John Hartshorne

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr John Hartshorne,
a prisoner at HMP Stafford,
on 14 February 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 John Hartshorne died in hospital from a brain stem stroke on 14 February 2023, while
he was a prisoner at HMP Stafford. He was 74 years old. I offer my condolences to Mr
Hartshorne’s family and friends.
The clinical reviewer concluded that the healthcare Mr Hartshorne received at Stafford was
of a good standard and was equivalent to that which he could have expected to receive in
the community. However, she highlighted some issues which the Head of Healthcare will
need to address.
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 September 2023
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 6 May 2022, Mr John Hartshorne was convicted of sexual offences and
sentenced to 30 months imprisonment. On 19 May, he was moved to HMP Stafford.
2. Mr Hartshorne had several health conditions including bradycardia (slow pulse) and
hypotension (low blood pressure). He was also obese. At a health check in August,
a nurse carried out a QRisk assessment which showed that Mr Hartshorne had a
high risk (over 20% chance) of a heart or circulation problem within the next ten
years.
3. On 9 January 2023, Mr Hartshorne said he felt unwell with abdominal pain. A nurse
took his clinical observations and undertook an electrocardiogram (ECG, a test to
check the heart’s rhythm) as she was concerned about Mr Hartshorne’s slow pulse.
A GP reviewed the result the next day and assessed that Mr Hartshorne needed a
heart scan. He referred Mr Hartshorne to a cardiologist (heart specialist) at the
hospital.
4. On 12 January, a GP recorded that Mr Hartshorne’s QRisk score had increased to
over 25%. The GP noted that Mr Hartshorne had already been referred to a
cardiologist.
5. During January, Healthcare Champions (prisoners trained to carry out basic clinical
tasks) recorded pulse and blood pressure readings for Mr Hartshorne. A nurse then
transferred these readings to Mr Hartshorne’s medical record.
6. At 12.55am on 1 February, Mr Hartshorne’s cellmate found him collapsed on the
floor of their cell. He pressed his emergency cell bell to alert staff. An Operational
Support Grade (OSG) responded and when she saw Mr Hartshorne on the floor,
she called a medical emergency code. A nurse and healthcare assistant arrived
within a few minutes and noted that Mr Hartshorne was unresponsive but breathing.
7. At 2.10am, an ambulance arrived at Stafford. Around 20 minutes later, paramedics
took Mr Hartshorne to hospital.
8. A hospital doctor assessed that Mr Hartshorne had a blood clot on his brain, so he
was taken into surgery to have this removed. After his surgery, he was moved to
the Intensive Therapy Unit (ITU) and he was put on a ventilator to help him breathe.
9. Over the next two weeks, Mr Hartshorne’s health deteriorated, and he was unable
to breathe without the support of a ventilator.
10. On 14 February at approximately 12.30pm, Mr Hartshorne died after his life support
was withdrawn.
11. A hospital doctor recorded Mr Hartshorne’s cause of death as a brain stem stroke.
The doctor listed atrial fibrillation (a condition that causes an irregular and often fast
heartbeat) as a contributing factor.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
12. The clinical reviewer found that the care Mr Hartshorne received at Stafford was of
a good standard and was equivalent to that which he could have expected to
receive in the community. However, she identified that there was no nursing care
plan in place for the management of Mr Hartshorne’s bradycardia and hypotension.
Recommendations
• The Head of Healthcare should ensure that all patients with long term conditions
have evidence of an appropriate nursing care plan within their medical record.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
13. HMPPS notified us of Mr Hartshorne’s death on 14 February 2023.
14. The investigator issued notices to staff and prisoners at HMP Stafford informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
15. The investigator obtained copies of relevant extracts from Mr Hartshorne’s prison
and medical records.
16. NHS England commissioned an independent clinical reviewer to review Mr
Hartshorne’s clinical care at the prison. The investigator and clinical reviewer
interviewed two members of healthcare staff at Stafford on 13 April 2023.
17. We informed HM Coroner for Staffordshire of the investigation. We have sent the
Coroner a copy of this report.
18. The Ombudsman’s family liaison officer contacted Mr Hartshorne’s son to explain
the investigation and to ask if he had any matters he wanted us to consider. He
asked whether prison protocols were followed when Mr Hartshorne collapsed and
about the clinical care Mr Hartshorne received at Stafford. These issues have been
addressed in our report and in the clinical review. Mr Hartshorne’s son also asked
questions which were outside the remit of our investigation which have been
addressed in a separate letter.
19. Mr Hartshorne’s son received a copy of the draft report. He raised three questions
that do not impact on the factual accuracy of this report which have been addressed
through separate correspondence.
20. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Stafford
21. HMP Stafford is a category C training prison for prisoners convicted of sexual
offences. It holds 751 male prisoners. The physical health care provider is Care UK
Health and Rehabilitation Services Ltd.
