John Devers

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr John Devers,
a prisoner at HMP Oakwood,
on 21 June 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, 2025
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Summary
1. 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.
2. 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.
3. Mr John Devers died from lung cancer in hospital on 21 June 2023, while a prisoner
at HMP Oakwood. He was 59 years old. We offer our condolences to Mr Devers’
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Devers received at
Oakwood was of a good standard and equivalent to that which he could have
expected to receive in the community. She made no recommendations.
5. We have previously found issues with the inappropriate use of restraints when
prisoners were going to hospital from Oakwood, and the Director wrote to the
Ombudsman in February 2023 to say that this issue had been addressed. However,
once again we found that restraints were inappropriately used with Mr Devers.
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The Investigation Process
6. HMPPS notified us of Mr Devers’ death on 21 June 2023.
7. NHS England commissioned an independent clinical reviewer, to review Mr Devers’
clinical care at Oakwood. The clinical reviewer’s report is attached as Annex 1.
8. The PPO investigator investigated the non-clinical issues relating to Mr Devers’
care. The investigator interviewed one member of staff.
9. The PPO family liaison officer wrote to Mr Devers’ next of kin, his wife, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies with the report.
Previous deaths at HMP Oakwood
11. Mr Devers was the 12th prisoner to die at Oakwood since June 2020. Nine of the
previous deaths were from natural causes, one was from drugs, and one was from
burns injuries. In several of these previous cases, we have raised concerns about
the inappropriate use of restraints.
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Key Events
12. On 8 January 2021, Mr Devers was remanded in custody at HMP Preston, pending
the outcome of a trial for sexual offences. On 19 July, he was sentenced to nine
years imprisonment. On 7 October, he was sent to HMP Oakwood.
13. When Mr Devers went to prison, he was already taking regular opioid painkillers for
arthritis (a common condition that causes pain and inflammation in joints) in his
spine, elbows, and knees. When he arrived at Oakwood, he was having difficulties
walking and shortly afterwards started using a walking stick for short distances and
a wheelchair for longer distances.
14. On 8 November, Mr Devers reported feeling pins and needles in his legs and feet
and a doctor at the prison referred him for an urgent MRI scan of his brain, neck,
and spine. On 16 December, a physiotherapist at the prison assessed Mr Devers.
They noted that he was unsteady, used a walking stick and held on to furniture to
move short distances, and was using a wheelchair for longer distances. The
physiotherapist thought that Mr Devers might have a brain lesion and noted that an
MRI brain scan was pending.
15. On 23 December, Mr Devers was moved back to Preston because it was close to
the court where he was standing trial on further criminal charges, for theft.
16. On 4 January 2022, Mr Devers said that he was experiencing stabbing pains in his
legs and that was losing strength in his right hand. A prison nurse noted that the
MRI scans were still pending and needed to be chased up.
17. Following his trial on 15 March, Mr Devers was sentenced to 15 months
imprisonment, concurrent to the previous sentence. On 19 April, he was transferred
back to Oakwood. Healthcare staff made a new referral for a brain and spine scan.
On 20 May, the prison was notified by the hospital of an appointment on 28 June.
18. On 3 June, Mr Devers had some paralysis to the left side of his face and was taken
to hospital with a suspected stroke (the term for when the blood supply is cut off to
part of the brain). At the hospital he was diagnosed with Bell’s palsy (a temporary
muscle weakness usually to one side of the face) and Mr Devers returned to the
prison the same day.
19. On 28 June, Mr Devers went to hospital for the scheduled scan. This showed no
signs of a stroke or any brain lesions but did show multilevel degenerative changes
to Mr Devers’ spine. Healthcare staff at Oakwood made a referral to a spinal
surgeon in August.
20. Mr Devers remained reliant on a wheelchair and his clinical notes in November
recorded an increase in his body pains and a reduction in his mobility. In January
2023, Mr Devers moved to a disabled access cell.
21. On 24 February, Mr Devers alerted staff with his personal wrist alarm that he had
fallen over and could not get himself up. Healthcare staff who attended, recorded in
Mr Devers’ clinical notes that he was uninjured but due to frailty and poor mobility
was unable to get himself off the floor by himself.
