John Warry

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Independent investigation into
the death of Mr John Warry,
a prisoner at HMP Stafford,
on 25 September 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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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr John Warry died in hospital on 25 September 2022, while a prisoner at HMP Stafford.
His death was due to cardiogenic shock caused by severe heart failure and a heart attack.
He also had underlying COVID-19. Mr Warry was 73 years old. I offer my condolences to
his family and friends.
The clinical reviewer identified several significant deficiencies in the management of Mr
Warry’s cardiovascular risk and his clinical management when he reported chest pains on
the day of his death. She concluded that these aspects of his clinical care were not
equivalent to that which he could have expected to receive in the community.
Mr Warry had been assessed by the pharmacist at Stafford as at a higher risk of a heart
attack or stroke, but this was not followed up by the GP or healthcare staff. The GP later
withdrew Mr Warry’s statin medication, but the rationale for his decision was not informed
by appropriate tests, or fully documented.
I am concerned that Mr Warry’s request for a medical appointment, five days before he
died, was not prioritised, despite concerning symptoms. On the morning of his death,
healthcare staff did not follow the expected procedures for managing and escalating
recent-onset chest pain and the clinical reviewer found examples of poor clinical record
keeping.
Mr Warry’s family was not informed that he was seriously ill and they have yet to be
reimbursed for the costs of his cremation.
I am also concerned that incorrect information about the circumstances of his death was
posted on social media and that there was a comment in the post about the nature of the
death, before HM Coroner had confirmed it. Given the widespread and increasing use of
social media, a reminder about the need for responsible use of social media would be
timely.
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 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
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Summary
Events
1. Mr John Warry had been in prison since October 2016 and transferred to HMP
Stafford on 7 February 2019. He was 69 years old. At reception health screens, it
was recorded that Mr Warry had no personal or family history of cardiovascular
disease. However, he had an existing prescription for simvastatin (a statin
medication to treat high cholesterol and prevent heart disease) which the GP at
Stafford re-prescribed.
2. In 2020, Mr Warry was assessed as at high risk of complications from COVID-19
and protective measures, such as shielding, were put in place.
3. On 29 October 2021, a QRISK assessment by the pharmacist at Stafford indicated
that Mr Warry had a raised risk of having a heart attack or stroke and his blood
pressure was raised.
4. Following blood tests and reviews of Mr Warry’s prescription for simvastatin on 25
May and 31 August 2022, the GP stopped prescribing simvastatin.
5. On 20 September, Mr Warry requested a medical appointment, as he had felt
unwell for two weeks, with symptoms of giddiness, breathlessness and weakness.
He had not been seen before his death five days later.
6. At around 7.00am on 25 September, Mr Warry reported chest pains. Nurses gave
him glyceryl trinitrate (GTN), but the pain continued. At 10.00am, a nurse requested
an emergency ambulance, as she was concerned about the nature of his pain.
Paramedics conducted an electrocardiogram (ECG) test. This indicated
abnormalities, so they arranged for Mr Warry to be taken to the coronary care unit
at Royal Stoke University Hospital. Mr Warry died at 8.34pm.
Findings
7. The clinical reviewer identified significant shortcomings in both the management of
Mr Warry’s cardiovascular risk and his care when he became acutely unwell and
concluded it was not equivalent to that he could have expected to receive in the
community.
8. The clinical reviewer found that the management of Mr Warry’s cardiovascular risk
was not in line with national guidance. Notably, the GP at Stafford did not act on the
pharmacist’s findings of a raised risk and high blood pressure; he did not repeat the
assessment, take a blood pressure reading, or collate relevant tests to evidence
that there was no longer a need for simvastatin.
9. The nurses who treated Mr Warry when he complained of chest pains on 25
September, did not comply with the national guidelines on the management of
recent-onset chest pain and the administration of GTN. They did not administer
another dose of GTN at the recommended interval of five minutes, or escalate his
care urgently when the GTN did not relieve the pain.
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10. Mr Warry’s healthcare application on 20 September was not appropriately
prioritised, given his symptoms.
11. Clinical record keeping did not meet the standards expected by professional
medical bodies. Entries in Mr Warry’s medical records did not reflect the rationale
for decisions such as discontinuing simvastatin and the medical emergency on 25
September was not fully documented.
