James Kiteley

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr James Kiteley,
a prisoner at HMP Sudbury,
on 5 June 2021
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr James Kiteley died on 5 June 2021, having been found unresponsive in his room in
HMP Sudbury. Post-mortem examinations concluded that he died from an overdose of
propranolol (a beta-blocker) and cocaine use. Mr Kiteley was 46 years old. I offer my
condolences to Mr Kiteley’s family and friends.
The investigation did not find any evidence to suggest that staff should have suspected the
Mr Kiteley was misusing drugs before he died. However, I share the clinical reviewer’s
concerns about the risk assessment for Mr Kiteley to hold his own medication and the lack
of a mental health care plan.
I am also concerned that Mr Kiteley appears to have been able to access illicit drugs while
a prisoner at Sudbury, although I note the proactive steps that the prison is taking to tackle
and reduce their supply.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman February 2022
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 9
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Summary
Events
1. In February 2017, Mr James Kiteley was sentenced to six years and eight months in
prison. He had a history of anxiety and depression, and alcohol misuse.
2. In April 2021, Mr Kiteley transferred to HMP Sudbury, an open prison. He was
anxious about being in open conditions. He was prescribed medication for anxiety
and was told about substance misuse services at the prison. A nurse assessed that
it was safe for Mr Kiteley to have his medication with him in his room.
3. After initially refusing to engage with substance misuse services, Mr Kiteley
eventually worked with them and with the mental health team. He said he was
having some difficulty adjusting to open conditions but was preparing for release
from prison. He continued to express anxiety at times but could also be positive
about the future.
4. On the night of 4 June, Mr Kiteley’s room-mate said they watched a film and then
went to sleep. His room-mate awoke at approximately 4.00am and said he heard
Mr Kiteley snoring. When a prison officer made a roll check on the morning of 5
June, Mr Kiteley was unresponsive. The officer called an emergency medical code,
prompting the control room to call for an ambulance. Officers attempted to
resuscitate Mr Kiteley, despite signs of rigor mortis. They continued until
ambulance paramedics arrived and confirmed that Mr Kiteley had died.
5. Post-mortem tests showed that Mr Kiteley died as a result of an overdose of
propranolol (which he was prescribed) and cocaine use.
Findings
Substance misuse
6. Mr Kiteley had a background of substance misuse. He worked with substance
misuse services at Sudbury and told his offender supervisor that he was determined
not to misuse drugs again. We are satisfied that there were no signs or intelligence
that Mr Kiteley was misusing drugs before he died.
7. We are concerned that Mr Kiteley could access drugs within the prison with
apparent ease, although we note the proactive steps the prison is taking to try to
address this problem.
Mr Kiteley’s clinical care
8. The clinical reviewer concluded that, overall, the healthcare provided to Mr Kiteley
was equivalent to that which he could have expected in the community.
9. However, she had concerns that the risk assessment for him to hold his own
medication was not adequate, and that he did not have a mental health care plan.
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Emergency response
10. Mr Kiteley showed signs of rigor mortis when he was found in his cell on the
morning on of 5 June. Despite this and nurses advising them to stop, officers
continued to attempt resuscitation, which was inappropriate.
Recommendations
• The Head of Healthcare and the manager of the integrated mental health team
should ensure that prisoners with mental health issues have appropriate reviews
and care plans which are recorded and implemented.
• The Head of Healthcare should ensure that the prisoner’s history and risk factors for
suicide and self-harm are taken into account in medication in-possession risk
assessments.
• The Governor should ensure that staff are aware of the signs of rigor mortis, and
fully understand the circumstances in which they should not start, or continue,
resuscitation, in line with Resuscitation Council Guidelines.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Sudbury informing
them of the investigation and asking anyone with relevant information to contact
him. No-one responded.
12. The investigator obtained copies of relevant extracts from Mr Kiteley’s prison and
medical records.
