John Reid

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Independent investigation into
the death of Mr John Reid,
a prisoner at HMP Winchester,
on 10 August 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, 2024
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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 HM Prisons 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 Reid died in hospital from COVID-19 on 10 August 2022, while a prisoner
at HMP Winchester. He was 58 years old. I offer my condolences to Mr Reid’s
family and friends.
4. The clinical reviewer found that Mr Reid’s care was equivalent to that which he
could have expected to receive in the community. However, he recommended that
newly arrived unvaccinated prisoners should be offered the COVID-19 vaccination;
prisoners should be moved to a suitable area for emergency and resuscitation
procedures; and healthcare staff should fully and accurately record medical events.
5. We identified additional concerns, including poor and inaccurate record keeping,
which we have raised in several previous investigations and therefore escalate to
the NHS commissioner; delays in allowing paramedics to enter and leave the
prison; and an ill-judged security risk assessment.
6. As Mr Reid tested positive for COVID-19 14 days after his remand to Winchester
(on the cusp of the accepted incubation period), we do not know whether he caught
the infection in the community before his remand, or in prison.
Recommendations
• The Governor should review the local Emergency Call Out Protocol 2018 and
ensure that there are no unnecessary delays in admitting and discharging
ambulances.
• The Head of Healthcare should ensure that in a medical emergency, the patient is
moved to an appropriate area where they can be fully assessed and treated.
• The NHS Commissioner for South Central should write to the Ombudsman, setting
out how they intend to improve clinical record keeping at HMP Winchester.
• The Governor and Head of Healthcare should ensure that all staff undertaking risk
assessments for prisoners taken to hospital understand the legal position on the
use of restraints and that in all cases:
• the medical information accurately reflects the prisoner’s current clinical
condition and impact on their ability to escape unaided; and
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• operational staff take account of this information and fully document all decisions
concerning the use of restraints.
• The Governor should ensure that staff complete all relevant sections of a prisoner’s
personal records and wing documents; and fully document all significant
interactions and decisions.
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The Investigation Process
7. NHS England commissioned an independent clinical reviewer to review Mr Reid’s
clinical care at HMP Winchester.
8. The PPO investigator investigated the non-clinical issues, including aspects of the
prison’s response to COVID-19 and shielding prisoners; Mr Reid’s location; the
security arrangements for his journey and admission to hospital; and liaison with his
family.
9. The investigator obtained from the coroner the name and contact details of Mr
Reid’s mother and daughter, his next of kin. The Ombudsman’s family liaison officer
wrote to them to explain the investigation. Mr Reid’s daughter asked for the
investigation to consider several issues around the circumstances leading to Mr
Reid’s death. They are listed in full in the clinical review and include the following
questions:
• What was Mr Reid’s condition when he went into prison, was he showing
signs of illness and when did he first become unwell?
• Was Mr Reid given a full examination and checked for anything other than
COVID-19?
• Given his rapid deterioration, why had medical staff not identified that Mr
Reid was seriously unwell?
• What was the ambulance response time?
10. The clinical review and this report address the issues relevant to Mr Reid’s clinical
management and cause of death.
11. We sent a copy of our report to Mr Reid’s daughter. She identified inaccuracies in
the investigation and clinical review reports, which have been amended. She also
raised issues which have been dealt with in correspondence.
12. The initial report was shared with HMPPS who found no factual inaccuracies. They
accepted our recommendations and their action plan is attached
Previous deaths at HMP Winchester
13. Mr Reid was the11th prisoner at Winchester to die since August 2020. Of the
previous deaths, seven were from natural causes (two related to COVID-19), two
were self-inflicted and one has yet to be determined. There have been two further
deaths, one from natural causes and the other self-inflicted. We have previously
made recommendations on clinical record keeping.
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Background Information
COVID-19 (coronavirus)
14. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
15. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. In response to the
pandemic, HM Prison and Probation Service (HMPPS) introduced several
measures to try and contain outbreaks - to be implemented at local level, depending
on the needs of individual prisons. (A key strategy was ‘compartmentalisation’ to
cohort and protect prisoners at high and moderate risk; isolate those who are
symptomatic; and separate newly arrived prisoners from the main population.)
16. In September 2021, the shielding programme ended in the community, but HMPPS
continued to routinely offer shielding to clinically high-risk prisoners. This has
recently been replaced by a system of individual risk assessments by clinical staff,
to determine the measures necessary to support such prisoners. The agreed
adjustments are documented in a Personal Management Plan, which is then
facilitated by operational staff.
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Key Events
17. Mr John Reid was remanded to HMP Winchester on 27 July 2022. He had been
charged with several offences, including harassment and threatening a person with
an offensive weapon.
18. Healthcare staff completed initial and second-stage health assessments on 27 and
28 July, respectively. This included clinical observations, such as checks of Mr
Reid’s blood pressure and temperature. No physical or mental health concerns
were identified. Mr Reid was fit and well and needed no medication.
19. Mr Reid went through the prison’s induction procedures. Nothing was recorded in
his personal records (NOMIS) over the following two weeks and he had no contact
with healthcare staff.
