John Rombach

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Independent investigation into
the death of Mr John Rombach,
a prisoner at HMP Stafford,
on 17 July 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 Rombach died from lung cancer on 17 July 2023 at HMP Stafford. Mr
Rombach was 76 years old. We offer our condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Rombach received at
Stafford was equivalent to that which he could have expected to receive in the
community. The clinical reviewer made six recommendations which were not
relevant to Mr Rombach’s death but which the Head of Healthcare will need to
address.
5. We found no evidence that the decision to restrain Mr Rombach when he was taken
to hospital was justified given his terminal diagnosis, deteriorating health and poor
mobility.
6. We also concluded that Mr Rombach’s second application for early release on
compassionate grounds was not adequately or promptly progressed.
Recommendations
• The Governor and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners who are attending hospital appointments:
• complete the risk assessment documents in full, clearly setting out their
rationale for the decisions; and
• understand the legal position on the use of restraints, including that their
assessments fully take into account the prisoner’s health and are based
on the actual risk the prisoner presents at the time.
• The Governor and Head of Healthcare should ensure that there is a robust
process in place to ensure that applications for early compassionate release
are properly monitored and completed without delay.
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The Investigation Process
7. HMPPS notified us of Mr Rombach’s death on 17 July 2023.
8. NHS England commissioned an independent clinical reviewer to review Mr
Rombach’s clinical care at HMP Stafford.
9. The PPO investigator investigated the non-clinical issues relating to Mr Rombach’s
care.
10. The PPO family liaison officer wrote to Mr Rombach’s son to explain the
investigation and to ask if he had any matters he wanted us to consider. He did not
have any questions.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
12. Mr Rombach’s son received a copy of the draft report. They did not make any
comments.
Previous deaths at HMP Stafford
13. Mr Rombach was the twenty-sixth prisoner to die at Stafford since 17 July 2020. Of
the previous deaths, twenty-three were from natural causes, two were self-inflicted
and one is yet to be ascertained. There are no similarities between the findings in
our investigation into Mr Rombach’s death and the findings from our investigations
into the previous deaths.
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Key Events
14. On 15 April 2021, Mr John Rombach was sentenced to sixteen years in prison for
sex offences and he was transferred to HMP Stafford on 24 May.
15. Before his arrival, Mr Rombach had been diagnosed with type 1 and 2 diabetes and
chronic obstructive pulmonary disease (COPD, a group of lung conditions).
16. On 11 October 2021, Mr Rombach was sent to hospital for a chest X-ray. A second
X-ray and a lung function test was carried out on 24 December.
17. On 28 January 2022, a nurse made an entry in Mr Rombach’s medical records. She
recorded that Mr Rombach had spoken to a respiratory physician on 19 January
and was told that he had suspected lung cancer.
18. On 3 February, Mr Rombach went to hospital for a biopsy.
19. On 17 February, a nurse noted that Mr Rombach had been diagnosed with lung
cancer and a cancer care plan had been created.
20. On 20 September, Mr Rombach attended the oncology clinic at the hospital. He
was told that his cancer had spread, it was not curable and any subsequent
treatment would only manage symptoms and extend his life.
21. On 11 October, Mr Rombach missed an appointment with the hospital oncology
clinic because the taxi that had been booked failed to arrive and another one could
not be arranged in time.
22. On 12 December, the prison completed a personal emergency evacuation plan
(PEEP) for Mr Rombach. It stated that he had limited mobility and used a walking
stick on the landing and a wheelchair when he left the wing.
23. On 10 January 2023, Mr Rombach attended hospital to have fluid removed from his
lungs. Before he left the prison, staff completed an escort risk assessment. A nurse
completed the medical section. She did not object to the use of restraints and
indicated that Mr Rombach’s condition did not restrict his ability to move unaided
and that he was neither seriously nor terminally ill.
24. Mr Rombach was assessed as posing a high security risk to his victim and a
medium security risk in all other areas. There was no escape history documented.
The decision was made to restrain Mr Rombach using a single cuff (where
the prisoner is handcuffed to a prison officer).
25. At approximately 7.55am on 22 January, an officer on the wing called a code blue
as Mr Rombach had complained of chest pain. A nurse attended and took his
physical observations. Mr Rombach’s National Early Warning Score (NEWS2, a tool
to detect and respond to clinical deterioration) was five so the decision was made to
send him to hospital.
26. Before Mr Rombach left the prison, a Custodial Manager (CM) completed the
medical risk assessment form. He indicated that there were no medical objections
to the use of restraints and Mr Rombach’s condition did not restrict his ability to
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move unaided. However, he indicated that Mr Rombach was either seriously or
terminally ill.