13. The investigator interviewed four members of staff and a prisoner at Sudbury. NHS
England commissioned an independent clinical reviewer to review Mr Kiteley’s
clinical care at the prison. All the interviews were conducted by telephone because
of the COVID-19 restrictions in place.
14. We informed HM Coroner for Derby and Derbyshire of the investigation. He gave
us the results of the post-mortem examination. We have sent the coroner a copy of
this report.
15. One of the Ombudsman’s family liaison officers contacted Mr Kiteley’s mother to
explain the investigation and to ask if she had any matters she wanted the
investigation to consider. She asked for any information about how her son died.
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Background Information
HMP Sudbury
16. HMP Sudbury is an open prison that houses over 580 adult men. Sudbury caters
for prisoners in the latter stages of their sentence and specialises in rehabilitation
and resettlement in preparation for release into the community. A number of
prisoners are released each day on licence to help with their resettlement.
17. Care UK provides primary and mental health services. South Staffordshire and
Shropshire Healthcare NHS Foundation Trust provides drug and substance misuse
services.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Sudbury was a short scrutiny visit in June 2020.
Inspectors reported that the COVID-19 pandemic had been difficult for prisoners in
open conditions who were preparing for release. There were some reports of
negative relationships between prisoners and staff but there was no evidence of
deterioration in security or order. Support from healthcare providers and
partnership working was good, and face-to-face support for prisoners with mental
health and substance misuse problems, including drug recovery work, continued
and access was good.
19. The most recent full inspection of Sudbury was in April 2017. Inspectors found that
the prison was proactive in its approach to controlling drugs, with enhanced CCTV
monitoring and a good flow of intelligence to the security department. The prison
had also built good relationships with the local police, which had led to
prosecutions. Inspectors considered that there was an effective strategic approach
to substance misuse treatment and the range of interventions was generally good.
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 31 May 2021, the IMB reported
that through the difficulties of COVID-19 restrictions the prison provided good
access to outside space for prisoners. Levels of self-harm were low, and wings
within the prison had acted as “bubbles” to maintain social contacts. The Board
noted that the open nature of the site made the availability of illicit items, including
drugs, a problem and quantities had been detected through the year. Support for
prisoners with drug and alcohol dependence was good.
Previous deaths at HMP Sudbury
21. Mr Kiteley was the third Sudbury prisoner to die since April 2019. Both of the
previous deaths were due to natural causes (including one due to COVID-19).
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Key Events
February 2017 – April 2021
22. In February 2017, Mr James Kiteley was convicted of wounding with intent to cause
grievous bodily harm and sentenced to six years and eight months imprisonment.
Mr Kiteley had problems with alcohol and suffered from anxiety and depression.
23. In December 2018, Mr Kiteley failed a drug test. He said that his cellmate used
psychoactive substances (PS) and that he had been feeling down at the time so
when offered drugs he took them for a short period. In 2020, Mr Kiteley began
working with Forward Trust, a charity which works with prisoners with problems with
drugs or alcohol. He said he was looking forward to moving to open conditions
(Category D) and wanted to ensure that he was doing all that was necessary to
ensure his progress.
HMP Sudbury: 13 April 2021 onwards
24. On 13 April 2021, Mr Kiteley transferred to HMP Sudbury. He told staff that he was
a little anxious and said he would keep a low profile. He was given written
information on substance misuse, including the services available and how to
access them. Healthcare staff noted that he had no physical health issues. He was
prescribed propranolol (a beta-blocker) for anxiety, and a nurse assessed that he
could hold the medication in his own possession.
25. On 16 April, Mr Kiteley said that he did not wish to engage with substance misuse
services (SMS). At a secondary health screen on 17 April, Mr Kiteley said that he
had no issues but asked to see someone from the mental health team.
26. On 20 April, Mr Kiteley told his offender supervisor that he had been surprised to
have to share a room and facilities, but that he was settling in and wanted to
progress. He was considering working with substance misuse services. He said he
had no physical health needs, but that he suffered from anxiety and paranoia and
he asked to see the mental health team. She suggested that he seek support from
the safer custody team if he needed it. She sent an email to the SMS team asking
them to make an appointment for Mr Kiteley.
