Graham Daggett

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Independent investigation into
the death of Mr Graham
Daggett, a prisoner at HMP
Lincoln, on 3 April 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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
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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 Graham Daggett died in hospital of necrotising fasciitis (a bacterial infection of the soft
tissues), caused by a perianal abscess and metastatic pancreatic cancer (cancer that has
spread from the pancreas) on 3 April 2024, while a prisoner at HMP Lincoln. He was 56
years old. We offer our condolences to Mr Daggett’s family and friends.
Mr Daggett had been in severe pain and had abnormal blood tests before he went to
prison. Healthcare staff did not consult his community clinical record until his condition
drastically deteriorated the day before he died. It is unclear whether Mr Daggett required
support in making healthcare appointments since, despite being in considerable pain, he
had not applied to see healthcare staff as advised. The clinical reviewer found that Mr
Daggett’s healthcare was partially equivalent to that he would have received in the
community.
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 ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 8
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Summary
Events
1. Mr Graham Daggett had complained about severe pain to community GPs in the
months before going to prison. On 23 February 2024, Mr Daggett was sentenced to
6 months imprisonment and taken to HMP Lincoln. This was his first time in prison.
2. Mr Daggett had two healthcare screening appointments when he arrived in Lincoln,
but he did not report any pain other than knee pain. After that, he reported to feeling
in pain to different members of staff.
3. Healthcare staff saw Mr Daggett a few times and noted that his clinical observations
were normal.
4. On 3 April, Mr Daggett became unwell, staff called an ambulance and paramedics
took him to hospital. He was restrained with an escort cable which was removed
early the next morning. Mr Daggett died a few hours later of a bacterial infection
and cancer that had spread from his pancreas.
Findings
5. The clinical reviewer concluded that the clinical care Mr Daggett received at Lincoln
was partially equivalent to that which he could have expected to receive in the
community. The clinical reviewer made recommendations about the process of
making appointments with healthcare, checking a prisoner’s community clinical
record and record keeping.
6. Despite being in considerable pain, Mr Daggett had not tried to schedule an
appointment with healthcare staff. It is unclear whether he needed support to do
this, but we have concluded that he had opportunity to raise this with staff if he was
struggling to do so.
Recommendations
• The Head of Healthcare should carry out an audit to ensure that healthcare staff
appropriately consult prisoners’ full medical records when they raise concerns
about their health.
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The Investigation Process
7. HMPPS notified us of Mr Graham Daggett’s death on 3 April 2024. The investigator
issued notices to staff and prisoners at HMP Lincoln informing them of the
investigation and asking anyone with relevant information to contact her. No one
responded.
8. The investigator obtained and reviewed copies of relevant extracts from Mr
Daggett’s prison and medical records.
9. NHS England commissioned an independent clinical reviewer to review Mr
Daggett’s clinical care at Lincoln. The investigator and clinical reviewer interviewed
five members of staff in May and June.
10. We informed HM Coroner for Greater Lincolnshire of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
11. The Ombudsman’s office wrote to Mr Daggett’s next of kin to explain the
investigation and to ask if she had any matters she wanted us to consider. She told
us that Mr Daggett had filled in a complaint form, which he never submitted, and
that he told staff he was in severe pain. She asked why he had not been given pain
medication or diagnostic tests, and why information about his symptoms had not
been pieced together. These questions have been addressed in this report and the
clinical review.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy, and this report has been amended
accordingly.
13. Mr Daggett’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP Lincoln
14. HMP Lincoln holds remanded and convicted men, in four residential wings. It serves
the courts of Lincolnshire, Nottinghamshire, and Humberside. Nottinghamshire
Healthcare NHS Trust provides health services, with 24-hour nursing cover.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Lincoln was in December 2019 and January
2020. Inspectors reported that Lincoln was a much safer prison since the previous
inspection in 2017.
16. Inspectors noted that there had been an increase in healthcare staff, with regular
clinical supervision and training, as well as a systemic approach to learning lessons.
New prisoners received a comprehensive health screen and appropriate specialist
referrals.
Independent Monitoring Board
17. 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, from February 2023 to January 2024, the IMB
reported that reception and induction assessments were in place. They also found
that prisoners were treated fairly and humanely. The IMB noted that most of the
concerns reported to them were about healthcare management issues. They noted
that there was a shortage of healthcare staff and although waiting lists could be
long, those with urgent needs were assessed sooner.