Events of 10 August
20. At around 10.00am on 10 August, Mr Reid tested positive for COVID-19 (we do not
know what prompted the test). At midday, a wing officer noticed that he seemed
unwell.
21. Two nurses examined Mr Reid in his cell and found he was grey, with a mottled
appearance on his hands and feet, cold and drowsy. Although he was alert, the
nurses were unable to take his blood pressure, pulse rate, or blood oxygen
saturation readings. The nurses called a code blue medical emergency and an
ambulance was requested at 12.08pm. They gave Mr Reid oxygen and glucose
while waiting.
22. Paramedics arrived at the prison at 12.37pm and reached the cell at 12.45pm.
Prison officers helped them to move Mr Reid from the top bunk of the bed to the
landing. The paramedics had similar problems to the nurses when they tried to take
clinical observations.
23. At around 1.10pm, Mr Reid went into cardiac arrest and stopped breathing. The
paramedics began cardiopulmonary resuscitation (CPR) and requested another
ambulance crew, which arrived a few minutes later. Mr Reid’s pulse returned
intermittently, but he had a further cardiac arrest.
24. CPR continued while Mr Reid was taken from the landing to the ambulance and
throughout the journey to hospital. He was escorted, without restraints, by two
prison officers.
25. Mr Reid arrived at the hospital at 1.30pm. His death was confirmed at 2.09pm.
26. The prison assigned a family liaison officer shortly after the ambulance left the
prison. While he and his deputy were discussing Mr Reid’s condition and reviewing
his records, they were told that he had died. No next of kin contact details had been
recorded. The family liaison officer checked with the police liaison officer and Mr
Reid’s community GP surgery and staff searched his cell for possible contacts. Mr
Reid had made no telephone calls in prison and a telephone number listed in his
records was out of service.
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27. A prison manager debriefed staff and offered support. Mr Reid’s cell mate received
a welfare check. The prison issued notices to other staff and prisoners, informing
them of Mr Reid’s death and reminding them of the avenues of support.
Post-mortem report
28. The post-mortem report concluded that Mr Reid died from COVID-19 infection.
Coronary artery atheroma (a build-up of fatty deposits on the walls of the arteries
around the heart) was listed as a contributory factor.
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Findings
Clinical Findings
29. The clinical reviewer considered that Mr Reid’s clinical care at Winchester was of a
reasonable standard and equivalent to that which he could have expected to
receive in the community. However, he identified deficiencies in Mr Reid’s care,
which we reflect in this report.
Management of Mr Reid’s risk of infection from COVID-19
30. To reduce the risk of infection, the HMPPS COVID-19 policy at the time of Mr
Reid’s death required new prisoners to be isolated away from the main population
for up to 14 days (known as reverse cohorting). Winchester held such prisoners on
two dedicated landings, C3 and C4 on the induction wing, and there were detailed
local operating procedures for the management of those landings. Although not
explicitly recorded, Mr Reid appears to have isolated, as he was given a cell on C3.
(We were unable to verify either this, or the cohort status of Mr Reid’s cell mate, as
the prison did not provide the relevant wing document.)
31. When Mr Reid arrived at Winchester, his health assessments identified no existing
health conditions or concerns. However, there is no evidence that his COVID-19
vaccination status was checked, or that he was offered the opportunity to receive
the vaccine.
32. As Mr Reid died 14 days after his remand to prison, it is unlikely that he would have
benefitted from the vaccine, as protection from the first dose begins around three or
four weeks after it is received. Since Mr Reid’s death, the Head of Healthcare has
reviewed the prison’s vaccination clinics. She has included this issue on the risk
register and implemented monitoring arrangements. In view of these steps, we
make no further comment.
33. The reason that Mr Reid was tested for COVID-19 was not documented in either his
medical or personal records, but the investigator was told that it was because he
had reported symptoms of COVID-19. The only reference to his positive test was a
brief entry by a clinical administrator, written shortly after his death. (We address
record keeping later in the report.)
34. As the incubation period for COVID-19 is thought to be between 2 and 14 days, we
cannot say whether Mr Reid caught the infection in the community, or in prison.
Emergency response
35. Prison Service Instruction (PSI) 3/2013, Medical Emergency Response Codes, sets
out the actions staff should take in a medical emergency. This includes a mandatory
requirement that prisons must, “…prevent any unnecessary delay in escorting
ambulances and paramedics to the patient and discharging them from the prison
(with or without the patient) …”
36. Winchester and South Central Ambulance Service have a jointly agreed Emergency
Call Out Protocol 2018, developed in conjunction with the local healthcare
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commissioner and local ambulance trust. The protocol is supposed to be reviewed
annually, or automatically if the agreed procedures are not fulfilled.
37. The paramedics recorded that there was a long delay in getting to Mr Reid’s cell,
and leaving the prison, as they had to be escorted through several locked gates.
Records show that after arriving at the prison, it took at least eight minutes for the
paramedics to reach the cell.
38. Healthcare staff initially treated Mr Reid on the top bunk of the cell bed. He was
moved at the request of the paramedics. The clinical reviewer noted that the clinical
assessment by healthcare staff might have been more effective if Mr Reid had been
moved to a more suitable space.