12. Mr Warry’s risk of infection from COVID-19 was managed appropriately. In spite of
this, it seems that he contracted the infection within the prison.
13. Staff did not follow HMPPS national policy and Stafford’s local protocol on medical
emergencies involving chest pain. There are conflicting accounts as to whether a
medical emergency code was called when Mr Warry first reported chest pain. There
is no record of such a code or a request for an ambulance.
14. Mr Warry’s next of kin was not informed that he was seriously ill in hospital, in line
with Prison Rule 22 and HMPPS national policy, and they have yet to be
reimbursed for the costs of Mr Warry’s cremation.
15. The Governor posted incorrect information about Mr Warry’s death on social media,
as well as a presumption about the nature of the death. Although HMPPS provides
training on the use of social media, we consider that staff should be reminded about
the need to comply with the Civil Service Code.
Recommendations
• The Head of Healthcare should ensure that information from the pharmacist is
shared with the healthcare team for review and action.
• The Head of Healthcare should ensure that GPs conduct a full, documented clinical
assessment, in line with relevant guidance, to inform medication reviews and
changes.
• The Head of Healthcare should ensure that prisoners presenting with chest pain are
managed in line with NICE guidelines on the diagnosis of chest pain and, where
indicated, referred for emergency treatment.
• The Head of Healthcare should ensure that prisoners who report acute symptoms
receive timely medical appointments.
• The Head of Healthcare should ensure that healthcare staff fully and accurately
document all clinical interactions and decisions, in line with the standards specified
by the General Medical Council and Nursing and Midwifery Council.
• The Governor and Head of Healthcare should ensure that all staff are fully aware of
and understand their responsibilities in a medical emergency, including the use of
an emergency response code if a prisoner has chest pains and documenting
incidents.
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• The Governor should ensure that if a prisoner becomes seriously ill, their next of kin
is notified immediately, in line with Prison Rule 22 and Prison Service Instruction
64/2011.
• The Governor should ensure that the cost of Mr Warry’s cremation is reimbursed,
without further delay.
• The Director General of Operations of HM Prisons and Probation Service should
remind staff of the requirement to adhere to the Civil Service Code and for sensitive
and responsible use of social media.
• The Governor should ensure that information published on social media about a
prisoner’s death is appropriate, accurate and that the nature of the death is not
revealed until confirmed by HM Coroner.
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The Investigation Process
16. 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.
17. The investigator obtained copies of relevant extracts from Mr Warry’s prison and
medical records.
18. NHS England and NHS Improvement (NHSE&I) commissioned a clinical reviewer to
review Mr Warry’s clinical care at the prison. The clinical reviewer and the
investigator interviewed three healthcare staff by Microsoft Teams video
conferencing on 26, 27, 28 and 31 October. (Due to a general alarm in the prison
on 27 October, one of the interviews was stopped and resumed on 31 October.)
Additional information was obtained by email throughout the investigation.
19. We informed HM Coroner for Staffordshire South of the investigation. The coroner
gave us the results of the post-mortem examination and we have shared this report
with him.
20. The Ombudsman’s family liaison officer contacted Mr Warry’s family to explain the
investigation. Mr Warry’s family asked for the investigation to consider several
matters relating to Mr Warry’s care. The clinical review and PPO report address
those which fall within our remit, summarised below:
• Why was Mr Warry’s simvastatin medication stopped and did this affect his
health, or contribute to his death?
• During the three weeks before Mr Warry’s death, he had twice requested an
appointment with the nurse as he felt unwell. He had also informed wing staff
several times.
• Why was Mr Warry’s family not informed that he was seriously ill in hospital.
• The Governor posted information on social media about Mr Warry’s death,
before some family members were informed and there were inaccuracies in
his statement.
21. We sent a copy of the initial report to Mr Warry’s family. They did not inform us of
any factual inaccuracies.
22. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Stafford
23. HMP Stafford holds approximately 750 men who have been convicted of sexual
offences. Practice Plus Group provides a 24-hour healthcare service.
