John Tunney

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Independent investigation into the
death of Mr John Tunney,
a prisoner at HMP Northumberland,
on 16 March 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, 2024
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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.
If my office is to best assist HM 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 Tunney died from pneumonia in hospital, on 16 March 2023, while a prisoner at
HMP Northumberland. He was 79 years old. I offer my condolences to Mr Tunney’s family
and friends.
The clinical reviewer concluded that, overall, Mr Tunney’s clinical care was equivalent to
that which he could have expected in the community.
While staff completing Mr Tunney’s security risk assessment acknowledged his advanced
age, frailty and medical condition, these factors were given insufficient weight in the
decision-making. I consider that the use of restraints on this elderly wheelchair user was
disproportionate to his risk and does not reflect well on the prison.
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 November 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
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Summary
Events
1. Mr John Tunney transferred to HMP Northumberland on 22 June 2017, while
serving a prison sentence of 12 years and 4 months for sexual offences.
2. In January 2022, Mr Tunney was diagnosed with fluid between his lungs and chest
wall. Over the next few months, he became increasingly frail, and his mobility
decreased. He received help with cell tasks, collecting meals and was given access
to a wheelchair and walking aids. Towards the end of the year and at the beginning
of 2023, Mr Tunney had recurrent falls and staff noticed that he had lost a
significant amount of weight.
3. On 8 March 2023, a GP at the prison noted that Mr Tunney was seriously
underweight and requested tests. The next day, after another fall and irregular
clinical observations, Mr Tunney was admitted to hospital, where he was initially
diagnosed with a bleed in his brain.
4. Mr Tunney died from pneumonia on 16 March. Frailty and heart failure contributed
to his death.
Findings
5. The clinical reviewer concluded that Mr Tunney’s clinical care was equivalent to that
which he could have expected to receive in the community. However, she identified
some weaknesses which the Head of Healthcare should consider.
6. In spite of Mr Tunney’s age, frailty, limited mobility and poor medical condition, an
escort chain was used for his final journey and admission to hospital. This decision
was inconsistent with HMPPS’ policy on security risk assessments and the use of
restraints.
Recommendation
• The Director 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:
• healthcare staff complete the medical section of the escort risk assessment to
say whether the prisoner’s current medical condition affects their mobility and
risk of escape; and
• authorising managers show that they have taken this information into account
when assessing a prisoner’s current level of risk.
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The Investigation Process
7. HMPPS notified us of Mr Tunney’s death on 16 March 2023. The investigator
issued notices to staff and prisoners at HMP Northumberland informing them of the
investigation and asking anyone with relevant information to contact her. No one
responded.
8. The investigator obtained copies of relevant extracts from Mr Tunney’s prison and
medical records.
9. NHS England commissioned an independent clinical reviewer to review Mr
Tunney’s clinical care at the prison. The investigator and the clinical reviewer jointly
interviewed four healthcare staff on 11 May, using Microsoft Teams
videoconferencing.
10. We informed HM Coroner for Northumberland of the investigation. He gave us the
cause of death. We have sent the coroner a copy of this report.
11. The Ombudsman’s family liaison officer contacted Mr Tunney’s sister, his
nominated next of kin, to explain the investigation and to ask if she had any matters
for the investigation to consider. She did not reply.
12. The initial report was shared with HMPPS, and they found no factual inaccuracies.
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Background Information
HMP Northumberland
13. HMP Northumberland is a Category C prison, located near Morpeth, with an
operational capacity of 1,348 adult men. Sodexo Justice Services manages the
prison under contract from the Ministry of Justice.
14. Spectrum Community Health provides healthcare services. Nurses are on duty
during the day and early evening. In addition to the NHS 111 service, prison staff
can speak to a GP or Advanced Nurse Practitioner provided by Spectrum, for
advice out-of-hours.
HM Inspectorate of Prisons
15. The most recent inspection of HMP Northumberland was in August and September
2022. Inspectors considered that the commissioned healthcare staffing profiles
were insufficient to meet demand, but staff worked flexibly and were committed to
providing good care. There was limited capacity for the GPs service to meet
additional demand and there were extended waiting times for services, such as
reviews of long-term conditions.
16. Inspectors reported that healthcare facilities were clean and patient records were
reasonable. PPO recommendations were addressed and shared at a monthly
forum. The Care Quality Commission issued ‘requirement to improve’ notices after
the inspection.
Independent Monitoring Board
17. 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 31 December 2022, the IMB
reported that the healthcare provider had experienced staffing and leadership
difficulties, which had led to unreliability in provision. Recruitment of additional staff
and a locum GP had led to some improvement.
