John Creevy

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Independent investigation into
the death of Mr John Creevy,
a prisoner at HMP Garth,
on 25 January 2022
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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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 John Creevy died at HMP Garth on 25 January 2022. His cause of death is
unascertained. Mr Creevy was 51 years old. I offer my condolences to his family and
friends.
I am concerned that there was no healthcare handover when Mr Creevy was transferred
from HMP Lowdham Grange to HMP Garth around two weeks before he died. Healthcare
staff at Lowdham Grange did not pass on to Garth important information about his medical
history and upcoming hospital appointments. This meant that Mr Creevy missed a hospital
consultant appointment shortly after he was transferred. I am also concerned that Mr
Creevy was transferred without the prescribed medication he needed and that his health
was not fully assessed when he arrived at Garth.
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 October 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 1
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. In September 2015, Mr John Creevy was sentenced to seven years in prison for
robbery and violence against a person and was sent to HMP Liverpool. He had
epilepsy.
2. On 12 March 2020, Mr Creevy was transferred to HMP Lowdham Grange.
3. Between March 2020 and 25 January 2022, Mr Creevy had 24 epileptic seizures.
4. On 27 October 2021, Mr Creevy was taken to hospital after he reported having
shortness of breath and cellulitis in his left leg. At hospital, he was diagnosed with
several serious illnesses relating to his heart and lungs. He remained in hospital
until 5 November.
5. On 13 January, Mr Creevy was transferred from Lowdham Grange to HMP Garth.
Lowdham Grange did not inform Garth about Mr Creevy’s epilepsy, important
impending follow-up appointments nor his recent admission to hospital. Mr Creevy
arrived at Garth without his critical prescribed medications and an initial health
screen was not completed.
6. The next day, Mr Creevy did not attend an epilepsy review at hospital as
information about the appointment was not handed over to Garth.
7. At around 8.30am on 25 January, an officer found Mr Creevy unresponsive. The
officer shouted for assistance from another officer and radioed a medical
emergency code blue (used when a prisoner is unconscious or has breathing
difficulties) and an ambulance was called straightaway. Healthcare staff found no
signs of life and did not try to resuscitate Mr Creevy. At 9.11am, paramedics
arrived and confirmed that Mr Creevy had died.
Findings
8. The clinical reviewer found that the physical care that Mr Creevy received was not
always equivalent to that which he could have expected to receive in the
community. She found that Lowdham Grange did not pass information to Garth
about Mr Creevy’s epilepsy, his recent hospital admission and follow-up
appointments. Mr Creevy arrived at Garth without critical medication, and he was
not fully assessed on arrival.
Recommendations
• The Head of Healthcare at HMP Lowdham Grange should ensure that prisoners
with significant health needs are transferred in line with national instructions,
including that:
• significant health information is shared with the receiving prison, including
about significant diagnoses, recent emergency hospital admissions and
hospital follow up appointments; and
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• all critical prescribed medications are transferred with prisoners to enable
continuity of care.
• The Head of Healthcare at HMP Garth should ensure that reception health screens
are completed for all newly arrived prisoners, in line with NICE guidelines.
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The Investigation Process
9. The investigator issued notices to staff and prisoners at HMP Garth informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
10. The investigator obtained copies of relevant extracts from Mr Creevy’s prison and
medical records.
11. The investigator interviewed six members of staff using Microsoft Teams on 23
March and 4 November.
12. NHS England and NHS Improvement (NHSE&I) commissioned a clinical reviewer to
review Mr Creevy’s clinical care at the prison. The clinical reviewer joined the
investigator for interviews with healthcare staff.
13. We informed HM Coroner for Lancashire and Blackburn with Derwen of the
investigation. The Coroner gave us the results of the post-mortem examination. We
have sent the Coroner a copy of this report.
14. The Ombudsman’s family liaison officer contacted Mr Creevy’s mother to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond to our letter.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Garth
16. HMP Garth holds up to 846 prisoners serving sentences of four years or longer or
indeterminate sentences. Primary care services are provided by Bridgewater NHS
Foundation Trust. Greater Manchester Mental Health NHS Foundation Trust
provides mental health services.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Garth was in December 2018 and January
2019. Inspectors reported that several aspects of healthcare provision had
improved and was now reasonably good. However, they found there were still
difficulties in ensuring prisoners could attend hospital appointments. Inspectors
reported governance structures and partnership-working were reasonable and that
staffing levels had improved. The management of long-term conditions had also
improved, and patients received regular reviews and a good level of care.
