Ian Deavall

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Independent investigation into
the death of Mr Ian Deavall, a
prisoner at HMP Forest Bank,
on 24 January 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, 2024
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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 Ian Deavall died of ischaemic heart disease on 24 January 2023, while a prisoner at
HMP Forest Bank. He was 65 years old. I offer my condolences to Mr Deavall’s family and
friends.
Mr Deavall died less than three weeks after he arrived in prison. The clinical reviewer
concluded the physical healthcare provided to him at Forest Bank was of a mixed standard
and not wholly equivalent to that which he could have expected to receive in the
community. Mr Deavall had a history of heart disease and, despite concerns about his
physical health and requests for follow-up care, he was not clinically monitored in the time
before his death, contrary to GP instructions.
The investigation also identified several issues with the management of the emergency
response.
Adrian Usher
Prisons and Probation Ombudsman March 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 7 January 2022, Mr Ian Deavall was remanded in prison for sexual offences and
taken to HMP Forest Bank.
2. Mr Deavall had a long history of heart disease. He was examined on reception, his
health conditions noted, and he was prescribed his usual medications.
3. On 11 January, Mr Deavall told staff that he felt unwell. He was seen by a nurse
after he had vomited, but his clinical observations were normal. The next day a
nurse and GP reviewed Mr Deavall and requested further tests. The GP also asked
that healthcare staff monitor Mr Deavall. He was given another appointment with a
GP for the next day, and it was noted that he would need to be taken to the
healthcare centre in a wheelchair as he was too physically unwell to walk. Mr
Deavall did not attend this appointment and there is no evidence that staff followed
up on his non-attendance. There was no evidence that further clinical observations
were completed.
4. On 24 January, Mr Deavall’s cellmate pressed the emergency cell bell to alert staff
that he was unresponsive. Staff entered the cell and, despite resuscitation efforts, a
prison GP declared Mr Deavall had died at 11.10am.
Findings
5. The clinical reviewer concluded that the physical healthcare that Mr Deavall
received at Forest Bank was not wholly equivalent to that which he could have
expected to receive in the community. Despite a GP requesting blood tests, an X-
ray, and an ECG, none of these were completed. There is no evidence Mr Deavall
had clinical observations between 15 January and his death.
6. When Mr Deavall was discovered unresponsive, a medical emergency code was
not immediately called, and officers did not start CPR until a nurse arrived. Control
room staff did not call for an ambulance immediately when a medical emergency
code was radioed.
Recommendations
• The Head of Healthcare should ensure that there are robust communication and
administrative processes to handover prisoner healthcare information and ensure
that all clinical requests are completed in a timely manner.
• The Director and Head of Healthcare should ensure that:
• control room staff call for an ambulance immediately when a medical
emergency code is called; and
• staff facilitate the access of ambulances and paramedics through the prison
gate to ensure there are no unnecessary delays.
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The Investigation Process
7. We were notified of Mr Deavall’s death on 24 January 2023.
8. The investigator issued notices to staff and prisoners at HMP Forest Bank informing
them of the investigation and asking anyone with relevant information to contact
her. Nobody responded.
9. The investigator obtained copies of relevant extracts from Mr Deavall’s prison and
medical records.
10. NHS England commissioned a clinical reviewer to review Mr Deavall’s clinical care
at the prison. The clinical reviewer and investigator jointly interviewed six healthcare
and prison staff in March 2023. The investigator also interviewed Mr Deavall’s
cellmate, an officer, the Head of Residence, and the Safer Custody Manager. The
prisoner who conveyed the message to staff that Mr Deavall was unwell declined to
be interviewed.
11. We suspended our investigation between 29 March and 27 September, awaiting Mr
Deavall’s cause of death.
12. We informed HM Coroner for Greater Manchester West of the investigation. He
gave us the cause of death. We have sent the Coroner a copy of this report.
13. The Ombudsman’s family liaison officer (FLO) wrote to Mr Deavall’s son, his
nominated next-of-kin, to explain our investigation and to ask if there were any
matters he wanted us to consider. He had no specific questions.
14. Mr Deavall’s wife contacted the Ombudsman’s FLO. She wanted to know if Mr
Deavall received appropriate care for his physical health and if the prison were
aware of his medical history, which we address in this report. Other questions she
asked were outside the remit of this investigation.