Previous deaths at HMP Northumberland
18. Mr Tunney was the nineteenth prisoner at Northumberland to die since March 2020.
Of the previous deaths, eleven were from natural causes, six were self-inflicted and
one was due to substance misuse. There have been two further deaths from natural
causes.
19. We have previously made a recommendation about security risk assessments and
the inappropriate use of restraints. Northumberland undertook to provide training for
those involved in completing such assessments, as well as a briefing for healthcare
staff. They also intended to quality assure ten per cent of completed risk
assessments and discuss the findings at safer prisons and security meetings
chaired by the Director and Deputy Director, respectively.
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Key Events
20. Mr John Tunney was convicted of sexual offences on 23 June 2016 and remanded
to HMP Durham. On 11 October, he was sentenced to 12 years and 4 months
imprisonment, with an extended licence period of one year. Mr Tunney transferred
to HMP Northumberland on 22 June 2017.
21. At his reception health screen, Mr Tunney’s health conditions were noted as
rheumatoid arthritis and atrial fibrillation (an irregular and fast heartbeat).
22. In November 2021, Mr Tunney had symptoms of pneumonia and pleural effusion
(excessive fluid between the lungs and the chest wall). He was formally diagnosed
with the latter condition in January 2022 and was initially treated in hospital. The
respiratory medicine team continued to manage his condition as an outpatient after
he was discharged.
23. During 2022, Mr Tunney’s key workers noted that he was increasingly frail and
struggling to breathe. He received help to collect meals and clean his cell, as well
as use of a wheelchair and walking aids.
24. On 17 December, Mr Tunney had a fall. There were conflicting accounts about its
severity. Wing staff indicated that he had hit his head, whereas healthcare staff
recorded that had felt dizzy and fell onto a chair. He was examined by a nurse and
no injuries were found.
25. On 30 December, a prisoner raised concerns about Mr Tunney’s weight. A nurse
examined and weighed him. He also underwent blood tests and screening for
malnutrition.
2023
26. By January 2023, Mr Tunney was increasingly using a wheelchair. Wing staff
documented his weight loss and restricted mobility in his personal records and later
raised concerns with healthcare staff.
27. Mr Tunney had further falls on 25 and 28 February. After the latter, the healthcare
team discussed him at the safety huddle (a short, daily multidisciplinary briefing
about patients most at risk). They noted his recurrent falls, weight loss and that he
was throwing away his food.
28. On 8 March, a GP at the prison examined Mr Tunney. The GP recorded that he was
‘massively underweight’ and requested blood and urine tests to determine whether
he had an infection. He also referred him to the dietitian and prescribed a dietary
supplement.
Events of 9 March
29. In the early hours of 9 March, Mr Tunney had a fall, but was able to get back into
bed unaided when night staff attended. Later that morning, a wing officer was
worried and asked healthcare staff to check him again. Mr Tunney looked and
sounded unwell, did not have enough strength to engage with staff and was in pain
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all over his body. On the advice of healthcare staff, the officer checked him several
times during the morning.
30. Mr Tunney’s carer told a nursing associate about the earlier falls. The nurse
discussed this with colleagues at the safety meeting and the GP, who asked her to
take clinical observations and assess whether his falls were mechanical or due to
collapse.
31. Just before 4.00pm, the nurse reviewed Mr Tunney in his cell. He was too weak to
stand, and both his blood pressure and blood oxygen saturation level were low.
Using the National Early Warning Score 2 (NEWS2), she calculated a score of 9,
which indicated the need for emergency assessment by a critical care team and
possible high dependency care. (NEWS2 is a clinical assessment tool to detect
acute illness.)
32. Paramedics took Mr Tunney to hospital. He was escorted by two prison officers and
handcuffed with an escort chain (which was removed the following day). A CT scan
showed that Mr Tunney had an acute subdural haemorrhage (bleeding in the brain
caused by a head injury) and he was admitted as an inpatient for neurological
observations and treatment. Healthcare staff sought updates from the hospital, but
there was no contact for a few days between 12 and 15 March.
Contact with Mr Tunney’s Family
33. On 13 March, the prison assigned a family liaison officer (FLO). She informed Mr
Tunney’s sister that Mr Tunney was in hospital and gave details of his condition.
34. On 15 March, it was decided that Mr Tunney could not return to the prison or leave
hospital, as he needed constant medical care. The FLO updated his sister.
35. Mr Tunney died at 3.05am on 16 March. The FLO and a colleague visited his sister
to break the news and offer support. She also informed another family member
through their solicitor.