HM Inspectorate of Prisons
24. The most recent full inspection of HMP Stafford was in January 2020. (There was
also a short scrutiny visit in June 2020.) Inspectors reported that healthcare had
improved since the previous inspection in 2016. There was strong clinical
leadership, staff received regular clinical supervision and the training provision was
impressive. Nurses triaged potentially urgent issues and clinical records were
professional and subject to audit. Responses to medical emergencies were sound
and staff knew how to obtain support from the ambulance service, if needed.
25. Inspectors found that there was an effective incident management system to review
serious concerns and the learning from untoward incidents was shared across the
healthcare team. PPO recommendations after investigations were implemented.
Independent Monitoring Board
26. 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 30 April 2022, the IMB reported
that the treatment of patients had been severely and negatively impacted by failings
in medicines management over an extended period. There had been systemic
failings and a focus on process rather than outcome.
27. The Board also noted that the COVID-19 pandemic had significantly impacted on
the prison. However, aside from medicines management, the quality of all other
aspects of healthcare was generally good.
Previous deaths at HMP Stafford
28. Mr Warry was the 17th prisoner at Stafford to die since September 2020. Of the
previous deaths, 16 were from natural causes and one was self-inflicted. There
have been five further deaths, of which one was self-inflicted and four from natural
causes. Disappointingly, in previous investigations, we have raised problems with
the prescribing and management of medication, information sharing between
healthcare staff, notifying prisoners’ next of kin that they are seriously ill and the
payment of funeral expenses.
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Key Events
29. Mr John Warry was remanded to prison on 19 October 2016. In November, he was
convicted of sexual offences and sentenced to nine years imprisonment, with an
extended licence period of one year.
30. Mr Warry transferred from HMP Parc to HMP Stafford on 7 February 2019. At an
initial health screen, his ongoing medical conditions were listed as asthma and
glaucoma. A secondary health assessment, completed on 18 February, noted that
he had no personal or family history of cardiovascular disease at that time.
31. The GP at Stafford re-prescribed an existing prescription for simvastatin. Mr Warry
had regular blood tests to monitor his lipid levels (fatty compounds) and the results
were reported as within normal range.
2020 to 2021
32. On 8 June 2020, a GP assessed Mr Warry’s risk of complications from COVID-19
as high, due to his asthma. Mr Warry was later allocated to a unit for men who were
shielding.
33. During the pandemic, Mr Warry had regular welfare checks and meetings with his
prison key worker. In 2021, he received three COVID-19 vaccinations. He was
tested for COVID-19 before hospital appointments and he was twice placed in
isolation after exposure to COVID-19. On 9 April 2021, following new NHS shielding
guidance, Mr Warry decided to stop shielding.
34. On 29 October 2021, the pharmacist at Stafford conducted a QRISK assessment to
calculate Mr Warry’s risk of cardiovascular disease and the score was 26.19%. (A
score of over 10% represents a raised risk of having a stroke or heart attack within
10 years.) He also noted that Mr Warry’s blood pressure was high and
recommended that the GP consider a calcium channel blocker medication (to help
lower blood pressure). There is no evidence that this was actioned.
2022
35. Mr Warry tested positive for COVID-19 in April 2022. He was placed in protective
isolation and monitored daily by healthcare staff.
36. On 25 May, a GP at Stafford reviewed Mr Warry’s simvastatin prescription. He
noted that a recent blood test had shown raised triglycerides (fat) levels and
recorded options to address this. (High levels can raise the risk of heart disease
and stroke.)
37. On 15 June, a prison GP discussed with Mr Warry whether he still needed to take
simvastatin and arranged a blood test. He noted that Mr Warry could not remember
why it had been prescribed, as he had no history of heart disease or stroke. A blood
test taken on 28 June, showed Mr Warry’s triglycerides level was within normal
limits.
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38. On 23 August, Mr Warry placed a request for a repeat prescription of simvastatin,
an asthma pump and eye drops.
39. At a review on 31 August, a prison GP found that Mr Warry’s triglycerides level was
lower and his lipid levels were within normal range. He therefore stopped the
simvastatin and planned to request another blood test in six months. He noted that
Mr Warry had agreed to this.
40. Mr Warry sent a reminder about his medication request on 7 September, but noted
that he no longer needed simvastatin as the GP had stopped it. At a meeting on the
same day, Mr Warry’s prison key worker noted that he appeared to be physically
well.