15. Mr Deavall’s family received a copy of the initial report. They did not identify any
factual inaccuracies.
16. The prison also received a copy of the report. They did not identify any factual
inaccuracies.
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Background Information
HMP Forest Bank
17. HMP Forest Bank holds adult men both on remand and sentenced and young
prisoners between the ages of 18-21. The prison serves the courts of Greater
Manchester and has an operational capacity of 1,460.
18. The prison is managed and run by Sodexo Limited, who were also responsible for
the provision of primary healthcare services, including primary mental health
services, inpatient facilities, and substance misuse services within the prison.
Spectrum Community Health became the primary healthcare provider on 1 April
2023.
HM Inspectorate of Prisons
19. The most recent inspection of HMP Forest Bank was in February 2022. Inspectors
noted that in late 2021, HM Prison and Probation Service (HMPPS) was forced to
issue Sodexo with a formal rectification notice over their concerns about the safety
of prisoners and the conditions in which they were being held. Inspectors reflected
this was a concerning step, but there was clear evidence that the company had
responded quickly and positively. New priorities focused on improving safety had
been identified, but still needed more development to ensure their implementation
was sufficiently robust. Inspectors found more also needed to be done to make sure
newly received prisoners were properly supported and inducted.
20. All new arrivals had a health screening and a COVID-19 risk assessment. The GP
and substance misuse team reviewed patients with more complex needs on their
first night, which was positive. Inspectors found that patients had good access to
urgent same-day GP appointments and non-urgent appointments within 10 days,
which was good. Inspectors found that medicines administration was appropriately
recorded. Reasons for non-attendance were not always recorded, but prisoners
who did not attend were consistently followed up.
21. In January 2023, inspectors completed an independent review of progress at Forest
Bank. They found that improvements had been made to early days processes,
although time out of cell for vulnerable prisoners in their first days in prison
remained poor.
Independent Monitoring Board
22. 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 31 October 2021, the IMB found
the healthcare team had worked extremely hard in difficult conditions to deliver a
service that is, possibly, in the current circumstances, better than what is available
to the general public.
Previous deaths at HMP Forest Bank
23. Mr Deavall was the fourteenth prisoner at Forest Bank to die since January 2020.
Of the previous deaths, eight were from natural causes, two were self-inflicted and
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three were drug related. There have been two natural cause deaths since. We have
previously recommended that control room staff request an ambulance as soon as
a medical emergency is radioed.
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Key Events
24. On 6 January 2023, Mr Ian Deavall was repatriated to the UK from America having
spent several months in a Florida prison. On 7 January, he appeared at Manchester
Magistrates’ Court and was remanded in prison for sexual offences. Mr Deavall was
taken to HMP Forest Bank and was due to appear in court again on 10 February.
As it was his first time in prison in the UK, prison staff started suicide and self-harm
prevention procedures (known as ACCT) when Mr Deavall arrived at Forest Bank.
25. At his initial health screen, a nurse noted Mr Deavall’s physical health history; heart
disease (which included having stents fitted to increase the flow of blood), high
blood pressure, high cholesterol and that he had previously had a mini stroke.
Healthcare staff obtained his medical records, which confirmed his medical history.
All his clinical observations were noted to be within normal parameters. Mr Deavall
did not have a history of mental health issues or substance misuse.
26. A GP at Forest Bank reviewed Mr Deavall and prescribed the medications to
manage his physical health conditions. Mr Deavall was not allowed to have his
medication in possession and needed to collect it each day from the medications
hatch on the wing. Staff allocated Mr Deavall a cell on E Wing.
27. On 8 January, Mr Deavall had his second stage health screen. A nurse identified
that he had a stent and no outstanding hospital or doctor appointments.
28. On 11 January, wing staff asked healthcare to assess Mr Deavall as he said that he
was unwell and had vomited. At 4.40pm, a nurse went to Mr Deavall’s cell and took
his clinical observations; all were within normal parameters although his blood
pressure was a little low. She returned 45 minutes later and repeated clinical
observations and noted Mr Deavall’s blood pressure had improved slightly. The
nurse recorded that there were no immediate concerns and Mr Deavall was
prescribed anti-sickness medication and paracetamol. She requested that Mr
Deavall was monitored during the night. A nurse did review him and noted that Mr
Deavall said he felt much better. He was added to the healthcare list to be reviewed
the next day.