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22. From mid-March, Mr Devers was consistently unwell. He had spells of headaches
and vomiting, with a loss of appetite. Mr Devers was taken to hospital on 27 March
and returned to prison with a diagnosis of a gastric or urinary infection. He fell out of
bed that night and was helped back in by staff.
23. On 28 March, healthcare staff found Mr Devers was still very ill with very little ability
to mobilise and sent him back to hospital. He was returned once again without
much idea for the healthcare staff as to what was wrong with him and without a
treatment plan.
24. Around 8.00am the following day, Mr Devers fell out of bed again. Initially the prison
called an ambulance but stood it down as he had no injuries. However, by the
afternoon healthcare staff felt that Mr Devers’ constant dizziness and inability to
stand up without falling over, was putting him in danger. Mr Devers once again
returned to hospital.
25. By 30 March, although the hospital was waiting for biopsies to confirm the
diagnosis, doctors said it was very likely that Mr Devers had lung cancer which had
spread to his brain, and that he had approximately two months to live.
26. Mr Devers returned to prison on 10 April. On 12 April, the hospital confirmed that he
had lung and brain cancer. Following another fall on 26 April, and his inability to get
himself back up, Mr Devers was sent back to hospital where he remained until 2
May. Healthcare staff recorded in Mr Devers’ clinical notes that now only palliative
treatment (care with the focus on optimising the quality of life and reducing
suffering) was possible. A special palliative care bed was delivered to the prison on
19 May.
27. On 20 May, Mr Devers fell out of his wheelchair. On the morning of 25 May, he fell
over getting dressed, and in the afternoon, he fell out of his wheelchair again, after
which he was taken to hospital but was returned to the prison later in the evening.
28. On 25 May, Mr Devers was given a different wheelchair to use. This, like the
previous one, was a wheelchair for general use rather than one customised for Mr
Devers, and at this point a dedicated wheelchair was ordered for Mr Devers by a
First Line Manager (FLM) from the Prison’s Safer Custody unit.
29. On the morning of 6 June, Mr Devers was taken to hospital with a possibly infected
wound to his elbow and because of clinical observations, healthcare staff at the
prison were concerned that he might have sepsis (a potentially life-threatening
condition that occurs when the body's response to an infection damages its own
tissues). Mr Devers discharged himself, because he did not like waiting in what he
felt was an overcrowded area. However, because of his deteriorating condition, Mr
Devers was taken back to the hospital in the early evening the same day. On both
hospital trips Mr Devers was restrained by single cuffs and an escort chain.
30. Mr Devers remained in hospital until he died there on 21 June.
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Cause of death
32. A post-mortem examination was not necessary as the Coroner accepted the cause
of death provided by hospital doctors. They said that Mr Devers died from
metastatic lung cancer (lung cancer which has spread to other parts of the body).
Hydrocephalus due to brain metastasis (pressure in the brain from cancer tumours),
was given as a condition that contributed to but did not cause the death.
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Non-Clinical Findings
Restraints, security and escorts
33. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007, known as the Graham Judgement,
made it clear that prison staff need to distinguish between a prisoner’s risk of
escape when fit (and the risk to the public in the event of an escape) and the
prisoner’s risk when suffering from a serious medical condition. It said that medical
opinion about the prisoner’s ability to escape must be considered as part of the
assessment process and kept under review as circumstances change.
34. Mr Devers had limited mobility from the outset of his time in prison and this
deteriorated. In June 2022, he was diagnosed with significant degenerative spine
problems. Mr Devers moved into a disabled access cell in January 2023. He had an
escalating problem with falls and by February, was already unable to get up by
himself when he fell over, and later in the year was falling out of the wheelchair he
was using. By that time, doctors had discovered that Mr Devers had lung cancer
which had spread to his brain.