HM Inspectorate of Prisons
22. The most recent inspection of HMP Stafford was in January 2020. Inspectors
reported that waiting times for most healthcare clinics were short and there was a
clear application system, with nursing staff triaging potentially urgent issues.
Patients with long-term conditions were managed well by a practice nurse and the
GP. Reviews of these conditions were reliably scheduled, and care plans were in
place. Additional health checks relating to long-term conditions were carried out as
required. Inspectors also found arrangements within the prison to provide a rapid
response to medical emergencies were sound and resuscitation equipment was
checked and maintained regularly. They found that prison and health services staff
were clear about how to obtain ambulance support if required, although not all
prison staff knew the location of the defibrillators.
Independent Monitoring Board
23. 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 ending 30 April 2022, the IMB
reported that the quality of care delivered by the patient-facing staff was often
praised and certainly on par with what could be expected in the community.
Previous deaths at HMP Stafford
24. Mr Hartshorne was the twenty-fourth prisoner to die at Stafford since February
2020. Of the previous deaths, 21 were from natural causes and two were self-
inflicted. We have previously made recommendations about the use of NEWS2 and
about calling an ambulance immediately when a medical emergency code is used.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
25. On 6 May 2022, Mr John Hartshorne was convicted of sexual offences and
sentenced to 30 months imprisonment. On 19 May, he was moved to HMP Stafford.
26. Mr Hartshorne had a number of health conditions, including bradycardia (slow
pulse) and hypotension (low blood pressure). He was prescribed appropriate
medication for his health conditions.
27. On 9 August, a nurse undertook a health check review with Mr Hartshorne. The
nurse recorded that his Body Mass Index (BMI) was 30.08kg/m2, which put him in
the obese range. The nurse also took his blood pressure and completed a QRISK2
assessment. (A QRISK2 assessment identifies potential risk of cardiovascular
(heart and blood vessel) related diseases.) Mr Hartshorne’s QRisk score was
21.71%, which meant that he was at high risk of having a heart or circulation
problem in the next ten years (more than a 20% chance).
28. On 9 January 2023, a nurse saw Mr Hartshorne after he said he was feeling unwell
with abdominal pain. She took his clinical observations but there is no record that
she calculated a NEWS2 score. (National Early Warning Score (NEWS2) is a
clinical tool used to assess clinical deterioration in adult patients.) Mr Hartshorne’s
pulse was slow and his respiratory rate slightly fast. She carried out an
electrocardiogram (ECG, a test to check the heart’s rhythm). Mr Hartshorne said he
was feeling a bit better after taking an indigestion tablet. He reported no chest pain
or dizziness.
29. The next day, a GP at Stafford reviewed Mr Hartshorne’s ECG test result. He found
that Mr Hartshorne’s heart rhythm was bradycardic (slow) and assessed that he
needed a heart scan. The GP referred Mr Hartshorne to a cardiologist (a heart and
blood vessel specialist) at a local hospital.
30. On 12 January, a GP recorded that Mr Hartshorne’s QRisk score had increased to
over 25%. He noted that Mr Hartshorne had already been referred to a cardiologist.
31. Over the next few weeks, the prison’s Healthcare Champions (prisoners trained to
undertake basic clinical tasks) took Mr Hartshorne’s observations regularly. This
included his blood pressure and pulse. They recorded the readings and then a
nurse entered them onto Mr Hartshorne’s electronic medical record several days
later.
32. On 31 January, a nurse reviewed the clinical observations that had been taken by
the Healthcare Champions. She noted that Mr Hartshorne had low blood pressure,
so she asked for him to be seen by the GP for further blood pressure tests.
Events of 1 February 2023
33. At 12.55am on 1 February, Mr Hartshorne’s cellmate found Mr Hartshorne
collapsed on the floor of their cell. He said that he tried to wake Mr Hartshorne, but
he could not get a response. He pressed his emergency cell bell to alert staff.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
34. At 12.56am, an Operational Support Grade (OSG) answered the cell bell. She saw
Mr Hartshorne lying unresponsive on the cell floor, so she called a code blue (a
medical emergency code used when a prisoner is unconscious or having breathing
difficulties). Approximately three minutes later, a nurse and a healthcare assistant
attended Mr Hartshorne’s cell. The nurse monitored Mr Hartshorne and took clinical
observations while they waited for paramedics to arrive.
35. At 1.02am, an OSG rang the emergency services. The call handler asked her if the
patient was breathing, but she did not know, as she had not been given any
information on his condition.
36. At 2.10am, an ambulance arrived at Stafford. Paramedics attended Mr Hartshorne’s
cell and took over his treatment. Around 20 minutes later, the ambulance left
Stafford and took Mr Hartshorne to a local hospital.