29. On 12 January, a nurse went to see Mr Deavall in his cell. He said he had vomited
again several times during the night and was not able to keep food down. She
referred Mr Deavall to the GP to investigate further.
30. Later the GP visited Mr Deavall in his cell with a healthcare assistant. The GP
prescribed antibiotics for a possible chest infection and noted that blood tests, a
chest X-ray and an ECG (electrocardiogram which records how the heart is
functioning) should be requested. He stopped one of Mr Deavall’s heart
medications, as it also reduced blood pressure. He prescribed an anti-sickness
medication. He tasked his GP colleague with reviewing Mr Deavall the next day and
requested that a nurse should list him for the outstanding tests. He documented that
Mr Deavall would require a wheelchair to convey him to his follow-up appointment
because he was weak and unable to walk.
31. On 13 January, another GP noted in Mr Deavall’s medical record that he did not
attend the clinic appointment and so he would be re-listed, but there is no evidence
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this happened. There is also no evidence that the outstanding tests were completed
or that Mr Deavall’s clinical observations were monitored.
32. On 15 January, Mr Deavall told prison staff he felt weak, dizzy, and had been
vomiting. Wing staff contacted healthcare and a nurse examined Mr Deavall in his
cell. His clinical observations were within normal parameters, although his blood
pressure was again a little low. The nurse noted that Mr Deavall’s blood pressure
was being monitored regularly due to a change in his medication and that he had
been added to the GP list as he had failed to attend his last appointment. There is
no evidence that Mr Deavall saw a prison GP or had his physical observations
checked between 15 January until the emergency response on 24 January.
33. On 23 January, during an ACCT case review, Mr Deavall said that he was unable to
get up out of bed, that he had an ongoing headache and that he felt dizzy when he
sat up. A mental health nurse who attended the review recorded in Mr Deavall’s
medical record that she had asked the wing manager to contact the duty nurse to
ask them if they were aware of his health issues and to review Mr Deavall. She also
noted that he was due to have blood tests later in the day. There is an entry which
recorded that Mr Deavall refused to attend for these blood tests and for his weight
and blood pressure monitoring. There is no evidence that a wheelchair was
considered to take Mr Deavall to his appointment and no record of why he refused
to attend the appointment.
34. Between 7 and 24 January, Mr Deavall made two calls to his son, totalling around
24 minutes. The investigator listened to these calls, during which Mr Deavall told his
son that he felt unwell and weak. (All prisoners’ telephone calls, except those that
are legally privileged, are recorded, and prison staff listen to a random sample.)
Events of 24 January
35. CCTV shows that a group of prisoners on E Wing (including Mr Deavall and his
cellmate) were unlocked at around 7.26am for morning association and locked in
their cells around an hour later. Mr Deavall did not leave the cell, but his cellmate
did.
36. Mr Deavall’s cellmate said that at around 10.25am, Mr Deavall got up to use the
toilet. He said he was surprised that Mr Deavall made his own way and did not ask
for help as he usually did. He said Mr Deavall had been on the toilet for around five
minutes when he asked if he was okay, and Mr Deavall ‘grunted’ in reply. Five
minutes later, he said he checked on Mr Deavall but did not get a response. He
went over and could see that he was breathing, but not responding. He said he
moved Mr Deavall while he was still sat on the toilet to prop him up against the wall,
so he did not fall.
37. At 10.52am, Mr Deavall’s cellmate pressed the emergency cell bell. (When an
emergency bell is pressed, a light comes on outside the cell and there is an audible
noise in the wing office; HMPPS policy instructs that staff should respond promptly.)
38. Mr Deavall’s cellmate told us that the cell bell was answered by a wing cleaner
(another prisoner). He asked him to get a nurse as his cellmate was unwell and the
cleaner said he would go to the office to alert staff. CCTV shows one of the
cleaners went over to the cell briefly before switching off the cell bell. He returned to
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chat with two other prisoners on the wing and, around a minute later, he got up and
walked to the wing office, where he spoke to staff for about 30 seconds.
39. Just before 10.56am, a Senior Prison Custodial Officer (SPCO) went to Mr
Deavall’s cell. She unlocked the door, looked into the cell, and let Mr Deavall’s
cellmate out. The SPCO said Mr Deavall was sat on the toilet and was
unresponsive. She did not check for a pulse and said that she radioed a code blue.
