Ian Taylor

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Ian Taylor,
a prisoner at HMP Kirkham, on
23 August 2023
A report by the Prisons and Probation Ombudsman
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© Crown copyright, 2025
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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 Taylor died in hospital of acute left ventricular failure (heart failure) on 23 August
2023, while a prisoner at HMP Kirkham. He was 54 years old. I offer my condolences to Mr
Taylor’s family and friends.
The clinical reviewer concluded that the care Mr Taylor received at Kirkham was of a good
standard and equivalent to what he could have expected to receive 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 December 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. On 5 November 2021, Mr Ian Taylor was convicted of drug offences and sentenced
to 63 months in prison. He was sent to HMP Durham.
2. On 8 June 2023, Mr Taylor was transferred to HMP Kirkham.
3. Mr Taylor had a significant medical history. He was supported by the long-term
conditions clinic and was prescribed appropriate medication to manage his
conditions.
4. At 10.45am on 23 August, some prisoners found Mr Taylor unresponsive in his cell.
They alerted staff and an officer radioed a medical emergency code.
5. Prison staff and healthcare staff attended and started CPR. Control room staff
called the emergency services.
6. At 11.46am, paramedics arrived at the prison and took over Mr Taylor’s care. At
12.56pm, Mr Taylor was taken to hospital where he died shortly after his arrival.
Findings
7. The clinical reviewer concluded that the care Mr Taylor received at Kirkham was of
a good standard and equivalent to what he could have expected to receive in the
community.
8. She found that Mr Taylor was appropriately reviewed by the long-term condition’s
clinic for his underlying health conditions, and he was promptly referred to specialist
services.
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The Investigation Process
9. HMPPS notified us of Mr Taylor’s death on 23 August 2023.
10. The investigator issued notices to staff and prisoners at Kirkham informing them of
the investigation and asking anyone with relevant information to contact her. Six
prisoners responded and provided written statements.
11. The investigator obtained copies of relevant extracts from Mr Taylor’s prison and
medical records.
12. The investigator interviewed three members of staff at Kirkham on 12 October
2023.
13. NHS England commissioned a clinical reviewer to review Mr Taylor’s clinical care at
the prison. She conducted joint interviews with the investigator on the 12 October
2023.
14. We informed HM Coroner for Blackpool of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
15. The Ombudsman’s office contacted Mr Taylor’s wife to explain the investigation and
to ask if she had any matters she wanted us to consider. Mr Taylor’s wife was
concerned about the quality of care Mr Taylor received in prison. Her concerns
have been addressed in the clinical review.
16. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies, and this report has been amended
accordingly.
17. Mr Taylor’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP Kirkham
18. HMP Kirkham is a category D (open) prison holding male prisoners. It is managed
by HMPPS. Spectrum community health provide health and social care services.
HM Inspectorate of Prisons
19. The most recent inspection of Kirkham was in June and July 2018. Inspectors
reported that the prison continued to be an effective open prison. Health services
and governance were mostly good, as was health promotion. There was good
identification of complex conditions, and nurses with specialist training provided
clinics for most conditions.
Independent Monitoring Board
20. 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 December 2021, the IMB
reported that prisoners were treated fairly and humanely. The good links and
working relationships between all departments meant that the health and wellbeing
of the prisoners had been a priority.
Previous deaths at HMP Kirkham
21. Mr Taylor was the first prisoner to die at Kirkham since August 2020.
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Key Events
22. On 5 November 2021, Mr Ian Taylor was convicted of drug offences and sentenced
to 63 months in prison. He was 52 years old. Mr Taylor was sent to HMP Durham.
23. Mr Taylor had ongoing health issues, including asthma, chronic obstructive
pulmonary disease (COPD), obesity, hypertension, type two diabetes, fluid
retention, cellulitis (infection of the skin) and attention deficit hyperactivity disorder
(ADHD). He was prescribed appropriate medication to manage these conditions
and was managed by the long-term condition’s clinic.
24. On 8 June 2023, Mr Taylor was transferred to Kirkham.
25. A nurse completed Mr Taylor’s initial health screen. She noted that Mr Taylor had a
history of illicit drug use, anxiety, depression, and panic attacks. Mr Taylor said that
he had not used any illicit drugs in prison and had stopped taking his medication for
anxiety and depression. Mr Taylor agreed to engage with the drug and alcohol
recovery team. She referred Mr Taylor to the long-term condition’s clinic for
monitoring and oversight of his underlying health needs and she created a care
plan for his diabetes. He was reviewed regularly.
26. On 16 June, a nurse saw Mr Taylor and completed a QRISK2 cardiovascular 10-
year risk score (a tool used to calculate the likelihood of a person having a stroke or
heart attack within 10 years). Mr Taylor scored 25.41% (a score over 10% would
warrant some intervention and support).
27. On 6 July, the nurse saw Mr Taylor again to discuss his QRISK2 score. Mr Taylor
was offered and refused statin medication to reduce the risk of illness and
developing cardiovascular disease.
28. On 3 August, Mr Taylor was referred to the specialist weight management service
at the hospital. He was given an initial appointment for 19 September 2023.
