Kim Chapman

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Ms Kim Chapman,
following her release from
HMP Send, on 6 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
© 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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Ms Kim Chapman died of breast cancer, which had spread to other parts of her
body, on 6 January 2024, following her early release on compassionate grounds
from HMP Send on 29 December 2023. She was 64 years old. We offer our
condolences to Ms Chapman’s family and friends.
5. On 4 December 2023, Ms Chapman was sent to hospital after reporting ongoing
pain and other symptoms. Ms Chapman remained in hospital, during which time
she was diagnosed with breast cancer which had spread to her liver.
6. On 20 December, hospital staff concluded that Ms Chapman was now suitable for
palliative care only. Prison staff began an application for early release on
compassionate grounds, which was approved. On 29 December, Ms Chapman was
released from her sentence.
7. On 4 January 2024, a nurse noted that Ms Chapman was too unwell to transfer to a
hospice.
8. On 6 January, Ms Chapman died in hospital, with her family present.
9. Prison staff made a timely and appropriate application for early release on
compassionate grounds. They might have given further consideration for release on
temporary licence – which would have allowed Ms Chapman to be unaccompanied
in hospital by prison staff – while the application was being consider.
Prisons and Probation Ombudsman 1
The Investigation Process
10. HMPPS notified us of Ms Chapman’s death on 8 January 2024.
11. The PPO investigator obtained copies of relevant extracts from Ms Chapman’s
prison and probation records.
12. We informed HM Coroner for Surrey of the investigation. He gave us the cause of
death. We have sent the Coroner a copy of this report.
13. The Ombudsman’s office contacted Ms Chapman’s daughter to explain the
investigation and to ask if she had any matters she wanted us to consider. Ms
Chapman’s daughter asked how Ms Chapman’s cancer had time to spread to her
liver. She asked why it took so long for her to be released, given her diagnosis on
11 December 2023, and why it had not been possible to transfer her to a hospice
before she became too ill to travel. Ms Chapman’s daughter asked why she had
prison officers with her in hospital when she could hardly walk.
14. We shared the initial report with HM Prison and Probation Service. They did not
identify any factual inaccuracies.
15. We also shared the initial report with Ms Chapman’s daughter. She did not make
any comments.
2 Prisons and Probation Ombudsman
Background Information
HMP Send
16. HMP Send is a closed training prison for female prisoners. Central and Northwest
London (CNWL) NHS Foundation Trust provide primary care, pharmacy and mental
health services. Primary care services operate a seven-day service from 7.30am to
6.30pm, with slightly reduced hours at weekends.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Send was in May 2021. Inspectors reported that
the Governor had a very positive vision for the prison and a clear set of priorities
that included among other aspects, release on temporary licence (ROTL).
Prisons and Probation Ombudsman 3
Key Events
18. On 29 July 2009, Ms Kim Chapman was remanded to HMP Peterborough. On 5
February 2010, she was convicted of murder and was sentenced to life in prison.
On 26 April 2017, Ms Chapman was transferred to HMP Send.
19. On 26 October 2023, Ms Chapman told a nurse at Send her that she had
experienced abdominal pain and constipation for three days. The nurse tasked a
GP at Send to see Ms Chapman. On 2 November, at a GP appointment, Ms
Chapman reported worsening right sided abdominal pain and sluggish bowels
despite taking laxatives. The GP noted that Ms Chapman had ‘a soft abdomen, mild
left upper quadrant tenderness, with no masses felt and no abnormal enlargement
of organs’. The GP suspected that the pain and swelling was due to faecal loading
and changed Ms Chapman’s laxative.
20. On 9 November, Ms Chapman told an officer that she had chest pain. A nurse then
saw Ms Chapman and noted that the chest pain had been worsening for several
days. The nurse carried out an electrocardiogram (ECG) and sent Ms Chapman to
hospital. In hospital, Ms Chapman had a chest X-ray, which was normal. A GP at
Send noted that hospital staff said Ms Chapman had pleurisy (inflammation of the
membrane of the chest cavity). She returned to Send on the same day.
21. On 16 November, Ms Chapman told a GP that, despite having increased bowel
movements, she still remained bloated and had ongoing pains in her chest and
back. The GP asked for urgent blood tests and planned for Ms Chapman to have an
ultrasound scan (a detailed image of the internal body structure).
22. On 17 November, Ms Chapman went to hospital for the ultrasound. The results
showed that she had a mass on her liver which needed further investigation. After
the scan, the GP at Send completed a referral to gynaecology under the two-week-
wait NHS pathway, which requires patients with suspected cancer to be seen by a
specialist within two weeks. The GP saw Ms Chapman and told her that she had a
tumour on her liver which could be cancerous.
23. On 4 December, a nurse at Send saw Ms Chapman to give her morning medication
and noted that Ms Chapman had been unable to open her bowels, was in pain,
sweating and looked jaundiced. Ms Chapman was admitted to hospital. In hospital
staff, carried out further tests which showed that Ms Chapman had breast cancer
which had spread to her liver.
24. Two prison officers accompanied Ms Chapman in hospital. Ms Chapman had
previously attended work in the community and hospital appointments on release
on temporary licence (ROTL – meaning she was not accompanied by prison
officers). However, in June 2023, her right to access ROTL was withdrawn because
she had left her work in the community to purchase a car without authorisation.