27. On 21 April, a nurse saw Mr Kiteley for a mental health case management risk
assessment. He said that he was paranoid and anxious, worrying constantly if
people were talking about him. He told her that he had taken an overdose in his
twenties and that he had fleeting thoughts of suicide. He had previously been
prescribed sertraline (an antidepressant) but did not feel it worked for him, so he
had stopped taking it. She recorded that she considered Mr Kiteley to be at risk of
deliberate self-harm and she referred him to the mental health team.
28. On 27 April, Mr Kiteley saw a substance misuse worker. He said that his current
emotional health was not good, but he did not want to be referred to the mental
health team. She gave Mr Kiteley some material to complete so that at their next
session they could work on a care plan. She gave him advice, including how his
tolerance to drugs might have changed after a period of abstaining from drug use.
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29. On 30 April, a nurse carried out a mental health review. Mr Kiteley said that he had
been prescribed sertraline in the past but not recently. He said he was having
trouble adjusting to the new regime in Sudbury and was feeling paranoid. She did
not record the outcome of the review.
30. On 4 May, the substance misuse worker saw Mr Kiteley and reviewed the
paperwork he had completed. He was worried about living in a hostel on release
where people might be abusing drugs or alcohol. She discussed alcohol blocker
medication and provided more material to help him prepare for managing substance
misuse issues after release.
31. On 5 May, Mr Kiteley had a meeting with his offender supervisor. He said he was
still feeling a bit awkward sharing a room but understood that there was a waiting
list for single rooms. He had been in contact with the mental health team and had
an appointment pending. He had also been engaging with the SMS team and he
was positive about the interaction. He said that he had agreed to the suggestion of
alcohol blocker medication.
32. On 18 May, Mr Kiteley went to a meeting with his offender supervisor and the
substance misuse worker to assess his progress. Mr Kiteley said he was not clear
how his release plan would work and was unhappy about having to live in a
Probation Service Approved Premises (formerly known as probation hostels). They
discussed his previous alcohol use and things he could do while he was in Sudbury
to improve his chances of employment. Mr Kiteley said that he was determined not
to return to drinking. He said he was working with the mental health team to
address his anxiety and knew how to seek support if he wanted it. A nurse saw Mr
Kiteley again on 20 May. She noted that he was quite negative, particularly about
settling into the new routine.
33. On 26 May, Mr Kiteley attended a sentence plan review meeting with his offender
supervisor and his offender manager (probation officer). His main target was to
complete further work around alcohol, and he updated them on what he had done
so far. His offender supervisor noted that he appeared motivated and was pleased
to have avoided temptation. He said he was still struggling with anxiety and was
thinking about taking medication again after a year off it. He was waiting for an
appointment with the psychiatrist. They discussed the process for applying for
release on temporary licence (ROTL).
34. An intelligence report on 1 June indicated that Mr Kiteley did not like being on the
wing where he lived (West 3) because there was drug use there. That day he saw
the substance misuse worker and his offender supervisor. He said that he worked
harder than others, which irritated him. They suggested he complete a Sudbury
training project in how to develop relationships.
35. Mr Kiteley worked in the prison gardens and reports indicated that he was doing
well. On 2 June, he asked his mother if she could lend him some money as he
needed a watch.
Events of Friday 4 and Saturday 5 June 2021
36. Mr Kiteley’s room-mate said that they watched a film together late on 4 June. This
finished at about 1.30am on 5 June, and his room-mate went to sleep. He said he
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woke up at approximately 4.00am and noticed that the television was switched off.
He heard Mr Kiteley snoring.
37. At approximately 10.55am, an officer was making a roll check, and when he
checked their room, he said he thought both Mr Kiteley and his room-mate were
asleep. He completed the roll check, but on his return to the office it occurred to
him that it was unusual for them both to be asleep at that time, so he decided to
check them. By now it was approximately 11.05am.