29. On 16 August, a nurse saw Mr Taylor to review his legs as he had oedema (fluid
retention). Healthcare suspected that he had lymphoedema (long-term condition
that causes swelling in tissues) which is secondary to heart failure or other
circulatory diseases.
30. On 17 August, a GP at the prison saw Mr Taylor as his lymphoedema symptoms
were still present. Mr Taylor had normal heart sounds, clear lung fluids and no
abnormal lung sounds. The GP requested blood tests to determine whether Mr
Taylor had heart failure. The GP noted that he wanted to review the results of the
blood tests, but this was not completed prior to Mr Taylor’s death. Mr Taylor was
referred to the lymphoedema service the day before he died.
Events of 23 August 2023
31. In his written statement of 25 August 2023, a prisoner said that he went to Mr
Taylor’s door at approximately 8.50am, and he saw Mr Taylor sitting in his chair,
snoring. He left the cell and went back at 10.00am. He knocked on Mr Taylor’s
door, but Mr Taylor was still sitting in his chair asleep and snoring. When he went
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back to his door at approximately 10.45am, he knocked again but got no response.
He then approached two other prisoners and told them that he could not wake Mr
Taylor up.
32. The prisoners went to Mr Taylor’s cell and found that he was unresponsive. They
noticed that Mr Taylor was shaking, his head was tilted to one side and dribble was
coming from his mouth. The prisoners tried waking Mr Taylor by kicking his door,
and they went outside and shouted to him through his cell window, but he did not
respond. The prisoners pressed Mr Taylor’s emergency cell bell to alert staff and
two of them left his cell to find staff. At approximately 11.15am, the two prisoners
approached an officer and told her that Mr Taylor was unresponsive and not
breathing. The officer radioed a medical emergency code blue (indicating a prisoner
is unconscious or is having breathing difficulties).
33. Prison staff arrived at the cell and asked the prisoners to go back to their own cells.
34. A nurse arrived at the cell and radioed for urgent assistance from healthcare.
Another nurse responded and, when he entered Mr Taylor’s cell, he noticed a
quantity of illicit substances in his cell. He alerted prison staff and informed the
paramedics. The drugs were placed in an evidence bag and given to the police.
35. Mr Taylor was not breathing correctly, and there was limited space in his cell, so
four prison officers moved Mr Taylor from the chair to the floor outside of his cell so
there was more room to treat him.
36. At 11.41am, prison staff and healthcare staff commenced CPR. At 11.43am, staff
attached a defibrillator which advised no shockable rhythm. Staff continued with
CPR.
37. At 11.46am, the first response paramedic arrived and examined Mr Taylor while
prison and healthcare staff continued with CPR.
38. At 12.17am, more paramedics arrived and at 12.56pm, Mr Taylor was taken to
hospital by emergency ambulance. Two officers escorted him, and he was not
restrained. The allocated family liaison officer (FLO) also accompanied Mr Taylor to
the hospital due to his condition.
39. At 1.30pm, the FLO called the prison to inform them that Mr Taylor had died.
Events following Mr Taylor’s death
40. Lancashire police took the illicit drugs found in Mr Taylor’s cell as evidence and
conducted an investigation. The police concluded that the drugs found in Mr
Taylor’s cell were class B and class C drugs, which were consistent with quantities
for personal use. They noted that Mr Taylor’s cause of death was of natural causes,
and not drug related.
Contact with Mr Taylor’s family
41. While Mr Taylor was being escorted to hospital, a senior manager informed Mr
Taylor’s wife that he was on his way to the hospital and made arrangements to take
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her there. Unfortunately, Mr Taylor died before his wife arrived. The FLO offered her
condolences to Mr Taylor’s wife and provided on-going support.
42. The prison contributed to the funeral costs in line with prison policy.
Support for prisoners and staff
43. After Mr Taylor’s death, a senior manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
44. The prison posted notices informing other prisoners of Mr Taylor’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 by Mr Taylor’s death.
Post-mortem report
45. The post-mortem report gave Mr Taylor’s cause of death as acute left ventricular
failure (where the heart fails to deliver sufficient blood to vital organs). Hypertensive
heart disease (caused by unmanaged high blood pressure) and steatohepatitis (a
type of fatty liver disease) were contributing factors but did not cause his death.
46. The toxicology report showed Mr Taylor had low levels of buprenorphine and
pregabalin in his system at the time of his death. Mr Taylor was not prescribed
these medications at Kirkham.
47. At the inquest held on 6 December 2024, the coroner concluded Mr Taylor died of
natural causes.
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Findings
Clinical care
48. The clinical reviewer concluded that the care Mr Taylor received at Kirkham was of
a good standard and was equivalent to what he could have expected to receive in
the community.
49. She found that Mr Taylor was appropriately reviewed in the long-term condition’s
clinic for his underlying health conditions, and he was promptly referred to specialist
services when required. Mr Taylor was made aware of how to access healthcare if
he needed support, and he attended all his appointments with healthcare.
50. The clinical reviewer said that the emergency response on 23 August 2023, was
timely and well documented in Mr Taylor’s medical records.
51. We make no recommendations.
Good practice
52. Prison and healthcare staff demonstrated care and compassion during the
emergency response. Nurses ensured they continued to speak to Mr Taylor
throughout, so he heard their voices, and they held his hand until he was taken to
hospital.
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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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