36. In line with national policy, the prison contributed to the costs of Mr Tunney’s
funeral, which was held on 3 April.
Support for prisoners and staff
37. The prison posted notices informing staff and other prisoners of Mr Tunney’s death
and signposting the avenues of support.
Cause of death
38. No post-mortem examination was carried out. The coroner accepted certification by
a hospital doctor that the cause of Mr Tunney’s death was pneumonia. Frailty and
chronic heart failure were listed as contributory factors.
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Findings
Clinical care
39. The clinical reviewer concluded that, overall, Mr Tunney’s clinical care was of a
good standard and equivalent to that he could have expected to receive in the
community. She considered that his chronic medical conditions were appropriately
monitored, but identified shortcomings, which are explained in detail in the clinical
review report. We comment on the clinical issues later in this report.
Security risk assessments and the use of restraints
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 a 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 HMPPS’ Prevention of Escape – External
Escorts Policy Framework, on the use of restraints. The policy encourages sensitive
handling to ensure that the needs of security are balanced against the clinical
needs of a seriously ill prisoner. The expectation is that restraints should not be
used when mobility is severely limited due to advanced age, or disability, unless
there is intelligence to suggest that an escape attempt might be made.
43. Mr Tunney was a 79-year-old, Category C prisoner, on the enhanced level of the
prison’s privileges scheme. There had been no disciplinary problems in prison, nor
any concerns about his behaviour during hospital visits. His frailty and diminished
mobility were well documented by clinical and operational staff.
44. The medical section of Mr Tunney’s escort risk assessment form was blank. He was
assessed as low risk on all the specific factors of concern, such as the risk of
escape and the likelihood of assistance to do so. The person who completed the
risk assessment recommended the use of handcuffs, but the duty manager who
took the decision reduced the level of restraints to an escort chain. He noted the
reason for his decision as, “… due to frail elderly prisoner and medical condition…”
45. Although the duty manager acknowledged Mr Tunney’s frailty, he seemed not to
have taken it into account in considering the necessity of restraints and therefore
failed to comply with the guidance. The Ombudsman has repeatedly criticised
HMPPS culture on this issue as being too risk averse and there not being a
sufficiently strong body of evidence to support that aversion. We recommend:
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The Director 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:
• healthcare staff complete the medical section of the escort risk
assessment to say whether the prisoner’s current medical condition
affects their mobility and risk of escape; and
• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk.
Director and Head of Healthcare to Note
Assessment and monitoring of Mr Tunney’s falls
46. The clinical reviewer noted inconsistencies between operational and healthcare
staff in recording and communicating medical incidents, as well as weaknesses in
assessing and monitoring Mr Tunney’s fall. Notably, there were significant
anomalies in the description of his fall on 17 December 2022.
47. In response to this, the Head of Healthcare and Head of Residence were working
together to improve communication and the reporting of incidents. However, there
had been some difficulty in addressing overnight reporting when there are no
healthcare staff on duty.
48. Additionally, no falls risk assessments were completed after Mr Tunney’s falls and
no clinical observations were taken on 25 February 2023. Although Mr Tunney was
discussed at a lunchtime safety huddle meeting on 28 February, no further
assessments were planned.
49. The Head of Healthcare said that falls risk assessments had already been
implemented for new prisoners who are over 70 years old, and he was working on
new processes to ensure that they are automatically completed after a fall.
50. We are satisfied that work is in progress to ensure consistency in completing falls
risk assessments; clinical observations; and improving accuracy in recording and
communicating medical incidents. In view of the actions already taken, we make no
further comment, but the Director and Head of Healthcare will need to address the
formal recommendations in the clinical review.
Contact with Mr Tunney’s next of kin
51. Prison Service Instruction (PSI) 64/2011, about safer custody, states that prisons
must have arrangements in place for an appropriate member of staff to engage with
the next of kin of prisoners who are either terminally or seriously ill. In addition, the
PSI and Prison Rule 22 says that a prisoner’s next of kin should be informed
immediately if they become seriously ill, or if there is an unpredicted or rapid
deterioration in their physical health. Staff at Northumberland did not comply with
these policies.
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52. We consider that, given the seriousness of his condition, Mr Tunney’s next of kin
should have been informed that he was in hospital at the outset. We commented on
this issue recently in another investigation at Northumberland, where assurances
were given that weaknesses in this area had been recognised and improvements
made. The Director will wish to ensure that the improvements are sustained.
Inquest
53. The inquest, held on 19 April 2024, concluded that Mr Tunney 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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