38. The officer went into the room and spoke to the two prisoners. The room-mate
woke up, but Mr Kiteley did not respond. The officer spoke directly to Mr Kiteley,
still with no response. Now concerned, he used his radio to warn the control room
of a potential code blue emergency (meaning a prisoner is not, or is having
difficulty, breathing). He then pulled the cover off Mr Kiteley and found that he was
not breathing. He used his radio to call the emergency code blue, and he was
joined by a colleague straightaway. The code blue call prompted the control room
to call for an ambulance, while the two officers began cardiopulmonary resuscitation
(CPR).
39. They were joined by colleagues including healthcare staff. A nurse applied a
defibrillator, but it could not detect a rhythm. She tried to insert an airway but could
not as Mr Kiteley was showing clear signs of rigor mortis. She advised the officers
that they should stop CPR, but they wanted to continue. The did so until
ambulance staff arrived and took over. At 11.36am, the paramedics pronounced
that Mr Kiteley had died.
Intelligence after Mr Kiteley’s death
40. When prison staff searched Mr Kiteley’s room, they found a quantity of pregabalin
tablets (a prescribed medication used to treat conditions including anxiety, but
which is also misused in prisons because it can produce feelings of euphoria and
enhance the effects of other drugs), together with steroids, needles, and four mobile
telephones. In a further search, they later found several USB chargers and cables,
and more tablets. Mr Kiteley’s room-mate said that they did not belong to him. He
was subsequently returned to closed conditions.
41. After Mr Kiteley’s death, there were intelligence reports about his interactions with
other prisoners, including that he had shared telephone accounts and banking
details, and about his use of pregabalin and other substances. There were no such
intelligence reports before Mr Kiteley died.
Contact with Mr Kiteley’s family
42. A supervising officer (SO) spoke to Mr Kiteley’s mother to break the news of her
son’s death. In line with Prison Service guidance, Sudbury offered a contribution to
the costs of Mr Kiteley’s funeral.
Support for prisoners and staff
43. After Mr Kiteley’s death, the Deputy Governor 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.
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44. The prison posted notices informing other prisoners of Mr Kiteley’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 Kiteley’s death.
Post-mortem report
45. The post-mortem report concluded that Mr Kiteley died of the effects of cocaine and
propranolol. Toxicology tests also found pregabalin in his system, although this
drug was at a therapeutic level. (Mr Kiteley was not prescribed pregabalin.)
46. The pathologist reported that although acute cocaine toxicity is rare, cocaine may
still cause death, even where the levels detected are low, as in Mr Kiteley’s case.
The levels of propranolol found in post-mortem tests indicated that Mr Kiteley took
an excessive amount of this drug before he died.
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Findings
47. Mr Kiteley was only at Sudbury for a short time. Other prisoners described him as
quiet and largely keeping to himself. Although he suffered from anxiety while
settling at Sudbury, his offender supervisor said that he was positive about his
future. He was open about his thoughts and feelings and willing to ask for help if he
needed it.
Substance misuse
48. Mr Kiteley had a background of substance misuse. He was offered substance
misuse services on arrival at Sudbury. After initially refusing, he did engage and
was seen promptly and, thereafter, regularly.
49. Post-mortem tests showed the presence of cocaine, propranolol and pregabalin in
Mr Kiteley’s system. Intelligence reports after his death suggested that he had
taken drugs previously at Sudbury.
50. During the COVID-19 pandemic, random drug testing was suspended, and drug
tests were only undertaken in Sudbury when there was reason to suspect a
prisoner was using drugs. Sudbury’s Head of Security said in interview that there
was no intelligence prior to Mr Kiteley’s death to suggest that he had been taking
drugs. There were no reports of him ever being under the influence of anything.
The offender supervisor, who worked closely with Mr Kiteley, said in interview that
she had no reason to suspect he had used drugs. He engaged with substance
misuse services and talked positively about the future. We are satisfied that staff
could not have known that Mr Kiteley was using drugs before he died.