27. The CM also completed the security assessment form and assessed that Mr
Rombach posed a low risk in all areas, except for his risk to the public and females
which was high. The decision was made to restrain Mr Rombach using an escort
chain (a long chain with a handcuff at each end, one of which is attached to the
prisoner and the other to an officer).
28. On 30 January, the prison began the application process for Mr Rombach to be
considered for early release on compassionate grounds (ERCG).
29. On 8 February, Mr Rombach was discharged from hospital and returned to the
specialist care unit at Stafford.
30. On 8 February, a prison offender manager (POM) completed his report for the
ERCG application.
31. On 21 February, a GP operating at the prison completed the medical report for the
ERCG application. He stated that Mr Rombach was relatively well but was due to
have a stent (a wire mesh that opens up an artery) fitted and he may be considered
too ill for chemotherapy. He said that if this was the case, his life expectancy would
only be a few months.
32. On 28 February, Mr Rombach attended hospital for an oncology appointment. A
nurse completed the medical risk assessment, indicating that there were no medical
objections to the use of restraints and that Mr Rombach’s condition did not restrict
his ability to move unaided. He indicated that Mr Rombach was neither seriously
nor terminally ill. Mr Rombach was assessed as posing a high security risk to the
public due to his offence but a low security risk in all other areas. The decision was
made to restrain Mr Rombach using an escort chain.
33. On 1 March, a nurse noted in the medical records that Mr Rombach had been told
by the consultant that they were unable to offer him any further treatment and a do
not attempt pulmonary resuscitation (DNAPR) order was put in place.
34. On 10 March, a community offender manager (COM) submitted her report for the
ERCG application.
35. On 18 March, a nurse completed Mr Rombach’s medical risk assessment ahead of
his hospital appointment scheduled for 21 March. She indicated that there were no
medical objections to the use of restraints, Mr Rombach’s medical condition did not
restrict his ability to move unaided and he was neither seriously nor terminally ill.
36. The security risk assessment was completed on 19 March. Mr Rombach was
assessed as posing a medium risk to hospital staff, the public and females and a
low risk in all other areas. The prisoner clothing form completed set out that Mr
Rombach was wearing a medical boot. He was restrained using a single cuff.
37. On 23 March, the Governor completed the required section of the ERCG application
form.
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38. On 23 March, staff completed the security risk assessment for Mr Rombach ahead
of his hospital appointment scheduled for 27 March. He was assessed as posing a
medium risk in all areas and the decision was made to restrain Mr Rombach using a
single cuff. However, this was changed to an escort chain on 27 March as Mr
Rombach was in a wheelchair and unable to walk.
39. On 26 March, a nurse completed the medical risk assessment which indicated that
there were no medical objections to the use of restraints and that Mr Rombach’s
medical condition did not restrict his ability to move unaided. She indicated that Mr
Rombach was neither seriously nor terminally ill.
40. On 29 March, the ERCG application was submitted to the Public Protection
Casework Section (PPCS) of HMPPS.
41. On 6 April, PPCS notified the prison that Mr Rombach’s application had been
refused because his prognosis was greater than 12 months and he was receiving
cancer treatment. This was shared with Mr Rombach on 11 April.
42. On 3 May at approximately 10.45am, a nurse carried out an examination of Mr
Rombach as he had complained of discomfort in his abdomen. Healthcare carried
out a bladder scan and decided that Mr Rombach should be admitted to hospital.
43. Before he left the prison, staff completed an escort risk assessment. The medical
risk assessment form was not completed in full and no details were noted about the
person who completed the form.
44. The security assessment indicated that Mr Rombach was considered to pose a
medium risk to public, hospital staff and females and a low risk in all other areas. It
was decided that Mr Rombach should be restrained using an escort chain.
45. On 5 May, the Clinical Manager notified the Offender Management Unit (OMU) that
Mr Rombach’s family wanted to appeal the ERCG decision because his situation
had changed, he was receiving palliative care and was no longer receiving
treatment. Later that day, a worker from OMU emailed colleagues to advise that a
new ERCG application would need to be completed.
46. On 10 May, Mr Rombach returned to the specialist care unit at Stafford.
47. On 16 May, the Clinical Manager noted in the medical records following a multi-
disciplinary meeting that a doctor needed to complete the ERCG paperwork. That
day, a prison GP noted in the medical records that Mr Rombach’s prognosis was
uncertain but given the progression on the CT scan, he believed his life expectancy
was less than three months.