41. On 20 September, Mr Warry sent an application to healthcare, stating that the GP
had stopped prescribing simvastatin at the end of August and that he had felt unwell
for two weeks. He described his symptoms as giddiness, racing heart,
breathlessness and no strength. One of the healthcare team annotated the form to
indicate that he had been added to the senior nurse list. (Mr Warry died before
receiving an appointment.)
Events of 25 September
42. At around 7.05am on 25 September, night patrol staff contacted healthcare staff, as
Mr Warry had chest pains. An officer recorded the incident in the wing observation
book, but it is unclear whether it had been reported as an emergency.
43. Two nurses assessed Mr Warry in his cell (time unknown). Mr Warry said that he
had pain on his left side that had started two weeks before, but had been worse
during the night. He thought it might have been caused by coughing. The nurses
took Mr Warry’s clinical observations and a COVID-19 test, which was positive.
They gave him two sprays of glyceryl trinitrate (GTN - used to treat angina) at the
same time, but it did not help the pain. They planned to review him in an hour.
44. A nurse asked a Nursing Associate to check Mr Warry before starting the
medication round (time unknown). When she did so, she was told that he was no
longer in pain. Just after 8.45am, a prison officer told the nurse that Mr Warry’s pain
had returned. The nurse told a colleague.
45. A nurse repeated a full assessment at around 10.00am. She was concerned about
Mr Warry’s description of his pain and thought that he needed an electrocardiogram
(ECG – recording of the heart’s electrical activity) as well as other checks. She
asked an officer to call a code blue, so that an emergency ambulance would be
requested.
46. The paramedics arrived at Mr Warry’s cell at 10.15am. An ECG showed that he had
had a serious heart attack, so they contacted Royal Stoke University Hospital and
arranged for Mr Warry to be admitted to the coronary care unit. They left the prison
just before 11.00am. Two prison officers escorted Mr Warry and no restraints were
used.
47. The escort officers updated the prison throughout the day. This included notification
that stents were inserted into Mr Warry’s blocked arteries at around 6.00pm; at
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6.40pm he had another cardiac arrest and was described as in a critical condition;
and at 7.50pm, there was a third cardiac arrest.
48. At 8.11pm, the escort officers briefed the family liaison officer. They informed him
that doctors were considering a ‘do not resuscitate’ order in the event of another
cardiac arrest. At 8.26pm, they said that Mr Warry had had a further cardiac arrest
and hospital staff were “working on” him.
49. Mr Warry died at 8.34pm.
Contact with Mr Warry’s family
50. Due to Mr Warry’s condition, the prison assigned him a family liaison officer (FLO),
at around 7.00pm, and he went to the prison.
51. At 9.55pm, the FLO and a prison officer left the prison to inform Mr Warry’s wife of
his death. They arrived at 1.20am, but no one answered the door. They then went
to the address listed for Mr Warry’s son and informed him that his father had died.
Mr Warry’s son told the officers the correct location for Mr Warry’s wife, as there
were two houses with the same door number.
52. The officers broke the news of Mr Warry’s death to his wife and daughter at around
2.30am. They offered support and the FLO kept in touch with Mr Warry’s wife and
daughter over the following weeks. In line with national policy, the prison offered Mr
Warry’s family a contribution to the costs of his cremation, which took place in
October 2022. This has yet to be processed.
Support for prisoners and staff
53. After Mr Warry’s death, the duty governor debriefed the escort staff, offering
immediate support and signposting them to other avenues of support. Debriefs and
offers of support were later extended to the family liaison officers, as well as
operational and clinical staff.
54. The prison posted notices informing other staff and prisoners of Mr Warry’s death
and offering support.
Post-mortem report
55. No post-mortem examination was held, as the coroner accepted the hospital’s
clinical certification that the cause of Mr Warry’s death was cardiogenic shock as a
result of severe left ventricular failure and late presenting myocardial infarction. Mr
Warry also had underlying COVID-19, which did not cause but contributed to his
death.
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Findings
Clinical Findings
56. The clinical reviewer considered that Mr Warry’s asthma and the risks relating to
COVID-19 were managed to a reasonable standard, at least equivalent to that
which he could have expected to receive in the community. However, she found
significant deficiencies in the management of his cardiovascular risk in 2022 and his
care when he became acutely unwell. She concluded that these aspects of his
clinical management did not meet the required standard.
57. Full details of the clinical reviewer’s findings are in the clinical review report. We
summarise them below and reflect the recommendations linked to Mr Warry’s
cause of death. The clinical reviewer made additional recommendations, which the
Head of Healthcare will need to consider.
Management of Mr Warry’s cardiovascular risk
58. National Institute for Health and Care Excellence (NICE) clinical guideline CG181,
on cardiovascular disease, covers the assessment and care of those at risk of
conditions such as heart disease and stroke. It states that patients should be
prioritised for a full, formal risk assessment if their QRISK score is 10% or more. It
includes advice on the need for discussions with patients about how lifestyle
changes and statins can be used to reduce their risk, as well as the risk/benefits of
changing to a high intensity statin. The clinical reviewer had several concerns about
the clinical management of Mr Warry’s cardiovascular risk.
59. There is no evidence that the pharmacist’s findings of a high QRISK score of
26.19% and raised blood pressure, in October 2021, were referred to the GP and
Mr Warry’s next blood pressure check was in March 2022.
60. The clinical reviewer also noted specific concerns about the prison GP’s
assessment of Mr Warry’s risk, including:
• He was not aware of the pharmacist’s QRISK findings, although this was
recorded on Mr Warry’s SystmOne medical records;
• there was no formal QRISK assessment or up to date blood pressure
reading when he reviewed Mr Warry’s prescription for simvastatin;
• there was no care plan in place, or specific advice to support Mr Warry to
make lifestyle changes to reduce his risk;
• blood test results in July 2022, suggested that the use of statin medication
was working, yet it was stopped; and
• relevant tests were not collated to evidence the decision to stop prescribing
simvastatin.
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61. A further concern was that the GP’s record keeping was not in line with the
standards specified by the Royal College of Physicians and the General Medical
Council. (We make further comment on record keeping below.)
62. We share the clinical reviewer’s concerns that Mr Warry’s cardiovascular risk was
not managed in line with NICE guidelines and recommend:
The Head of Healthcare should ensure that information from the pharmacist is
shared with the healthcare team for review and action.
The Head of Healthcare should ensure that GPs conduct a full, documented
clinical assessment, in line with relevant guidance, to inform medication
reviews and changes.
63. The GP no longer works at Stafford, but is still employed by Practice Plus Group,
and the clinical reviewer has recommended that her findings are shared with him.
Recognition of Mr Warry’s deteriorating health
64. NICE clinical guideline CG95 about recent-onset chest pain states that chest pain
that lasts longer than 15 minutes might be a sign of an acute coronary syndrome,
such as a heart attack. It lists several actions that should be taken to monitor chest
pain, including taking ECG tests.
65. A nurse said that as Mr Warry was COVID-19 positive, she considered it
inappropriate to take him through the prison to use the ECG machine in the
healthcare centre and there was no portable machine.
66. British National Formulary (BNF) guidelines states that a second dose of GTN
should be given five minutes after the first, if needed. However, urgent medical
attention should be sought if the pain does not subside five minutes after the
second dose, or sooner if the pain is worsening or the patient is unwell.
67. Another nurse said he did not follow the BNF guidance to give another dose of
GTN, as he thought that Mr Warry’s blood pressure might drop and the pain was
more likely to muscular due to coughing.
68. The clinical reviewer found that the assessment, treatment and escalation of Mr
Warry’s report of chest pain on 25 September and the administration of GTN was
not in line with NICE and BNF guidance, respectively and healthcare staff should
have requested an ambulance sooner. We recommend:
The Head of Healthcare should ensure that prisoners presenting with chest
pain are managed in line with NICE guidelines on the diagnosis of chest pain
and, where indicated, referred for emergency treatment.
Healthcare appointments
69. Mr Warry applied for a healthcare appointment on 20 September, listing his
symptoms as a racing heart, giddiness and breathlessness. He was placed on the
waiting list for review by the senior nurse. There is no record of Mr Warry informing
operational staff that he had felt unwell around that time.