Independent Monitoring Board
18. 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 May 2022, the IMB reported that
each new prisoner goes through the standard arrival procedure. They noted that a
healthcare representative is available at each induction and that prisoners receive
a triage medical check (ensuring that prescribed medication is provided from the
first day). The induction includes full healthcare checks being carried out within a
week of prisoners arriving and ensures that health needs are met in a timely and
efficient manner. The IMB noted from its observations that procedures in Reception
and ongoing induction are carried out courteously and correctly, with prisoner
queries responded to appropriately.
Previous deaths at HMP Garth
19. Mr Creevy was the eleventh prisoner to die at Garth since January 2020. Seven of
the previous deaths were from natural causes, two were self-inflicted and one was
drug-related. Since Mr Creevy’s death, there have been two further two deaths,
one from natural causes and one in which the cause is unclear. We have
previously raised a concern about welfare checks.
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Key Events
20. In September 2015, Mr John Creevy was sentenced to seven years in prison for
robbery and violence against a person and was sent to HMP Liverpool.
21. Mr Creevy had several chronic health conditions, including diagnosed epilepsy,
hepatitis C, anxiety and depression, schizophrenia and psychosis, emotionally
unstable personality disorder, antisocial personality disorder, low back pain and
cellulitis (a common bacterial skin infection that causes redness, swelling and pain
in the infected area) in his legs.
22. On 12 March 2020, Mr Creevy was transferred from Liverpool to HMP Lowdham
Grange.
23. Between March 2020 and 25 January 2022, records show that Mr Creevy had 24
epileptic seizures, most of which were unwitnessed.
24. On 14 April 2020, Mr Creevy’s epilepsy care plan was reviewed.
25. On 18 January 2021, Mr Creevy’s consultant neurologist at Queen’s Medical
Hospital changed his epilepsy medication and on 23 July, increased the dose. The
consultant scheduled a review for 14 January 2022. There were no further reviews
of Mr Creevy’s epilepsy care plan.
26. On 8 October, Mr Creevy was admitted to hospital following a seizure.
27. On 27 October, a health professional assessed Mr Creevy because he was short of
breath, had cellulitis in his left leg and his haemoglobin (iron) levels had decreased.
She sent him to hospital, where he was diagnosed with sepsis (a generalised
infection that overwhelms the body), cellulitis, pericardial effusion (a build-up of fluid
around the heart) with possible cardiac tamponade (excess fluid around the heart
that prevents the heart from pumping properly) and pulmonary embolus (a lung
clot).
28. On 5 November, Mr Creevy was discharged from hospital and returned to Lowdham
Grange. Healthcare staff saw him almost daily to administer medication and
change his leg dressings until he was transferred to HMP Garth (in January 2022).
29. On 15 December, Mr Creevy missed a cardiology telephone appointment because
the consultant did not have the prison’s telephone number. An echocardiogram
(when an image of the heart is made using sound waves) was booked for January
2022.
30. On 13 January, a nurse reviewed Mr Creevy in his cell before he was transferred to
Garth. She recorded that he raised no concerns and that his medication had been
sent on transfer.
HMP Garth
31. On 13 January 2022, Mr Creevy was transferred to Garth. He arrived at around
5.30pm. Healthcare staff did not complete a full initial health screen. A nurse
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observed Mr Creevy through his open cell door. She described the brief
assessment as “meet and greet”. She recorded that Mr Creevy said that he was
well and had no concerns about his health and wellbeing. She noted that some of
Mr Creevy’s critical medications had arrived with him from Lowdham Grange. The
remaining medication was obtained from Garth’s out-of-hours cupboard. No health
risks were recorded, and she did not record that Mr Creevy had a history of
epilepsy.
32. The Head of Healthcare at Garth told the investigator that Lowdham Grange did not
provide a handover of Mr Creevy’s complex health needs.
33. The next day, a nurse completed Mr Creevy’s initial health screen. She took his
clinical observations and recorded Mr Creevy’s medical history as suspected heart
disease, epilepsy and hepatitis C.
34. That day, Mr Creevy missed his epilepsy review at hospital. It had been booked
when he was at Lowdham Grange, but he apparently missed it because staff at
Lowdham Grange had not informed Garth about the appointment.
35. On 17 January, Mr Creevy did not have his scheduled secondary health screen due
to a lack of staff.
36. On 20 January, a nurse completed Mr Creevy’s full health assessment. She
recorded that he had memory impairment, a history of head injury, regular
headaches, a heart condition, epilepsy, medications and regular check-ups for long-
term conditions and hospital reviews. She advised Mr Creevy how to make an
application for a health appointment and to inform wing staff of any emergency.
Events of 25 January
37. At around 5.47am, an officer completed the morning roll check. The officer looked
into the cell observation panel with a torch light for about three seconds. He said
that he saw nothing that caused him concern.
