previously made recommendations to
address this issue.
Recommendations
The Governor and Head of Healthcare should introduce a robust quality
assurance process to assure themselves that:
• in line with policy, a thorough escort risk assessment is completed for
every non-life-threatening emergency hospital escort;
• healthcare staff are routinely involved in the escort risk assessment
process, taking a prisoner’s current medical condition into
consideration, including how this impacts on their ability to escape;
• all staff involved in the escort risk assessment process receive training
on the Graham judgment and have a clear understanding of how it
applies to the Prevention of Escape – External Escorts policy
framework; and
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• staff are using the current escort risk assessment template, as outlined
in the policy framework.
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The Investigation Process
7. HMPPS notified us of Mr Stringer’s death on 25 August 2024.
8. NHS England commissioned an independent clinical reviewer to review Mr
Stringer’s clinical care at HMP Wormwood Scrubs.
9. The PPO investigator investigated the non-clinical issues relating to Mr Stringer’s
care. She interviewed two members of staff on 1 and 23 October 2024.
10. The Ombudsman office wrote to Mr Stringer’s next of kin, his wife, to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond to our letter.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out a factual inaccuracy and this report has been amended
accordingly.
Previous deaths at HMP Wormwood Scrubs
12. Mr Stringer was the fourteenth prisoner to die at HMP Wormwood Scrubs since 23
August 2021. Of the previous deaths, seven were from natural causes, four were
self-inflicted, one was drug-related, and one was unascertained. We have
previously made a recommendation about the need for staff to take into account a
prisoner’s medical condition when they consider using restraints for emergency
hospital journeys. We also recommended that all staff undertaking risk
assessments should understand the legal position on the use of restraints.
13. HMP Wormwood Scrubs agreed to implement our recommendations and told us
that a review of local policy and risk assessments would be conducted by February
2024 to ensure that escort risk assessments for emergency hospital escorts are
completed appropriately, taking into account the prisoner’s medical condition when
deciding the level of restraints. They also told us that all managers involved in the
risk assessment process would receive training on the Graham judgment.
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Key Events
14. On 3 May 2024, Mr Eric Stringer was sentenced to three years and nine months in
prison for sexual offences and was sent to HMP Wormwood Scrubs. A nurse
completed his initial health screen. She noted that Mr Stringer was prescribed
medication for angina and high blood pressure, and that his mobility was reduced,
and he walked with a crutch.
15. On 8 May, a nurse saw Mr Stringer to monitor his vital signs as he had multiple
health conditions. She recorded that his blood pressure was slightly low. She
encouraged him to drink fluids.
16. On 25 May, a nurse saw Mr Stringer and he reported abdominal pains. She
checked his vital signs and advised him to drink warm water.
17. On 17 June, a nurse visited Mr Stringer to help to move him. He reported that he
was in a lot of pain and was unable to move around his cell without help.
18. On 18 June, a nurse saw Mr Stringer for a welfare check. She recorded that he was
alert and had no tenderness to his abdomen. She took his observations which were
all within normal limits.
19. On 20 June, Mr Stringer did not attend his nurse clinic appointment.
20. On 21 June, a nurse saw Mr Stringer for an in-cell welfare check as he was unable
to get out of bed. He took Mr Stringer’s observations, which were stable, and asked
prison staff to monitor Mr Stringer closely.
21. At 12.32pm on 22 June, a nurse saw Mr Stringer in his cell after he complained of
abdominal pain. He had been unable to get out of bed and eat since the previous
day. She checked Mr Stringer’s vital signs and asked for a second opinion from a
senior member of the healthcare team.
22. At 5.53pm, a prison paramedic attended Mr Stringer’s cell to examine him. Due to
Mr Stringer’s recent deterioration, confusion and reduced mobility, she decided that
he should be admitted to hospital as she suspected he had a urinary tract infection.
Mr Stringer was restrained with an escort chain (a long chain with a handcuff at
each end, one of which is attached to the prisoner and the other to an officer) and
taken to hospital by ambulance. A Custodial Manager (CM), who attended the
escort and decided on the level of restraint, told us that escort risk assessments are
not completed for emergency hospital escorts.
23. On 23 June, the Head of Security completed an escort risk assessment which
stated that Mr Stringer should be restrained with an escort chain while in hospital.
She told us that as Mr Stringer was in hospital at this point, healthcare staff did not
contribute to this decision.
24. On 24 June, a nurse contacted the hospital. They told her that Mr Stringer was
awaiting test results for suspected cancer. The healthcare team remained in regular
communication with the hospital throughout his admission.
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25. On 27 June, healthcare team contacted the hospital, and they said that Mr Stringer
had a confirmed diagnosis of lung cancer. There were no plans to discharge him as
he was awaiting further tests and examination. The bed watch log noted that Mr
Stringer was irritable and shouting at nurses.
26. On 30 June, a new risk assessment was completed which stated that Mr Stringer
should be unrestrained as he was unable to sit up, stand or walk and bed watch
officers removed Mr Stringer’s restraints.
27. On 3 July, Mr Stringer had a biopsy and an endobronchial ultrasound (to help
determine the stage of lung cancer). Two members of staff were appointed as
family liaison officers (FLOs), and they contacted Mr Stringer’s wife to tell her he
was in hospital. Arrangements were made for his wife to visit him.
28. On 8 July, the FLOs facilitated a visit between Mr Stringer and his wife at the
hospital. During Mr Stringer’s hospital admission, Wormwood Scrubs organised and
paid for twice-weekly transport for his wife. Both FLOs attended the hospital for
each visit to ensure she could find Mr Stringer and to arrange her taxi home.