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70. The clinical reviewer considered that the delay in assessing Mr Warry was possibly
a missed opportunity for investigation of his symptoms before he became acutely
unwell. We consider that the symptoms Mr Warry noted in his application merited
higher priority and a more urgent response. We recommend:
The Head of Healthcare should ensure that prisoners who report acute
symptoms receive timely medical appointments.
Clinical record keeping
71. The clinical reviewer identified several weaknesses in clinical record keeping,
including:
• The GP’s medical records were brief. They did not fully reflect his discussion
with Mr Warry, or any information given to him about lifestyle management
and the use of statins and lacked detail about his rationale for withdrawing
simvastatin;
• the member of the healthcare team who processed Mr Warry’s healthcare
application on 20 September did not record their name;
• the medical emergency on 25 September was not fully documented. There
was insufficient detail about the times and sequence of events, and there
were no entries by a nurse and a Nursing Associate, who had assessed Mr
Warry that morning.
We recommend:
The Head of Healthcare should ensure that healthcare staff fully and
accurately document all clinical interactions and decisions, in line with the
standards specified by the General Medical Council and Nursing and
Midwifery Council.
Management of Mr Warry’s risk of infection from COVID-19
72. Mr Warry was identified as at high risk of complications if he contracted COVID-19
and was managed appropriately. He was given the opportunity to shield, was tested
at appropriate points and received all the vaccinations due at the time of his death.
When he was either exposed to, or caught the virus, he was placed in isolation.
73. From late August to mid-October 2022, Stafford was a COVID-19 outbreak site. In
line with HMPPS policy, Stafford put in place several protective measures across
the prison to manage the risks, such as wing closures, testing prisoners and
suspension of routine medical appointments. Healthcare staff completed daily
welfare checks and clinical observations for COVID-19 positive patients.
74. We are satisfied that Mr Warry’s risk of infection from COVID-19 was managed
appropriately. However, in spite of the protective measures, it seems that he
contracted the virus at the Stafford, as he had not left the prison for some time.
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Emergency response
75. Prison Service Instruction (PSI) 3/2013, Medical Emergency Response Codes and
Stafford’s local policy SIN 208/18, Response to Medical Emergencies set out the
actions staff should take in a medical emergency. This includes a mandatory
requirement that a code blue emergency should be called if a prisoner has chest
pain or breathing difficulties and the communications room should request an
ambulance immediately.
76. There are conflicting accounts as to whether Mr Warry’s first report of chest pain
was communicated by telephone, or radioed as a code blue medical emergency.
The nurses who examined him believed there had been a code blue call (although
the Head of Healthcare said there was no evidence of this) and it was listed as such
in the report by the prison’s duty manager. The entry in the wing observations book
did not record the incident as a code blue and, significantly, there is no reference to
it in the communications room log. The Ambulance Service has no record of a
request for an ambulance for an incident at that time.
77. The guidance is very clear that chest pains must be treated as a medical
emergency with an urgent response and healthcare staff have the discretion to
stand down an ambulance if it is not required. In view of the conflicting information,
we are not satisfied that staff complied with the expected emergency response
procedures. We recommend:
The Governor and Head of Healthcare should ensure that all staff are fully
aware of and understand their responsibilities in a medical emergency,
including the use of an emergency response code if a prisoner has chest
pains and documenting incidents.
Informing Mr Warry’s family of his illness and death
78. Prison Rule 22 and Prison Service Instruction (PSI) 64/2011, Safer Custody,
requires prisons to inform a prisoner’s next of kin immediately if they become
seriously ill, or if there is unpredicted or rapid deterioration in their physical health. It
also sets out the actions to be taken after a death in custody.
79. We are concerned that the prison did not inform Mr Warry’s wife that he was
seriously unwell and in hospital. A prison manager told the investigator that the
prison’s protocol is for a prisoner’s next of kin to be notified if he has been admitted
to hospital for more than 72 hours, unless it is an emergency. She added that they
did not consider Mr Warry to be critically ill as the hospital had not asked for his
family to be informed.