39. The clinical reviewer was also concerned that the sequence of events during the
emergency response was unclear, as staff actions were not recorded in sufficient
detail. The quality of healthcare record keeping is a matter that we have raised at
Winchester several times. We recommend:
The Governor should review the local Emergency Call Out Protocol 2018 and
ensure that there are no unnecessary delays in admitting and discharging
ambulances.
The Head of Healthcare should ensure that in a medical emergency, the
patient is moved to an appropriate area where they can be fully assessed and
treated.
The NHS Commissioner for South Central should write to the Ombudsman,
setting out how they intend to improve clinical record keeping at HMP
Winchester.
Security risk assessments
40. 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.
41. A judgment in the High Court in 2007 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 he has a serious medical
condition. The judgment indicated 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.
42. These requirements are reflected in the Prison Service policy on the use of
restraints, which encourages sensitive handling to ensure that the needs of security
are balanced against the clinical needs of a seriously ill prisoner. It also makes clear
that the handcuffing of a prisoner receiving lifesaving treatment must be justified by
documented security considerations which are specific to the prisoner.
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43. Mr Reid had been resuscitated after a cardiac arrest and lost consciousness
several times during the resuscitation attempts. Paramedics continuously performed
CPR from the cell to the ambulance (and during the journey). Despite this clinical
background, the medical section of the security risk assessment was ticked to
indicate that Mr Reid’s medical condition did not impact on the escort and there
were no objections to the use of restraints. The only written comment was that Mr
Reid was COVID-19 positive.
44. The security risk assessment concluded that Mr Reid was a low risk of escape and
the likelihood of outside assistance was also low. The authorising manager (head of
operations) instructed that Mr Reid should be restrained with double handcuffs,
which could be reduced to an escort chain for treatment. This decision was
rescinded, but the change was not documented. The prison informed the
investigator that a custodial manager had verbally told the escort officers not to use
restraints.
45. Although restraints were not actually used, we are concerned that they were
authorised while paramedics were still actively resuscitating Mr Reid after a cardiac
arrest. The judgements in the risk assessment suggest that some prison and
healthcare staff were either unfamiliar with, or ignored the guidance on use of
restraints. A further concern is that the retraction of the decision on restraints was
not documented.
46. Since Mr Reid’s death, representatives from the PPO and HMPPS’ senior casework
team have delivered a joint awareness session on this issue to senior managers at
the prison. The Head of Safety has also briefed staff on learning from escorts and
the Group Safety Team complete regular checks of risk assessments and feed back
to the team. We hope this has helped to improve the quality of security risk
assessments. We recommend:
The Governor and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners taken to hospital understand the legal
position on the use of restraints and that in all cases:
• the medical information accurately reflects the prisoner’s current clinical
condition and impact on their ability to escape unaided; and
• operational staff take account of this information and fully document all
decisions concerning the use of restraints.
Record keeping
47. The investigation found several examples of poor and inaccurate record keeping.
48. Very little was recorded about Mr Reid. His personal prison record (NOMIS) was
blank, except for the details of a restraining order and a few personal details (his
name, date of birth, age, ethnicity and level on the incentives scheme). No
interactions with staff were recorded, neither were there any alerts about risks, or
reverse cohorting dates. The date of Mr Reid’s remand to Winchester and his
remand status were added to NOMIS after his death.
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49. One of the induction forms, dated 27 July and signed by an officer, suggested that
Mr Reid had declined to give emergency contact details. Mr Reid had not signed the
section for prisoners to confirm this.
50. The national COVID-19 policy, at that time, required prisons to record periods of
reverse cohorting, shielding and protective isolation in prisoners’ personal records.
In addition, Winchester’s local policy stated that prisoners on the reverse cohorting
unit should be identified and added to the C wing COVID-19 new reception
spreadsheet. Prison staff were expected to include the prisoner’s reception date
and when they would relocate to a standard wing. The prison did not provide the
spreadsheet.
51. The Notice to Staff about Mr Reid’s death, issued on 11 August, stated that his
family had been informed of his death and were being supported. This was not the
case. We recommend:
The Governor should ensure that staff complete all relevant sections of a
prisoner’s personal records and wing documents; and fully document all
significant interactions and decisions.
Contacting Mr Reid’s next of kin
52. The family liaison officer unsuccessfully tried to identify Mr Reid’s next of kin
through several sources.
53. In September 2022, the investigator asked the coroner’s officer to share the details
of Mr Reid’s next of kin with the PPO and the prison, if they had been traced. This
was provided to the PPO in October. However, towards the end of the investigation,
it came to light that the prison had not been informed.
54. A prison manager explained that the family liaison officer was new to the role and
had not been fully trained, as there were no training courses during the COVID-19
pandemic. She did not contact the coroner, as she thought there was no family
involvement. The prison has since contacted Mr Reid’s family to offer a contribution
to funeral expenses. In view of the mitigating circumstances, we make no further
comment.
Adrian Usher
Prisons and Probation Ombudsman February 2024
Inquest
The inquest, held on 11 March 2024, concluded that Mr Reid died from natural causes.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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