38. At around 8.25am, while conducting welfare checks, an officer looked through the
cell observation panel and noted that Mr Creevy’s bed was made and that he could
see Mr Creevy’s feet in the toilet area. He said that he assumed Mr Creevy was on
the toilet and so continued with welfare checks along the landing. He returned to
Mr Creevy’s cell two minutes later. He looked through the cell observation panel
and unlocked the cell door. As he opened it slightly, he noticed Mr Creevy slumped
on the floor next to the toilet. He shouted for assistance from another officer and
called a medical emergency code blue on his radio (triggering the control room
operator to call an ambulance). He went into the cell, checked for signs of life and
noted that Mr Creevy was cold. Another officer attended the cell with a defibrillator,
and a nurse also attended. The nurse assessed Mr Creevy and found no signs of
life and that Mr Creevy was cold and rigid. The staff therefore decided not to
attempt resuscitation.
39. At 9.11am, paramedics confirmed that Mr Creevy had died.
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Contact with Mr Creevy’s family
40. At 10.40am, a prison family liaison officer telephoned Mr Creevy’s mother and told
her of his death. The prison contributed to funeral costs, in line with national policy.
Support for prisoners and staff
41. After Mr Creevy’s death, an operational 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.
42. The prison posted notices informing other prisoners of Mr Creevy’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 Creevy’s death.
Post-mortem report
43. The cause of death was not available when we issued our report.
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Findings
Clinical care
44. The clinical reviewer found that the physical care that Mr Creevy received was not
always equivalent to that which he could have expected to receive in the
community.
45. Prison Service Order (PSO) 3050 on the continuity of healthcare for prisoners
instructs that prisoners’ current healthcare needs must be assessed and continuity
of care ensured when they transfer between prisons. It instructs that this should
include the identification of physical health problems and ensuring that information
on continuing care is conveyed to other prisons on transfer. Prisoners with more
complex health needs may require detailed planning such as communicating
directly with the receiving health care team in advance of transfer.
46. National Institute for Health and Care Excellence (NICE) guidelines (NG57) instruct
that continuity of care should be ensured for people transferring between prisons
by, for example, accessing relevant information from their patient clinical record.
When a prisoner arrives at a new prison, a full health assessment should be carried
out and NICE guidelines identify questions that should be put to all new arrivals.
47. The clinical reviewer found that there was no healthcare handover when Mr Creevy
was transferred from Lowdham Grange to Garth. This meant that his epilepsy risks
and information about his recent hospital admission were not shared with Garth. It
also meant that Mr Creevy missed a consultant epilepsy review scheduled for 14
January, and also missed a repeat echocardiogram. Additionally, he arrived at
Garth without some critical medications, and he was not fully assessed on arrival.
We make the following recommendation:
The Head of Healthcare at HMP Lowdham Grange should ensure that
prisoners with significant health needs are transferred in line with national
instructions, including that:
• significant health information is shared with the receiving prison,
including about significant diagnoses, recent emergency hospital
admission and hospital follow up appointments; and
• all critical prescribed medications are transferred with prisoners to
enable continuity of care.
The Head of Healthcare at HMP Garth should ensure that reception health
screens are completed for all newly arrived prisoners, in line with NICE
guidelines.
48. The clinical reviewer also made several recommendations about continuity of care
and healthcare processes which the Head of Healthcare at Lowdham Grange will
need to address.
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Welfare check on 25 January 2022
49. During the COVID-19 pandemic, Garth introduced additional welfare checks for
prisoners which it decided to keep while emerging from the pandemic. Garth’s local
policy on welfare checks during restricted regime period says, “Best practice on a
welfare check is that staff must ensure they have full sight of the individual and gain
a verbal response from occupant/occupants located within the cell.”
50. When an officer completed his welfare check on Mr Creevy, he saw his feet in the
toilet area and assumed that he was on the toilet. The landing was noisy and Mr
Creevy’s bed was made which made the officer believe that he was up and using
the toilet. Two minutes later, the officer returned to unlock Mr Creevy and realised
that he was slumped on the floor. The officer responded immediately, called for
help from a nearby officer and appropriately radioed a medical emergency code
blue.
51. The officer did not complete his welfare check in line with Garth’s published
guidance. An operational manager told us that she spoke to the officer after Mr
Creevy’s death and gave him advice and guidance. She also told us that the
prison’s local welfare check policy had been reissued to all staff. We do not
therefore make a recommendation.
Inquest
52. The inquest, held from 20 to 22 June 2023, concluded that Mr Creevy’s death was
due to 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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