37. A hospital doctor diagnosed a blood clot on the brain and Mr Hartshorne was taken
into surgery to have this removed. After his surgery, he was moved to the Intensive
Therapy Unit (ITU), and he was put on a ventilator to help him breathe.
38. Over the next two weeks, Mr Hartshorne’s health deteriorated, and he was unable
to breathe without the support of a ventilator. On 14 February, at approximately
12.30pm, Mr Hartshorne died after his life support was withdrawn.
Contact with Mr Hartshorne’s family
39. A prison manager contacted Mr Hartshorne’s family on 1 February to let them know
that he had been taken to hospital. On the day of Mr Hartshorne’s death, the prison
appointed a family liaison officer (FLO). The same day, the FLO went to the hospital
to introduce herself to Mr Hartshorne’s family, explain her role, and offer support.
She remained in contact with the family to ensure their questions were answered
and that Mr Hartshorne’s belongings were returned to them.
Support for prisoners and staff
40. After Mr Hartshorne’s death, a prison manager debriefed the staff who were present
at the hospital at the time of Mr Hartshorne’s death to ensure they had the
opportunity to discuss any issues arising, and to offer support. The staff care team
also offered support.
41. The prison posted notices informing other prisoners of Mr Hartshorne’s death and
offering support.
Post-mortem report
42. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The hospital doctor recorded Mr
Hartshorne’s cause of death as basilar artery thrombus (brain stem stroke). Atrial
fibrillation (a heart condition that causes an irregular and often abnormally fast heart
rate) was listed as a contributing factor.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Clinical care
43. The clinical reviewer found that the care Mr Hartshorne received at Stafford was of
a good standard and was equivalent to that which he could have expected to
receive in the community. However, she identified some issues.
44. The clinical reviewer found that when a nurse identified Mr Hartshorne as having
bradycardia and hypotension, she took appropriate action to assess, monitor and
ensure that he was referred to a cardiologist. However, there was no nursing care
plan in place for the management of Mr Hartshorne’s hypotension or bradycardia.
We recommend:
The Head of Healthcare should ensure that all patients with long term
conditions have an appropriate nursing care plan within their healthcare
record.
Head of Healthcare to note
45. The clinical reviewer found that Mr Hartshorne’s hypotension and bradycardia were
monitored by Healthcare Champions. Although the readings were reported back to
qualified nurses, the clinical reviewer found that there was a delay in the recording
of these results into Mr Hartshorne’s medical record. At interview the Head of
Healthcare said that this concern had already been noted and was being addressed
by the healthcare team.
46. The clinical reviewer found that the Healthcare Champions took clinical
observations using a battery-operated blood pressure machine, which also
recorded a pulse. The clinical reviewer noted that these machines were not suitable
for monitoring irregular pulses, for example in those with atrial fibrillation. She noted
that this reading should be taken manually by a qualified nurse who could correctly
identify irregularity in a pulse. The clinical reviewer also found that there was no
record of a physical review of the Healthcare Champion’s assessment by a qualified
nurse. These are issues that the Head of Healthcare will need to consider.
47. The clinical reviewer found that when Mr Hartshorne became unwell on 9 January
2023, the nurse who assessed him did not record a NEWS2 score. Inconsistent use
of NEWS2 by staff at Stafford is an issue that we have raised before. In May, we
were told that NEWS2 training was due to be delivered to healthcare staff by the
end of August 2023. The Head of Healthcare may wish to consider spot checks in
the meantime to ensure that NEWS2 is being used consistently.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Governor to note
Emergency response
48. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
says that when a code blue is called, the control room should call an ambulance
immediately.
49. There was a delay of six minutes between the code being called, and the control
room ringing the emergency services. This did not affect the outcome for Mr
Hartshorne given that there was an hour wait for the ambulance, but such a delay
could be critical in a future medical emergency.
50. Prison Service Instruction (PSI) 03/2013 says that the member of staff using the
medical emergency code must also provide relevant information about the condition
of the prisoner to the control room staff, so that they can pass it on to the
ambulance service for use in the triage process.
51. When the OSG called the code blue, she did not provide sufficient information on
Mr Hartshorne’s condition to the control room. As a result, the OSG in the control
room was unable to answer the emergency services call handler’s question “Is the
patient breathing?”. Although this did not affect the care Mr Hartshorne received, or
delay the arrival of the ambulance, we are concerned that if the control room are not
given sufficient information about the nature of the emergency and the patient’s
condition, it could result in the wrong category of ambulance being sent to
somebody. The Governor and Head of Healthcare will want to consider how to
ensure staff are aware of their responsibilities in a medical emergency.
Inquest
52. At the inquest, held on 29 July 2025, the Coroner concluded that Mr Hartshorne
died from natural causes.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE