Joseph Louis

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Independent investigation into
the death of Mr Joseph Louis,
a prisoner at
HMP Wormwood Scrubs,
on 26 April 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
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 Joseph Louis died on 26 April 2023, at HMP Wormwood Scrubs. He was 84
years old. The cause of Mr Louis’ death was heart failure caused by heart disease
and other cardiovascular conditions. He also had underlying diabetes, high blood
pressure and a respiratory disorder. We offer our condolences to Mr Louis’ family
and friends.
4. The PPO family liaison officer wrote to Mr Louis’ next of kin to explain the
investigation and to ask if there were any matters they wanted us to consider. They
did not reply.
5. NHS England commissioned an independent clinical reviewer to review Mr Louis’
clinical care at HMP Wormwood Scrubs. She found that Mr Louis was a challenging
patient, whose long-term medical conditions were managed well and he was
monitored daily. However, she concluded that the clinical care Mr Louis received
was only partially equivalent to that which he could have expected to receive in the
community, as his deteriorating condition was not recognised in the hours before
his death and concerning clinical observations had not been escalated at other
times.
6. The clinical reviewer made recommendations not related to Mr Louis’ death that the
Head of Healthcare will wish to address, as well as the following which are related
to his death:
• The Head of Healthcare to assure herself that the healthcare staff who
undertake the role of Nurse in Charge on H3 have the sufficient skills and
competencies to recognise a clinically deteriorating patient.
• The Barnet, Enfield and Haringey Mental Health Trust Service Manager
should ensure that the RMN and all H3 staff are invited and have the
opportunity to engage in a reflective session utilising the Practice Plus Group
reflective presentation already completed. This session should include any
additional learning required around the use of appropriate emergency codes.
• The Head of Healthcare to provide reflective and supportive supervision to
the RMN who provided care to Mr Louis overnight on the 26 April 2023, and
specifically to address the record keeping issues identified. To ensure that
the RMN is supported to improve the standard of his record keeping in
accordance with the NMC Code for good record keeping.
• The Head of Healthcare to ensure that all patients who have life limiting
conditions have an advanced care plan in place in accordance with the
Prisons and Probation Ombudsman 1
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National Institute for Health and Care Excellence (NICE) guideline [NG142]
for ‘end of life care for adults: service delivery’ (2019) and the NHSE
‘universal principles for advanced care planning’ (2022). This care plan will
include advanced decision made regarding any refusal of treatment including
a refusal of transferring to hospital against medical advice.
7. The PPO investigators investigated the non-clinical issues relating to Mr Louis’
care. We found no non-clinical issues of concern. We make no recommendations.
8. We shared our initial report with HMPPS and the prison’s healthcare providers,
Practice Plus Group (PPG) and Barnet, Enfield and Haringey (BEH) Mental Health
Trust. They found no factual inaccuracies. They provided an action plan which is
annexed to this report.
9. The inquest, held on 9 April 2024, concluded that Mr Louis died from natural
causes.
Adrian Usher
Prisons and Probation Ombudsman December 2024
2 Prisons and Probation Ombudsman
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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
OFFICIAL - FOR PUBLIC RELEASE