35. At the time of his cancer diagnosis on 30 March, Mr Devers was noted in the Family
Liaison Officer’s (FLO) log, to be unrestrained because of his immobility. When he
was taken to hospital on 26 April, Mr Devers was initially restrained, but the
restraints were later removed after a review. A member of the healthcare staff,
wrote in Mr Devers’ clinical notes on 27 April, “Could Mr Devers be discussed [at]
Director and security [level] … about the use of restraints if he is still cuffed. On
review of his most recent CT scan, his probable diagnosis and his decreased
mobility the risk of escape is very low so could this be [taken into] consideration.”
36. On 6 June, when Mr Devers was taken to hospital in the morning, staff completed a
risk assessment. In the section filled in by the Head of Security, she listed Mr
Devers as medium risk to the public but as low risk in all the other categories
including the risk of escape. The member of the healthcare staff who filled in the
medical section of the risk assessment, in response to the question, “Are there any
medical reasons that would prevent normal cuffing procedures from being applied
for the duration of the escort / Bed Watch?”, she circled “yes”, and as an
explanation wrote, “cancer patient”. In response to the question, “Does the prisoner
have the physical ability to attempt an escape (unaided) from the escort if the cuffs
are removed?”, she circled “No”, and gave the explanation “wheelchair bound”. She
also recorded in Mr Devers’ clinical notes that she had spoken to the Head of
Security and told her that Mr Devers’ risk was low, he was not in good health and
due to the spread of his cancer he was immobile and used a wheelchair.
37. The Security Intelligence Manager, who was Duty Director on 6 June, was the
authorising manager for the risk assessment. He authorised the use of single cuffs
and an escort chain (a handcuff on a prisoner linked by a chain to a handcuff on an
officer) to restrain Mr Devers, accompanied by two officers. In the comment section
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he wrote, “Confirmed that is not wheelchair dependent by SC [Safer Custody].
Review when updated on treatment plan”.
38. When Mr Devers returned to hospital in the evening a separate risk assessment
should have been carried out but there was no new assessment and Mr Devers
was restrained for both trips.
39. On 7 June, a note in Mr Devers’ clinical records was made by a different nurse to
the one who filled in the risk assessment. He said that he had spoken to the Head
of Security and advised that because of Mr Devers’ terminal cancer, his restricted
mobility, use of wheelchair and limb impairment, he should not be restrained. She
told the nurse that the decision would go to the Director for sign off, which is what
happened, and the restraints were removed.
40. The investigator asked the Security Intelligence Manager who he had spoken to in
Safer Custody regarding Mr Devers’ wheelchair dependence. He said he recalled
that it was a First Line Manager (FLM) in the Care Team. However, the FLM said
this was not the case. She confirmed that Mr Devers had originally been using a
wheelchair unofficially for his own convenience (they are available on the wings for
prisoners to use as and when they need them), but following a request from
healthcare staff, he had been issued with a dedicated wheelchair.
41. The investigator also asked the Security Intelligence Manager why he had referred
the matter to Safer Custody, rather than relying on the information provided by the
nurse on the risk assessment. He said it was because the prison has a lot of
agency nurses who would not necessarily know the prisoners very well. He said
that his understanding was that although Mr Devers used a wheelchair, he did not
really need it.
42. With Mr Devers’ mobility history, it is hard to understand how the use of restraints
could be justified with the presence of two able bodied prison officers in attendance.
It is appropriate for healthcare related advice to be given by a healthcare
professional, and if this was contradicted by other information, a contemporaneous
note should have been made on the risk assessment to say exactly who had been
spoken to, and exactly what they had said. The risk assessment should also be
based on the actual presentation of a prisoner at the time of the assessment and
not on any subsequent treatment plan. The decision to restrain Mr Devers was
excessively precautionary and not compliant with the Graham Judgement, although
we acknowledge this was addressed the next day.
43. The inappropriate use of restraints on prisoners being taken to hospital is an issue
we have raised with Oakwood before. We recommend:
The Operational Security Group Director for HMPPS should monitor
compliance with policy on the use of restraints during hospital escorts (for
inpatient admissions and outpatient appointments), including at HMP
Oakwood, and discuss the findings with the Ombudsman.
Adrian Usher
Prisons and Probation Ombudsman January 2024
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Inquest
44. The inquest into Mr Devers’ death concluded in July 2024 and found that he 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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