Prison staff did not therefore consider Ms Chapman for ROTL in hospital.
25. On 15 December, the Head of Safety reduced the number of staff at the hospital to
one, who would not wear uniform.
26. On 20 December, healthcare staff had a multidisciplinary team meeting (MDT) at
the Royal Surrey County Hospital. They noted that Ms Chapman was now suitable
4 Prisons and Probation Ombudsman
for palliative care and wanted to move to a hospice near her family in Peterborough,
with her second choice a move to Woking hospice. They noted that Ms Chapman
had signed a do not resuscitate order and that staff had begun to complete an
application for early release on compassionate grounds. At the time, Ms Chapman
had a prognosis of days to two weeks. A nurse planned a referral to the Sue Ryder
Hospice in Peterborough and to the Woking Hospice and noted that prison staff
would complete the application for compassionate release.
27. On 21 December, the Head of Safety emailed a completed application for early
release on compassionate grounds to a team leader at the Public Protection Group
at HMPPS. In the application, a GP at Send noted that Ms Chapman was admitted
to hospital on 4 December, and that hospital staff reported a significant deterioration
in her condition over the last two and a half weeks. He noted that Ms Chapman had
been diagnosed with breast cancer which had spread to other parts of her body and
told that she was too unwell for active cancer treatment. The GP noted that the
hospital medical team gave Ms Chapman a prognosis of days to maybe one to two
weeks. The Governor and probation staff submitted evidence in support of the
application.
28. On 27 December, the Head of Reducing Reoffending emailed the team leader and
said that a bed had become available at a hospice in Peterborough, and that
hospital staff were keen to move Ms Chapman to the hospice. The Head said that
this was extremely time critical as Ms Chapman’s condition was deteriorating.
29. On 28 December, the team leader emailed the completed compassionate release
application to the Deputy Head of Reconsideration and Specialist Casework, Public
Protection Group.
30. On 29 December, the Secretary of State authorised Ms Chapman’s release from
prison with immediate effect.
31. That day, a palliative care consultant at the Royal Surrey County Hospital advised
healthcare staff that Ms Chapman was not transferred to the hospice that day
because of an issue with hospital transport provision. The transfer was planned
instead for 2 January 2024.
32. On 4 January 2024, a nurse at Send noted that Ms Chapman was too unwell to
transfer to the hospice and would remain at the hospital.
33. On 6 January 2024, Ms Chapman died in hospital. Her family were present when
she died.
Post-mortem report
34. There was no post-mortem examination. A hospital doctor said that Ms Chapman
died from metastatic breast cancer (cancer which had spread to other parts of her
body).
Support for prisoners and staff
35. On 8 December, after Ms Chapman’s health deteriorated, the Governor posted a
notice to staff informing them that she was in hospital and reminded them of the
Prisons and Probation Ombudsman 5
available support services. On 15 December, the Governor reminded staff who may
be asked to carry our bedwatch duties at the hospital with Ms Chapman that this
duty may be emotional and difficult, and reminded them of the support services
available.
36. On 2 January, the Governor posted notices informing prisoners and staff that Ms
Chapman had been released on compassionate grounds. She advised them of the
available support networks, Listeners and the Samaritans. The Governor posted
further notices when Ms Chapman died.
Contact with Ms Chapman’s family
37. On 5 December, the Head of Safety appointed a Supervising Officer (SO) as the
family liaison officer. The SO arranged for Ms Chapman’s family to visit her in
hospital. After Ms Chapman died, the SO telephoned Ms Chapman’s daughter and
offered her condolences.
6 Prisons and Probation Ombudsman
Findings
Early Release on Compassionate Grounds
38. Early release on compassionate grounds is the 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).
39. On 20 December, at an MDT meeting, prison staff were told that Ms Chapman was
for palliative care only, with a prognosis of days to maybe one to two weeks. Prison
staff promptly completed and submitted a completed application for early release to
the relevant HMPPS department. On 29 December, the Secretary of State
authorised Ms Chapman’s immediate release.
40. Obtaining a prognosis that might meet the criteria for early release is difficult and it
is often the case that such a prognosis is only available close to death. We are
pleased that prison staff at Send were able to make a timely, successful application
before Ms Chapman died.
Governor to Note
Release on Temporary Licence
41. In submitting an application for early release, prison staff recorded that they were
now satisfied that Ms Chapman’s risk to the public was sufficiently reduced to allow
her to be released from her sentence. She had previously been released on
temporary licence (ROTL) to work in the community, a privilege which was
withdrawn earlier in 2023 when Ms Chapman left her workplace to buy a car without
authorisation.
42. The HMPPS Release on Temporary Licence Policy Framework identifies that
prisoners may be suitable for special purpose ROTL for urgent medical attention.
While Ms Chapman had previously been withdrawn from ROTL, her circumstances
had now significantly changed, and her medical condition meant that her risk of
reoffending was significantly reduced. It would have been appropriate for prison
staff to consider ROTL for Ms Chapman at the same time that they submitted her
application for early release on compassionate grounds.
Adrian Usher
Prisons and Probation Ombudsman July 2024
Prisons and Probation Ombudsman 7
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