Previous deaths at HMP Lincoln
18. Mr Daggett was the fifth prisoner to die at HMP Lincoln since April 2021. Of the
previous deaths, two were from natural causes and two were self-inflicted. There
were no similarities between the findings in our investigation into these previous
deaths and Mr Daggett’s death. Since Mr Daggett’s death and up to the end of
October 2024 there have been two further deaths. One of these was self-inflicted
and the cause of the other one is so far unascertained.
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Key Events
Background
19. In January 2024, Mr Graham Daggett’s medical record notes that he had several
appointments with different community GPs (as he was of no fixed abode). He said
he had been very unwell for 18 months, was in pain, felt sick and thought something
was wrong with his digestive system. Examinations revealed a lump in his
abdomen, and blood tests were abnormal and required follow up tests for cancer.
Due to staff not being able to contact Mr Daggett or him moving area these tests did
not occur. Mr Daggett’s pre-sentence report, completed on 20 February 2024, notes
that Mr Daggett said he was in constant agony and rated his pain as ten out of ten.
HMP Lincoln
20. On 23 February, Mr Daggett was sentenced to six months imprisonment for assault.
He was taken to HMP Lincoln. It was his first time in prison. During his initial
healthcare screening, he did not tell staff about any health concerns other than
knee pain for which he was given ibuprofen (a painkiller).
21. On 28 February, Mr Daggett attended his second healthcare screening with a
nurse. Again, he only spoke about his chronic knee pain. The nurse told Mr Daggett
how he could make healthcare appointments. In interview, the nurse said that Mr
Daggett did not tell him that he had recently seen his GP or had tests. He said that
he would have read his community medical record had he been aware of this.
22. On 4 March, prison staff called healthcare staff to see Mr Daggett as he said he
was in pain and short of breath. A nurse assessed Mr Daggett and did not identify
any urgent concerns. His physical observations were normal. She noticed that the
room was hot and Mr Daggett was wearing a jumper and she advised him to take
off the jumper and open the window. She noted that she would put him on the
nurses’ list to be seen later that day. (After he died, a complaint form was found in
Mr Daggett’s cell relating to this interaction. He claimed that he had been called ‘a
lying hypochondriac’ and that at the time he was seen, he was feeling cold. Mr
Daggett had also written that he had been in excruciating pain for the previous 20
months. He did not submit the complaint.)
23. Later that day, a paramedic who worked in the prison assessed Mr Daggett and
noted that he got up without difficulty, was breathing normally and had a good skin
colour. His physical observations were normal. Mr Daggett told him that he had had
dull aches all over his body for nearly two years and he had seen several
community GPs but had not received a diagnosis. The paramedic consulted Mr
Daggett’s summary care record (SCR – a database containing clinical information
about a patient such as medications and allergies) but this did not contain
information about his recent GP appointments or blood tests. He told Mr Daggett to
request a GP appointment.
24. On 6 March, Mr Daggett told a chaplain from the chaplaincy department that he was
in pain in his upper body and needed medication to relieve this. The chaplain sent
an email to healthcare staff and to the wing managers. He also spoke to an officer
on the wing, who said he would get Mr Daggett to the medication hatch. On 7
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March, healthcare staff emailed the chaplain to say that Mr Daggett had been seen
by a nurse. There is no note in Mr Daggett’s medical record that he attended the
hatch, was seen by healthcare staff or received any pain medication.
25. On 17 March Mr Daggett met his keyworker for the first time. He said he had not
been feeling well since arriving at Lincoln and was waiting for healthcare to follow
up with appointments for his treatment. She told Mr Daggett that it may take a little
while, but if healthcare staff did not contact him soon he should submit a healthcare
application or use the red phone (a phone which can be used by prisoners to call
healthcare).
26. In interview, the Clinical Matron told us that there was no record of Mr Daggett
using the red phone to contact healthcare, nor was there any record that he had
submitted applications to make healthcare appointments during his time at Lincoln.
27. On 19 March, Mr Daggett did not feel well enough to attend work. An entry on the
prison system says that a staff contacted healthcare staff on his behalf, but there is
no record of what was discussed.