(Code blue is medical emergency code used to indicate that a prisoner is
unconscious or having breathing difficulties. The control room does not have a
record of the SPCO’s first radio call.) The SPCO said that she did not think staff had
heard her radio transmission, so she locked the cell door and walked back to the
wing office to get assistance. Around a minute later she returned to the cell and
went in with a Prison Custody Officer (PCO). At 10.57am, the SPCO radioed a code
blue, which was logged by the control room. Ambulance records and the prison’s
communications log show that a request for an emergency ambulance was made at
11.02am, five minutes later.
40. At 10.58am, healthcare staff arrived at Mr Deavall’s cell carrying emergency
medical equipment. Staff moved Mr Deavall to the landing where there was more
space and they started cardiopulmonary resuscitation (CPR). A defibrillator was
attached to him which indicated there was no shockable rhythm. A GP also
responded to the emergency and, at 11.10am, he pronounced that Mr Deavall had
died. Paramedics arrived at Forest Bank at 11.07am and reached Mr Deavall just
before 11.15am.
Contact with Mr Deavall’s family
41. The prison’s family liaison officer and her deputy were appointed. They travelled to
the home of Mr Deavall’s son, who he had listed as his next of kin, to break the
news of his death. Mr Deavall’s funeral took place on 3 March 2023. The prison
contributed to the costs in line with national policy.
Support for prisoners and staff
42. After Mr Deavall’s death, the Director debriefed many of the prison and healthcare
staff who responded to the emergency to ensure that they had the opportunity to
discuss any issues arising, and to offer support. Healthcare held a separate debrief
for all healthcare staff who responded.
43. The prison posted notices informing other prisoners of Mr Deavall’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected. A chaplain provided individual
support to Mr Deavall’s cellmate.
Post-mortem report
44. The post-mortem report concluded that the cause of Mr Deavall’s death was
ischaemic heart disease.
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Findings
Clinical care
45. The clinical reviewer concluded that Mr Deavall received a mixed standard of care
which was not wholly equivalent to the healthcare which he could have expected to
receive in the community. We do not repeat all the recommendations in the clinical
review report, but they should be addressed by the Head of Healthcare.
Assessment of Mr Deavall’s physical health
46. When Mr Deavall complained of feeling unwell on 11 January, healthcare staff
responded quickly, and he was later assessed in his cell. A GP saw him the next
day, reviewed his medication and referred Mr Deavall for further tests. The clinical
reviewer concluded the decision to stop one of Mr Deavall’s medications, which
could have further reduced his blood pressure, was the correct clinical decision.
47. Despite the GP requesting ongoing review of Mr Deavall’s clinical observations,
blood tests, a chest X-ray and heart monitoring, these did not happen. The GP also
noted that Mr Deavall would need to be taken by wheelchair to the healthcare
centre for follow up appointments, but there is no evidence this was facilitated. Mr
Deavall was noted to have “refused” to attend. It is possible that he was not
physically well enough to attend, but no one recorded a reason and the clinical
reviewer found that the Head of Healthcare was unable to provide any further
explanation. There is also no evidence his non-attendance was followed up. Mr
Deavall was not examined or assessed by healthcare staff after 15 January.
48. During his ACCT review on 23 January, a mental health nurse noted that Mr
Deavall was “unable to get up out of bed ... states he has an ongoing headache and
when he sits up, he feels dizzy”. The mental health nurse asked the chair of the
ACCT review to contact the duty primary care nurse to review him, but there is no
evidence this happened. We would have expected the mental health nurse to have
contacted the duty nurse herself, as the issue related to healthcare, rather than
expect prison staff to do this.
49. We found that the healthcare Mr Deavall received at Forest Bank was disjointed
and requests were not followed up, which resulted in him having no contact with
healthcare staff specifically about his physical health in the eight days before he
died. We make the following recommendation:
The Head of Healthcare should ensure that there are robust communication
and administrative processes to handover prisoner healthcare information
and ensure that all clinical requests are completed in a timely manner.
Emergency response
50. PSI 03/2013, Medical Emergency Response Codes, requires all prisons to have a
medical emergency response code protocol in place, the purpose of which is to
ensure a timely, appropriate, and effective response to medical emergencies. When
a medical emergency is discovered, staff should call the appropriate medical
emergency code straightaway so that relevant staff, including healthcare staff, are
alerted, the correct equipment is brought, and an ambulance is called immediately.