80. A critical care unit provides high dependency care for serious heart conditions
which require continuous monitoring and treatment. We consider that Mr Warry’s
immediate admission to the unit when he arrived at the hospital at around 11.00am,
clearly indicated serious illness and should have prompted the prison to notify his
wife immediately. We do not know whether she would have been permitted to visit
or speak to him, but she would have at least had the opportunity to get updates on
his condition directly from hospital staff.
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81. Clinical deterioration can be rapid and prison staff could not have predicted Mr
Warry would die. However, the escort staff had kept the prison closely informed of
events throughout the day and reported that his condition had become life
threatening around two hours before he died.
82. We consider that the prison had ample opportunity to inform Mr Warry’s wife that he
was seriously ill and that the lack of a request from the hospital was not a reason to
disregard national HMPPS policy. We recommend:
The Governor should ensure that if a prisoner becomes seriously ill, their
next of kin is notified immediately, in line with Prison Rule 22 and Prison
Service Instruction 64/2011.
83. Another concern was the delay in notifying Mr Warry’s wife of his death. PSI
64/2011 states that, if possible, the family liaison officer must break the news of a
death in person and timing is important to try to ensure that the deceased’s family
do not find out from another source. It also says that if a prisoner was located a long
distance from their family, prisons must consider asking a family liaison officer from
the nearest prison, or the police, to break the news. Stafford’s decision log guides
family liaison officers to consider resource limitations and available specialist
assistance.
84. Mr Warry’s wife lived around 150 miles from the prison, and the family liaison officer
made a considerable effort to inform her face to face. There was no evidence in the
family liaison decision log that a quicker way of contacting her was considered, but
a prison manager explained that most other prisons would have had reduced staff
in the evening.
85. On balance, we are satisfied that the prison’s rationale was sound, given the limited
capacity at other prisons at that time of night, as well as little risk of the news being
leaked. However, decisions in these circumstances should be better documented.
Reimbursement of cremation expenses
86. PSI 64/2011 sets out the processes after a death in custody, including financial
help. Prisons must offer a contribution of up to £3,000 towards funeral expenses.
87. The discussions with Mr Warry’s family about expenses were not documented, but
a prison manager told the investigator what had happened. The prison had offered
a contribution towards Mr Warry’s cremation and told his family that the funeral
director would be paid directly, on receipt of an invoice. However, Mr Warry’s family
had settled the invoice before sending it to the prison for reimbursement and it was
unclear how to resolve this.
88. We are concerned that, over six months after Mr Warry’s cremation, the payment to
his family has yet to be processed. We recommend:
The Governor should ensure that the cost of Mr Warry’s cremation is
reimbursed, without further delay.
Prisons and Probation Ombudsman 13
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Use of social media
89. Social media guidance for civil servants: October 2014, sets out the principles for
using social media appropriately and the requirement to do so in accordance with
the Civil Service Code. Notably, users are expected to apply the same standards
online as offline, whether acting in an official or personal capacity; and should check
accuracy and sensitivity before posting online.
90. Mr Warry’s family was concerned that the Governor had posted information on
social media about Mr Warry’s death before all the family members had been told.
This included a statement implying that prison staff and the emergency services
had given life support and that the death was due to natural causes.
91. The Governor did not name the deceased in his message. In a reply, also on social
media, Mr Warry’s daughter had asked if he was referring to her father and gave his
name, which the Governor then confirmed.
92. By the time Mr Warry’s family raised concerns with us about the content of the post,
it had been removed, but the wording of it suggests the Governor posted it a few
days after Mr Warry died. Mr Warry’s family was understandably upset that some of
the information in the message was inaccurate and we agree that it was
inappropriate to categorise it as a natural death before the coroner had confirmed
this.
93. We understand that the HMPPS Communications team provides guidance and
training on the use of social media. The team is actively considering how to
increase awareness of senior leaders and prisons about the risks and sensitivities
around this. We recommend:
The Director General of Operations of HM Prisons and Probation Service
should remind staff of the requirement to adhere to the Civil Service Code
and for sensitive and responsible use of social media.
The Governor should ensure that information published on social media
about a prisoner’s death is appropriate, accurate and that the nature of the
death is not revealed until confirmed by HM Coroner.
Inquest
94. At an inquest held on 4 February 2025, the Coroner concluded that Mr Warry died
of natural causes.
14 Prisons and Probation Ombudsman
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