28. On 21 March, the keyworker had a second key worker session with Mr Daggett.
She noted that there was no change in his circumstances and he had no further
concerns.
29. On 27 March, healthcare staff gave Mr Daggett two paracetamol. There is no
reason recorded as to what this was for. He later told his keyworker that he felt
constantly sick and had not been going to education as he could not manage the
stairs. He said he had tried to book appointments with healthcare but had not heard
back yet. They spoke about his release. He said he needed to speak to his sister
but had no money for telephone credit to call her. There is no recorded follow up
action from this conversation and Mr Daggett only made one 43 second call in early
March. He did not have any telephone credit when he died. Lincoln explained that
prisoners are given at least £2.50 every week which they can use towards phone
credit. They can also send free letters to their family. This is explained to prisoners
during induction.
30. On 2 April at 3.41am, Mr Daggett fell out of his bed. Healthcare staff attended and
he reported always feeling dizzy. A nurse noticed that his hand was swollen and
had some signs of jaundice. Mr Daggett’s pulse and respiratory rates were raised.
After seeing Mr Daggett, the nurse reviewed his past medical record and noted that
Mr Daggett had some abnormal blood test results when he was in the community.
He booked an urgent GP assessment for later that day and requested that Mr
Daggett had urgent blood tests. Mr Daggett was seen four times that day by
medical staff but not by a GP as there was none available. Mr Daggett had urgent
blood tests done.
31. At 8.30pm, prison staff found Mr Daggett on the floor of his cell. He told them he
had fallen. Prison staff asked for healthcare support urgently. Two nurses went to
see Mr Daggett and struggled to get a definitive reading of his blood pressure and
oxygen saturation. During their assessment, prison staff were called to a different
location to deal with an emergency. Both nurses had to leave the cell as they could
not remain inside without prison staff present. They remained at the cell door and
continued to observe Mr Daggett through the observation panel.
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32. Prison staff returned ten minutes later. They unlocked the cell and the nurses
further assessed Mr Daggett. His blood pressure was normal but his oxygen
saturation was low. They administered oxygen and noted that his pulse was also
slow. Mr Daggett’s National Early Warning Score (NEWS2 – used to determine the
urgency of response needed) was eight, which meant that Mr Daggett needed an
urgent response. A nurse asked officers to urgently request an ambulance.
33. The ambulance arrived prison at 9.58pm, paramedics assessed and treated Mr
Daggett and took him to hospital at around 11.00pm.
34. As part of the process for Mr Daggett to leave prison, a Custodial Manager (CM)
completed an emergency escort risk assessment. He had seen Mr Daggett in his
cell and then left to complete the risk assessment. He noted that Mr Daggett’s
health situation did not have an impact on his mobility to escape and that there
were no medical objections to the use of restraints. In interview, he explained that
Mr Daggett’s health situation was unclear. A nurse said in interview that she did not
input in the risk assessment (there is no space on the form for her to do so). She
said that since she did not know what was wrong with Mr Daggett, she did not know
if his condition would improve or deteriorate and would not have objected to the use
of restraints in any case. Due to time constraints, the CM did not have any security
information, so he assessed that Mr Daggett should be escorted by two officers and
restrained by a single cuff (when a standard handcuff has one end attached to the
prisoner’s wrist and the other is attached to a prison officer).
35. When the CM saw Mr Daggett being taken to the ambulance on a stretcher, he
thought that he would need paramedics to treat him in the ambulance, so he
decided to authorise the use of an escort cable instead (a long cable with a
handcuff at each end, one of which is attached to the prisoner and the other to an
officer).
36. Once Mr Daggett arrived hospital, staff removed his restraints at 2.15am for ten
minutes because Mr Daggett needed a CT scan.
37. At 2.52am on 4 April, Mr Daggett went into cardiac arrest. The officers with him
removed the restraints so that medical staff could treat Mr Daggett. At 11.10am, Mr
Daggett died.
Contact with Mr Daggett’s family
38. The CM contacted Mr Daggett’s next of kin once Mr Daggett went to hospital.
Hospital staff also contacted the next of kin to discuss Mr Daggett’s condition. Mr
Daggett’s family arrived at the hospital at 5.30am and were with him when he died.
