Lawrence Johnson

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Independent investigation into
the death of Mr Lawrence
Johnson, a prisoner at HMP
Frankland, on 13 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, 2025
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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 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.
Mr Lawrence Johnson died of a ruptured atherosclerotic abdominal aortic aneurysm (AAA)
on 13 January 2024 at HMP Frankland. He was 82 years old. I offer my condolences to Mr
Johnson’s family and friends.
The clinical reviewer concluded that the clinical care that Mr Johnson received at
Frankland was equivalent to what he could have expected to receive in the community.
My investigation found that when healthcare staff asked an officer to open Mr Johnson’s
cell door to allow them to conduct observations on him, the officer did not. The officer was
unaware that all staff have the authority to open cell doors in patrol state, in line with local
protocol.
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 January 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 21 January 2000, Mr Lawrence Johnson was sentenced to life imprisonment,
with a minimum tariff of eight years and three months for sexual offences. He was
sent to HMP Swansea. In January 2001, he was transferred to HMP Frankland.
2. In January 2017, Mr Johnson was diagnosed with mild Chronic Obstructive
Pulmonary Disease (COPD). He was urgently referred to a Consultant Respiratory
Physician, and for a computed tomography scan (CT scan).
3. On 11 April, a CT scan of the thorax (chest) was completed. The results confirmed
that there was a blood clot in the lower part of the lung that was blocking and
stopping blood flow to an artery in the lung. Mr Johnson was prescribed Apixaban,
however his medical records suggest that he only occasionally took his medication
as prescribed.
4. On 15 April 2019, the GP at the prison saw Mr Johnson. He presented with several
concerns, including chronic constipation and difficulty passing urine. The GP
referred him for an ultrasound of his abdomen. On 4 June, Mr Johnson was
diagnosed with an abdominal aortic aneurysm (AAA).
5. On 4 September, Mr Johnson attended an appointment with a Consultant Vascular
Surgeon, and declined any further monitoring or follow-up screening for his AAA.
6. At 5.53pm on 13 January 2024, Mr Johnson pressed his cell bell. When an officer
responded, Mr Johnson said he was not feeling well. She asked him what was
wrong and if he required assistance from healthcare, but he continued to say he
was not well.
7. At 5.58pm, the officer radioed healthcare for assistance and at 6.02pm, the officer
went to collect healthcare staff from the wing gate and brought them back to Mr
Johnson’s cell.
8. The nurse observed Mr Johnson through the observation panel and asked him what
was wrong, and again he responded that he was not well. She told the officer that
she needed to get into Mr Johnson’s cell to conduct observations. The officer did
not open the cell, and instead radioed for the Custodial Manager (CM) to attend so
he could open the cell door.
9. At 6:07pm, the CM attended the wing and opened Mr Johnson’s cell door.
Healthcare staff entered the cell and carried out observation checks. Mr Johnson
appeared to be struggling to breathe and his speech was laboured.
10. At 6.10pm, the CM called a medical emergency code due to Mr Johnson’s
deteriorating presentation. Control room staff called an ambulance immediately. Mr
Johnson became unresponsive and suffered a cardiac arrest. The nurse attached
the defibrillator and staff began cardiopulmonary resuscitation (CPR). The
defibrillator could not find a shockable pulse.
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11. At 6.35pm, paramedics arrived and took over Mr Johnson’s care. At 6.55pm, they
decided to stop treatment as Mr Johnson was not responding to CPR attempts and
confirmed that Mr Johnson had died. The post-mortem confirmed that Mr Johnson
died from a ruptured AAA.
Findings
12. The officer who responded to Mr Johnson’s cell bell radioed for healthcare
assistance, however when healthcare attended and requested she open Mr
Johnson’s cell door she did not and instead radioed for a Custodial Manager (CM)
to attend the wing to open the door, which is not in line with local guidance.
13. The clinical reviewer concluded that the care Mr Johnson received at Frankland
was of a good standard and was equivalent to what he could have expected to
receive in the community. She had some concerns about recording keeping and
medication reviews.
Recommendations
• The Head of Healthcare should ensure clinic letters are obtained and are available
to view within the patient’s SystmOne medical records. This will ensure continuity of
care and support the ongoing management of diagnosed health conditions.
• The Head of Healthcare should ensure that a medication review is undertaken
when a patient does not request a repeat prescription of critical medications. This
will ensure that the patients reasoning for non-concordance can be discussed and
documented.
• The Governor should assure himself that senior managers are completing the
monthly audits checks of staff’s understanding of night procedures as stated in the
HMPPS action plan dated March 2023.
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The Investigation Process
14. HMPPS notified us of Mr Johnson’s death on 13 January 2024.
15. The investigator issued notices to staff and prisoners at HMP Frankland informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
16. The investigator obtained copies of relevant extracts from Mr Johnson’s prison and
medical records, CCTV and body worn video camera (BWVC) footage, and
recordings of radio transmissions.
17. NHS England commissioned a clinical reviewer to review Mr Johnson’s clinical care
at the prison. The investigator and clinical reviewer conducted joint interviews with
four members of staff from Frankland in March 2023.
18. We informed HM Coroner for Durham of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
19. The Ombudsman’s office contacted Mr Johnson’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. We did
not receive a response.