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Ambulance delays
51. When the emergency code was radioed, the control room did not immediately
request an ambulance (there was a delay of around five minutes), something we
have identified in a previous investigation. Forest Bank responded to our previous
recommendation and issued a Directors Instruction which included that it was a
mandatory requirement for the communication room to call an ambulance
immediately to attend the establishment as soon as a code is called. This has
clearly not been sufficient, and the prison need to do more to ensure staff are aware
of their responsibilities.
52. Paramedics noted on the ambulance record that once they had reached Forest
Bank, they were delayed reaching Mr Deavall due to “security procedures at the
prison”. The first ambulance arrived 11.07am, but did not arrive on E Wing until
around six minutes later.
53. Director’s Instruction No.10 (dated March 2022) says that the Gatehouse should
“prepare to receive the ambulance”. It does not provide any further detail of what
this entails. While we appreciate that Forest Bank is a large site and several
security gates need to be accessed, any delays can be crucial.
54. We recommend that:
The Director and Head of Healthcare should ensure that:
• control room staff call for an ambulance immediately when a medical
emergency code is called; and
• staff facilitate the access of ambulances and paramedics through the
prison gate to ensure there are no unnecessary delays.
Director and Head of Healthcare to note
Resuscitation
55. A nurse said that when she arrived at his cell, Mr Deavall was still sat on the toilet,
and she asked for him to be moved out of the cell onto the landing so there was
more room to start resuscitation. The nurse said officers seemed unsure about what
to do and so CPR was not started until she and her colleagues arrived, a delay of
around one minute. When the SPCO entered Mr Deavall’s cell, she said she was
unsure whether he had a pulse but did not check. She said Mr Deavall was very
heavy and would have been difficult to move on her own. She said she did not feel
confident enough to start CPR and believed that Mr Deavall was dead. An officer
who assisted with moving Mr Deavall to the landing said he did not check for a
pulse or start CPR but did not think Mr Deavall was dead.
Any delay did could be critical in future emergencies and it is important that staff are
aware of their responsibilities.
Administered medication during resuscitation
56. The clinical reviewer found that once resuscitation had started, it was well
coordinated by healthcare staff. However, an emergency response nurse
administered 300mcg of adrenalin, via an EpiPen (usually used for an allergy
response), into Mr Deavall’s thigh (intramuscular). While this medication would have
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caused no adverse effect, adrenaline was administered inappropriately. The nurse
was also not up to date with Immediate Life Support (ILS) training, which should
have been completed before she was assigned the role of emergency response
nurse.
57. The emergency response nurse was suspended by Sodexo Healthcare on 19
March 2023, pending an investigation. She resigned from her post on 23 March.
Body Worn Video Cameras
58. PSI 04/2017, Body Worn Video Cameras (BWVC), requires prison staff to use
BWVCs during any reportable incident, including medical emergencies. It requires
staff to start recording at the earliest opportunity, to maximise the material captured
by the camera. BWVC’s are an important source of evidence for PPO
investigations, and wider learning for prisons following an incident.
59. Body worn video cameras were not activated when Mr Deavall was discovered
unresponsive. We recognise that during an emergency event staff might forget to
switch on their cameras, but someone managing the incident should have reminded
staff this was necessary. The Director has since reminded operational staff that
BWVC must be activated when responding to an incident.
Updating the ambulance service
60. A second ambulance arrived at Forest Bank around nine minutes after Mr Deavall
had been declared dead. We found no evidence that anyone considered updating
the control room with the change in Mr Deavall’s status so they could inform the
ambulance service. Given the pressure on ambulance service resources it is
important staff consider updating the ambulance service.
Response to cell bells
61. When Mr Deavall’s cellmate used the emergency cell bell to alert staff that he was
unwell, a prisoner switched off the bell from outside of the cell.
Inquest
62. The inquest into Mr Deavall’s death concluded in September 2024, and that he died
due to ischaemic heart disease. The inquest found that Mr Deavall died because of
a naturally occurring cardiac arrest. There was an admitted failure to arrange for
him to be sent to hospital between 20 and 24 January for assessment however, on
the balance of probabilities, this did not cause or contribute to his death.
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