Kevin Noel

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Independent investigation into
the death of Mr Kevin Noel,
a prisoner at HMP Leyhill,
on 18 January 2024
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 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 Kevin Noel died of congestive cardiac failure due to hypertensive heart disease
with cardiomegaly on 18 January 2024, at HMP Leyhill. He was 63 years old. We
offer our condolences to Mr Noel’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Noel received at Leyhill was
equivalent to that which he could have expected to receive in the community.
5. The staff who found Mr Noel on the night that he died promptly alerted the
emergency services and started cardiopulmonary resuscitation. They did not use a
defibrillator, and some told us that they did not know where they were stored in the
prison. There was no immediate debrief following Mr Noel’s death, and the staff
who responded to the emergency left the prison without any of the expected
support.
Recommendations
• The Governor should ensure that all staff are aware of the location of defibrillators
and that they understand how to access and use them during a medical emergency.
• The Governor should ensure that a senior manager debriefs all relevant staff
immediately following a death in custody and that they receive appropriate support
afterwards.
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The Investigation Process
6. HMPPS notified us of Mr Noel’s death on 18 January 2024.
7. The investigator issued notices to staff and prisoners at HMP Leyhill informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
8. The investigator obtained copies of relevant extracts from Mr Noel’s prison and
medical records.
9. The investigator interviewed four members of staff at Leyhill on 21 March.
10. NHS England commissioned a clinical reviewer to review Mr Noel’s clinical care at
the prison.
11. We informed HM Coroner for Avon of the investigation. She gave us the results of
the post-mortem examination. We have sent the Coroner a copy of this report.
12. The Ombudsman’s office contacted Mr Noel’s daughter to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond.
13. We shared the initial report with HM Prison and Probation Service. They did not
identify any factual inaccuracies.
Previous deaths at HMP Leyhill
14. Mr Noel was the twelfth prisoner to die from natural causes at Leyhill since January
2021. To the end of May 2024, there have not been any further deaths at the
prison. There are no significant similarities between our findings in this investigation
and those of the other deaths.
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Key Events
15. On 29 April 2008, Mr Kevin Noel received an indeterminate sentence for public
protection (IPP) for sex offences, with a minimum tariff of five years.
16. On 25 February 2019, Mr Noel was transferred to HMP Leyhill.
17. Mr Noel had a history of hypertension (high blood pressure), hyperlipidaemia
(elevated levels of lipids, like cholesterol and triglycerides (a type of fat) which
causes atherosclerosis (hardening of the arteries) and other serious heart
conditions), angina, pre-diabetes, gastro-oesophageal reflux disease (GORD -
stomach acid which causes heartburn), benign prostatic hypertrophy (BPH - an
enlarged but not cancerous prostate) and left knee pain.
18. On 2 May 2023, a GP at Leyhill carried out Mr Noel’s annual hypertension review.
He recorded Mr Noel’s QRisk score (a tool to calculate the likelihood of having a
stroke or heart attack in the next 10 years) as around ten per cent. The clinical
reviewer noted that most of Mr Noel’s blood pressure readings at Leyhill were within
acceptable parameters.
19. On 24 October, Mr Noel reported a crushing pain in his chest, a tingling feeling in
his left arm and some breathlessness. A nurse sent him to hospital by ambulance.
Mr Noel had an electrocardiogram (ECG), which showed that he had an underlying
cardiac pathology (a collection of diseases that involve the heart or blood vessels).
Hospital staff referred Mr Noel to the Rapid Access Chest Pain Clinic for further
investigations and sent him back to Leyhill.
20. On 31 October, a GP at Leyhill saw Mr Noel because blood test results showed that
his lipids were elevated. Mr Noel told him that he had not been taking his
atorvastatin (medication used to treat high blood cholesterol) in recent months. The
GP advised him to restart his medication.
21. On 15 November, Mr Noel had a telephone consultation with a cardiologist and told
him that he had recurring episodes of left-sided chest pain and episodes of
breathlessness. The cardiologist arranged for Mr Noel to have a CT angiogram (an
imaging test that looks at the arteries that supply blood to the heart).
22. On 16 November, a GP at Leyhill prescribed Mr Noel amlodipine (for angina) to
reduce his episodes of chest pain.
23. On 18 November, a nurse sent Mr Noel to hospital because he had another episode
of acute chest pain. Mr Noel’s symptoms settled after he had several doses of
glyceryl trinitrate spray. (GTN- which dilates the coronary arteries and gives relief
for symptoms of angina.) Hospital staff sent him back to Leyhill.
24. ON 18 December, Mr Noel had the CT angiogram, which showed that there was
“trivial coronary calcification” and “no other visible disease”. The report of the CT
angiogram was not received by the prison until after Mr Noel’s death.