39. The CM appointed a family liaison officer, who went to the hospital before Mr
Daggett’s death and stayed in contact with the family in the weeks afterwards. In
line with national instructions, the prison contributed to the cost of Mr Daggett’s
funeral.
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Support for prisoners and staff
40. After Mr Daggett’s death, staff involved in the emergency response were not offered
a debrief to ensure they had the opportunity to discuss any issues arising, and to
offer support. The prison posted notices informing staff and other prisoners of Mr
Daggett’s death and offering support.
Post-mortem report
41. The post-mortem report concluded that Mr Daggett died of necrotising fasciitis
caused by perianal abscess and metastatic pancreatic cancer.
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Findings
Clinical Care
42. The clinical reviewer concluded that Mr Daggett’s care was partially equivalent to
that he which he would have received in the community. She concluded that
healthcare screenings occurred according to guidelines. She also found that when
nurses became aware that Mr Daggett was acutely unwell on 2 April, they read his
previous medical records, ordered urgent blood tests and ultimately requested his
transfer to hospital.
43. However, healthcare staff were unaware of Mr Daggett’s abnormal blood tests and
interactions with community GPs before coming into prison until they read his
records when he became acutely unwell on 2 April. The Head of Healthcare said
that this was appropriate unless there was a reason to review these records. The
clinical reviewer concluded that the prison paramedic should have reviewed Mr
Daggett’s record on 4 March when he said he had been suffering pain for a long
time. However, she recognised that Mr Daggett did not appear to be acutely unwell
during this assessment and he was advised to see a GP. We endorse and recast
the clinical reviewer’s recommendation that:
The Head of Healthcare should carry out an audit to ensure that healthcare
staff appropriately consult prisoners’ full medical records when they raise
concerns about their health.
44. The clinical reviewer also raised concerns in relation to communication between
healthcare and prison staff which we discuss further below. She made further
recommendations about record keeping which the Head of Healthcare will wish to
address.
Making healthcare appointments
45. Before receiving his prison sentence, Mr Daggett had, over a period of months,
reported considerable pain to community healthcare staff and required urgent
further tests. He also told the probation practitioner who completed his pre-sentence
report. However, he did not report this pain to nurses who completed both his health
screenings when he arrived at Lincoln. We do not know why Mr Daggett did not tell
the nurses about his history of pain but as a result, and in line with local practice,
the nurses did not check his community GP records - where they would have been
able to see recent abnormal blood tests and follow ups that were outstanding.
46. During his time in prison, Mr Daggett said he was in pain to several staff. He was
told to schedule healthcare appointments. His keyworker also explained he could
use the red phone to call the healthcare department, if he did not hear from them.
47. On 6 March, chaplaincy staff told healthcare staff and wing staff that Mr Daggett
was in pain. On 7 March, healthcare staff responded that Mr Daggett he had been
seen by nurses. There is no record of him seeing healthcare staff that day and it is
unclear if this referred to an earlier interaction he had with healthcare staff.
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48. On 19 March, Mr Daggett told prison staff he was in pain. They noted that they told
healthcare staff but this is not noted on the clinical record nor was there any follow-
up action. On 27 March, Mr Daggett told his keyworker that he constantly felt sick
and had asked for healthcare appointments, but that he had not heard back from
them. The CM told us that the role of key workers is to signpost prisoners to
services, and he would not expect keyworkers to routinely schedule healthcare
appointments.
49. Various staff had explained to Mr Daggett how to book healthcare appointments
and there is no specific information suggesting he required extra support in
scheduling these. However, healthcare staff had not received any applications for
appointments from Mr Daggett. It is unclear whether Mr Daggett genuinely thought
he had requested healthcare appointments and therefore did not properly
understand the process that had been explained to him, or whether he was aware
that he had not. Either way, we conclude that he had opportunity to raise any
concerns he had about making appointments with staff and we are satisfied that
they supported him appropriately.
Governor and Head of Healthcare to note
Staff debrief
50. Both prison and healthcare staff said that they were not given the opportunity to
attend a debrief after Mr Daggett died. We bring this to the Governor and Head of
Healthcare’s attention.
Adrian Usher
Prisons and Probation Ombudsman January 2025
Inquest
The inquest hearing was held on 22 January 2025. The Coroner concluded that Mr
Daggett died of natural causes.
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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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