29. On 10 July, the hospital told healthcare staff that Mr Stringer had been diagnosed
with stage 4 lung cancer, which could not be treated. They said that only supportive
care could be provided.
30. On 11 July, Mr Stringer was transferred to another hospital for inpatient palliative
radiotherapy. He was given a prognosis of a few months.
31. On 22 July, Mr Stringer’s palliative radiotherapy was complete.
32. On 2 August, Mr Stringer was granted release on temporary licence (ROTL), which
meant that he no longer required supervision from bed watch staff. An application
for Mr Stringer’s early release on compassionate grounds (ERCG) was submitted to
HMPPS’ Public Protection Casework Section (PPCS).
33. On 16 August, the Secretary of State refused Mr Stringer’s ERCG application as
they were not satisfied that Mr Stringer had addressed his offending behaviour, his
risk had not been reduced and there was no evidence that his current health needs
were not being met.
34. On 20 August, healthcare staff discussed Mr Stringer in a multi-agency meeting. He
remained on ROTL, on a palliative care pathway, and was awaiting a hospice
placement.
35. At 23.18pm on 23 August, Mr Stringer died in hospital.
36. At 7.33am on 24 August, a FLO visited Mr Stringer’s wife to tell her that Mr Stringer
had died.
Post-mortem report
37. A hospital doctor gave Mr Stringer’s cause of death as squamous cell lung cancer
which had spread to other parts of the body. The Coroner accepted this cause of
death, and no post-mortem examination was carried out.
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Inquest
38. At an inquest held on 26 March 2025, the Coroner concluded that Mr Stringer died
of natural causes.
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Non-Clinical Findings
Restraints, security and escorts
39. 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 (the Graham judgment) 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 he
has a serious medical condition. It said that medical opinion about the prisoner’s
ability to escape must be considered as part of the assessment process and kept
under review as circumstances change.
40. An escort risk assessment must be completed for every hospital escort and
healthcare staff must always be included in this process. If an emergency escort is
dispatched without a full escort risk assessment due to a life-threatening situation,
an emergency escort risk assessment must be completed, and the prisoner escort
record (PER) must be annotated with ‘no restraints to be used’ and the risk
assessment must be completed within 18 hours.
41. When Mr Stringer was escorted to hospital on 22 June 2024, an escort risk
assessment was not completed, and healthcare staff were not involved in the
decision to apply restraints. Therefore, the decision was solely based on perceived
risk and did not take his medical condition and ability to escape into consideration.
42. The Head of Security told us that as Mr Stringer went to hospital on an unplanned
emergency escort, there was not time to do a thorough risk assessment, which
would involve input from healthcare staff. However, Mr Stringer was admitted to
hospital with ongoing confusion and reduced mobility. Therefore, it was not a life-
threatening situation and healthcare staff were already present, so there was
sufficient time for a risk assessment to be completed and for healthcare staff to be
involved.
43. The CM was unable to recall how Mr Stringer was transported to the ambulance,
but he thought it was either by a wheelchair or stretcher. He told us that the only
situation where somebody would not be restrained was if the restraints impeded
medical treatment. He said that he was not aware that Mr Stringer had a personal
emergency evacuation plan in place or that he used a walking aid, however, that
would not stop him from applying restraints. He told us that mobility was not
something he factored into his decision unless the prisoner was completely unable
to move.
44. While the Head of Security confirmed that she had an understanding of the Graham
Judgment and had received training on it a long time ago, she said that further
training would be helpful, and the CM said he was not aware of it. This is
concerning, as we were told that all managers involved in the escort risk
assessment process would receive training on the Graham Judgment by February
2024. We were told that the escort risk assessment process would be reviewed by
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February 2024 to ensure that a prisoner’s medical condition is taken into
consideration. However, this has still not happened.
45. Additionally, Wormwood Scrubs did not use the current hospital escort risk
assessment template as outlined in the Prevention of Escape – External Escorts
July 2023 policy framework (annex H) which has a mandatory healthcare section.
46. The Deputy Head of Healthcare confirmed that as Mr Stringer went out on an
unplanned emergency escort, healthcare information would not be provided as part
of an escort risk assessment. She said in these cases, healthcare staff would only
provide a brief summary of the prisoner’s condition to the paramedics.
47. The CM and Head of Security were solely responsible for the decisions to apply
restraints for the escort risk assessments completed on 22 and 23 June. Without
input from healthcare staff, Mr Stringer’s current ability to escape was not assessed
and any medical objections to the use of restraints were not considered. This is the
case for all unplanned hospital escorts at Wormwood Scrubs. We therefore make
the following recommendations:
The Governor and Head of Healthcare should introduce a robust quality
assurance process to assure themselves that:
• in line with policy, a thorough escort risk assessment is completed for
every non-life-threatening emergency hospital escort;
• healthcare staff are routinely involved in the escort risk assessment
process, taking a prisoner’s current medical condition into
consideration, including how this impacts on their ability to escape;
• all staff involved in the escort risk assessment process receive training
on the Graham judgment and have a clear understanding of how it
applies to the Prevention of Escape - External Escorts policy
framework; and
• Staff are using the current escort risk assessment template, as outlined
in the policy framework.
Good practice
48. Wormwood Scrubs facilitated and paid for multiple visits between Mr Stringer and
his wife while he was in hospital. The family liaison officers also bought flowers and
a rose bush for his wife’s garden and helped scatter Mr Stringer’s ashes there.
Adrian Usher
Prisons and Probation Ombudsman March 2025
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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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