51. Although Sudbury has a comprehensive drug strategy, we are very concerned that
Mr Kiteley appears to have had no difficulty in obtaining and using both illicit drugs,
such as cocaine, and prescription drugs, such as pregabalin.
52. Drug taking and trading is a serious problem across much of the prison estate.
Individual prisons are, for the most part, doing their best to tackle the problem by
developing their own local drug strategies. In April 2019, the Prison Service
introduced a national drug strategy. This says that:
“Every prison is different and will benefit from tools to assess their specific
security needs. We have worked with prisons to carry out Vulnerability
Assessments in prisons to build a picture of the security risks and enable
establishments to better target their resources to tackle them. This resource
will continue to be offered across the estate.”
53. Sudbury has a strategy to address both the supply of, and demand for, drugs. It
includes numerous actions intended to reduce the supply of drugs into the prison
and movement of drugs around the prison. There are also measures to educate
and support those known to use drugs and disciplinary measures to deter drug use,
as well as partnership working with local police to secure prosecution for those
involved.
54. Given the proactive steps the prison has taken in addressing the issue of drug
misuse at Sudbury, we make no recommendation.
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Mr Kiteley’s clinical care
55. The clinical reviewer concluded that, overall, the healthcare provided to Mr Kiteley
was equivalent to that which he could have expected to receive in the community.
56. The clinical reviewer noted that Mr Kiteley was referred to mental health services
promptly and reviewed in line with guidance. However, the clinical reviewer was
concerned that there was no evidence of a mental health care plan. The Head of
Healthcare explained that a care plan would normally be generated by a full mental
health assessment, and Mr Kiteley had not had such an assessment before he
died.
57. The clinical reviewer reflected that national clinical guidelines require a care plan for
prisoners with identified mental health needs. We agree with the clinical reviewer’s
concerns and make the following recommendation:
The Head of Healthcare and the manager of the integrated mental health team
should ensure that prisoners with mental health issues have appropriate
reviews and care plans which are recorded and implemented.
58. The clinical reviewer was also concerned about the nurse’s assessment of the risk
of Mr Kiteley looking after his own medication. She was concerned that the nurse
did not properly take into consideration Mr Kiteley’s history of self-harm, particularly
his previous overdose, and therefore inaccurately recorded his risk was zero.
59. We share the clinical reviewer’s concern that the nurse assessing whether Mr
Kiteley should have medication in his possession did not properly reflect all of his
history and risk factors in her assessment. Mr Kiteley’s death was partially caused
by an overdose of his prescribed medication.
60. We make the following recommendation:
The Head of Healthcare should ensure that the prisoner’s history and risk
factors for suicide and self-harm are taken into account in medication in-
possession risk assessments.
Emergency response
61. When the officer found Mr Kiteley on the morning of 5 June, he described him as
‘blue’. When a nurse assessed Mr Kiteley shortly afterwards, she found evidence of
rigor mortis and advised the officers to stop resuscitation attempts. Prison officers
wanted to continue as they believed that they had to.
62. The Quality Standards for Clinical Practice and Training in Cardiopulmonary
Resuscitation, published by the Resuscitation Council, were updated in 2020. The
Resuscitation Council guidance says, “There will be some people for whom
attempting CPR is clearly inappropriate; for example, …. there will be cases where
healthcare professionals discover patients with features of irreversible death, for
example, rigor mortis”.
63. We appreciate that staff wanted to do their best for Mr Kiteley. However, trying to
resuscitate someone who is clearly dead is distressing for staff and undignified for
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the deceased. When the nurse advised that staff should stop CPR, they should
have accepted her advice.
64. We make the following recommendation:
The Governor should ensure that staff are aware of the circumstances in
which resuscitation is inappropriate.
Inquest
65. The inquest, held on 10 July 2024, concluded that Mr Kiteley’s death was drug
related.
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