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Events of 17-18 January 2024
25. At 11.00pm on 17 January 2024, an Operational Support Grade (OSG) and an
officer carried out a routine roll check on Ash Unit, where Mr Noel lived in a single
cell. (All cells at Leyhill are single cells, although there are some dormitories. Unlike
most prisons, there are no observation panels in the cell doors.) The OSG opened
Mr Noel’s cell door to carry out the check. He said that he could not remember the
check or what Mr Noel was doing, but that he always made sure that prisoners
moved or were breathing. He said that roll checks at Leyhill are both a count and a
welfare check.
26. At about 5.25am on 18 January, the OSG and officer carried out the morning roll
check. The OSG opened the door to Mr Noel’s cell and saw him lying in bed on his
back with his mouth and eyes open. The OSG said that he was very pale and cold
to touch. He thought that Mr Noel was dead. He called the officer, who entered the
room and checked for a pulse. The officer said that Mr Noel looked lifeless. He said
that Mr Noel’s eyes were half open, he was very pale in the face, and he was cool
to touch. He said that he also thought that Mr Noel was dead. The OSG radioed a
medical emergency code blue (which indicates that a prisoner is unconscious or not
breathing). The control room operator radioed for an emergency ambulance.
(Healthcare staff are not contracted to work overnight at Leyhill and were not
therefore available to attend the emergency.)
27. The OSG and officer started chest compressions. A Custodial Manager (CM) and
another officer went to the cell. When they saw Mr Noel, they both said that he
looked like he had died. The officers rotated chest compressions. The officer said
that even though they thought that Mr Noel was dead they carried out
cardiopulmonary resuscitation (CPR) as it was standard practice, and they were not
qualified to say that a prisoner was dead. The prison staff did not bring a defibrillator
to Mr Noel’s cell.
28. At 5.46am, ambulance paramedics arrived at Mr Noel’s side. They moved him onto
the landing and took over life support. At 6.09am, the paramedics confirmed that Mr
Noel had died.
Contact with Mr Noel’s family
29. On 18 January, Leyhill appointed a CM as the family liaison officer and a
Supervising Officer (SO) and an officer as the deputy family liaison officers. As Mr
Noel’s daughter, his next of kin, lived in the Channel Islands, the CM arranged for
local police to inform her he had died.
Support for prisoners and staff
30. The staff involved in the emergency response were not debriefed before they
finished their shift and left the prison. They did not have the opportunity to discuss
any issues arising and were not offered support.
31. A CM said that it was unfortunate that the staff involved in the incident were coming
to the end of their 13-hour night shift and that they would not have wanted to be
further delayed in going home by attending a debrief. The Head of Residence, who
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was the duty senior manager that day and therefore responsible for holding the
debrief, has since left the prison.
32. The Governor later wrote to the prison staff involved in the emergency response
thanking them for their actions and offering support.
33. The prison posted notices informing other prisoners of Mr Noel’s death and offering
support. Staff reviewed all prisoners assessed as being at risk of suicide or self-
harm in case they had been adversely affected by Mr Noel’s death.
Post-mortem report
34. A post-mortem examination established that Mr Noel had died of congestive cardiac
failure (where the heart is unable to pump blood efficiently, leading to a build-up of
fluid in the body) caused by hypertensive heart disease with cardiomegaly (an
enlargement of the heart due to long-term high blood pressure).
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Findings
Clinical care
35. The clinical reviewer concluded that the clinical care Mr Noel received at Leyhill was
of a good standard and was equivalent to that that which he would expect to receive
in the community. He found that Mr Noel’s hypertension was managed in line with
national guidelines.
36. Mr Noel was sent to hospital twice in the three months before he died. The clinical
reviewer said that after this he received appropriate follow up with a cardiologist. He
also found that, in the last few weeks of his life, Mr Noel did not report any
symptoms that indicated a need for readmission to hospital or an escalation of his
treatment.
Emergency response
37. The prison staff who responded to the medical emergency promptly radioed a
medical emergency code blue and promptly started CPR. The clinical reviewer
found that Mr Noel might have died very recently, and, in the circumstances, it was
appropriate to initiate CPR and continue this while awaiting the arrival of the
paramedics.
38. However, the prison staff did not bring or use a defibrillator to the emergency, which
is crucial when a prisoner is unresponsive and not breathing. They told us that they
did not think to bring a defibrillator, and some were unsure of where it was kept. Of
the four staff who responded, two had up to date life support training. The other two
were out of date with their training. Local guidance is that at least one member of
staff on duty at night has in-date training. We make the following recommendation:
The Governor should ensure that all staff are aware of the location of
defibrillators and that they understand how to access and use them during a
medical emergency.
Debrief and support for staff
39. Prison Service Instruction (PSI) 64/2011, on managing prisoner safety, instructs
that a ‘hot debrief’ must be held immediately after all deaths in custody.
40. The prison staff who were involved in the medical emergency were not debriefed by
a senior manager and were not offered support before they went off duty. We make
the following recommendation:
The Governor should ensure that a senior manager debriefs all relevant staff
immediately following a death in custody and that they receive appropriate
support afterwards.
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Inquest
41. The inquest into Mr Noel’s death concluded on 6 August 2024, and returned a
verdict of natural causes.
Adrian Usher
Prisons and Probation Ombudsman June 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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