48. On 4 July, a prison GP saw Mr Rombach and noted that Mr Rombach only had a
few weeks left to live.
49. At 11.40pm on 16 July, a nurse, who had been sitting with Mr Rombach, saw him
take his last breath. At 3.48am on 17 July, paramedics confirmed his death.
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Post-mortem report
50. The Coroner accepted the cause of death provided by the prison doctor and no
post-mortem examination was carried out.
51. The doctor gave Mr Rombach’s cause of death as pulmonary adenocarcinoma
(lung cancer). He also had ischaemic heart disease (where the heart is starved of
oxygen due to a lack of blood flow), type 1 diabetes mellitus (the body does not
produce enough insulin) and COPD. These conditions contributed to but did not
cause his death.
Inquest into Mr Rombach’s death
52. Th inquest into Mr Rombach’s death was held on 26 July 2023 and a verdict of
natural causes was recorded.
53. The coroner concluded Mr Rombach’s death was due to pulmonary
adenocarcinoma.
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Non-Clinical Findings
Restraints, security and escorts
54. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It 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.
55. The Prevention of Escapes: External Escorts Policy Framework states that
escorting seriously or terminally ill prisoners requires sensitive handling to ensure
that the needs of security are balanced with the clinical needs of the prisoner.
Individual risk assessments need to make the distinction between the risk of escape
and harm posed by the prisoner when fit and those risks posed by that prisoner
when he has a serious medical condition.
56. Mr Rombach was restrained using a single cuff or an escort chain for every hospital
appointment from 1 January 2023 onwards. We identified a number of issues:
Medical risk assessments
57. Mr Rombach was diagnosed with terminal cancer on 20 September 2022. In
December 2022, Stafford’s PEEP assessment for him concluded that he needed a
walking stick to move around the wing and a wheelchair when he left the wing.
58. Despite this information, healthcare staff completing the risk assessment forms for
10 January, 28 February, 21 and 27 March indicated that Mr Rombach’s medical
condition and age did not restrict his ability to move unaided. They also repeatedly
stated that Mr Rombach was neither seriously nor terminally ill when this was not
the case.
59. The medical risk assessment of 21 January was completed by a custodial manager
rather than a clinician and the medical risk assessment on 3 May was only partially
completed.
Security risk assessments
60. Mr Rombach’s security information was checked for each escort risk assessment.
He had no history of escape and was identified as being either a standard or
enhanced prisoner, with no poor behaviour noted. However, his risk rating (against
specific risk factors) varied from assessment to assessment, and was not supported
by evidence.
61. Given the issues identified with both aspects of the security risk assessment
process we make the following recommendations:
The Governor and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners who are attending hospital appointments:
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• complete the risk assessment documents in full, clearly setting out
their rationale for their decisions; and
• understand the legal position on the use of restraints, including that
their assessments fully take into account the prisoner’s health and are
based on the actual risk the prisoner presents at the time.
Compassionate release
62. Release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. A clear
medical opinion of life expectancy is required. The criteria for early release are set
out in the Early Release on Compassionate Grounds Policy Framework. Among the
criteria is that the risk of reoffending is expected to be minimal, further imprisonment
would reduce life expectancy, there are adequate arrangements for the prisoner’s
care and treatment outside prison, and release would benefit the prisoner and his
family. An application for early release on compassionate grounds must be
submitted to the Public Protection Casework Section (PPCS) of HM Prison and
Probation Service (HMPPS).
63. The prison started the application for ERCG on 30 January, at which time Mr
Rombach was receiving treatment for lung cancer and had a life expectancy greater
than 12 months. This application was refused.
64. On 5 May, following contact from Mr Rombach’s family who wanted to appeal the
ERCG decision due to a change in Mr Rombach’s circumstances, the COM emailed
the healthcare team to say that a new ERCG application was to be made and they
should provide OMU with the required information. However, a new application was
never completed.
65. OMU told the investigator that a new application was not submitted because the
required medical update from the healthcare team was never received which meant
that the POM and COM were unable to provide their report. Despite asking, the
Head of Healthcare did not explain why they did not provide a report.
66. While there are no prescribed timescales for completing an ERCG application, it is
imperative, given the short life expectancy of the prisoner, that applications are
progressed as quickly as possible. We therefore make the following
recommendation:
The Governor and Head of Healthcare should ensure that there is a robust
process in place to ensure that applications for early compassionate release
are properly monitored and completed without delay.
Adrian Usher
Prisons and Probation Ombudsman February 2024
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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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