20. 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 Frankland
21. HMP Frankland is a high security prison. It holds male prisoners, aged 21 and over.
22. Spectrum provide healthcare services. Tees, Esk and Wear Valleys Mental Health
NHS Foundation Trust provides mental health services. The establishment has an
inpatients unit, with primary healthcare cover 24 hours a day.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Frankland was in January 2020. Inspectors
reported that in a survey of prisoners, 38% described GP services as good and
41% described the overall quality of healthcare as good. Inspectors found that
skilled nurses cared for prisoners with complex long-term health conditions and that
healthcare staff provided an impressive range of primary and secondary health
clinics.
Independent Monitoring Board
24. 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 November 2022, the IMB reported
that staffing in healthcare was an ongoing challenge and that waiting times for
clinics were a concern.
Previous deaths at HMP Frankland
25. Mr Johnson was the seventh prisoner to die at Frankland since January 2022. Of
the previous deaths, five were natural causes and one was self-inflicted.
26. We have previously made a recommendation to the Governor about staff being
aware of and understanding their responsibilities during medical emergencies. The
Governor agreed to publish a Governor’s Notice to all staff to explain their
responsibilities during a medical emergency.
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Key Events
27. On 21 January 2000, Mr Lawrence Johnson was sentenced to life imprisonment,
with a minimum tariff of eight years and three months, for sexual offences. He was
sent to HMP Swansea. He transferred to HMP Frankland on 18 January 2001.
28. Between 2001 and 2017, Mr Johnson had little contact with healthcare staff. In
2014, he was invited to attend a routine abdominal aortic aneurysm (AAA)
screening but he declined, in 2016, he had cataract surgery and in 2017, he was
diagnosed with mild Chronic Obstructive Pulmonary Disease (COPD).
29. On 27 March, healthcare staff urgently referred Mr Johnson to the Consultant
Respiratory Physician after he reported that he was experiencing shortness of
breath and had observed flecks of blood in his sputum (mucus that is coughed up).
30. On 6 April, Mr Johnson attended an outpatients appointment with the Consultant
Respiratory Physician. During this appointment he was referred for a computed
tomography scan (CT scan).
31. On 11 April, the CT scan results showed that there was a blood clot in the lower
part of Mr Johnson’s lung that was blocking and stopping blood flow to an artery in
the lung. Mr Johnson was prescribed Apixaban, however his medical records
suggest that he only occasionally took his medication as prescribed. There is no
evidence that healthcare staff followed up to establish why he was not taking his
medication.
32. On 15 April 2019, a GP at the prison saw Mr Johnson after he complained of
chronic constipation and difficulty passing urine. The GP referred him for an
ultrasound of his abdomen.
33. On 4 June, the ultrasound showed a 4.7cm abdominal aortic aneurysm (AAA).
34. On 5 August, the GP met with Mr Johnson to explain the findings of the ultrasound.
Mr Johnson agreed to be referred to the Vascular Service to discuss his diagnosis
further with a vascular surgeon.
35. On 4 September, Mr Johnson attended an appointment with the consultant vascular
surgeon, and declined any further monitoring or follow-up screening for his AAA.
Events of 13 January 2024
36. At 5.45pm on 13 January 2024, two prison officers started their routine checks.
37. At 5.53pm, Mr Johnson pressed his cell bell. An officer responded and Mr Johnson
said that he was not feeling well.
38. Mr Johnson’s cell door was locked as the prison was in patrol state. The officer
spoke to Mr Johnson and observed him through the observation panel. She asked
him what was wrong and if he required assistance from healthcare, but he
continued to say he was not well. The officer said that Mr Johnson was swearing,
throwing himself around on his bed and grunting.
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39. At 5.58pm, the officer radioed healthcare for assistance. While waiting for them to
attend, the officer said that Mr Johnson got up off his bed and went to the window
and then returned to lie down on his bed again.
40. At 6.02pm, the officer left Mr Johnson’s cell to go and collect healthcare staff from
the wing gate. At 6.05pm, CCTV shows the two officers, a senior nurse, and a
healthcare support worker (HCSW) returning to Mr Johnson’s cell door.
41. The nurse observed Mr Johnson through the observation panel and asked him what
was wrong. Mr Johnson said that he was not well. The nurse told an officer that she
needed to get into Mr Johnson’s cell to conduct observations.
42. The officer radioed the custodial manager (CM) to attend so he could open the cell
door.
43. During this time, Mr Johnson’s presentation started to deteriorate so the HCSW
went to collect the emergency response bag and defibrillator.
44. At 6.07pm, the CM attended the wing and opened Mr Johnson’s cell door.
45. The nurse and the HCSW entered the cell to tend to Mr Johnson and assess him.
The nurse noted that Mr Johnson was grey in colour and was “moaning and
groaning” but he did not say what was wrong. Mr Johnson appeared to be
struggling to breathe and his speech was laboured. The nurse said that when
attempting to obtain his clinical observations, Mr Johnson was clammy and had a
weak pulse.
46. At 6.10pm, the CM called a code blue (indicating a prisoner is unconscious or is
having breathing difficulties). Control room staff called an ambulance.
47. Mr Johnson then vomited and became unresponsive. Staff moved him from his cell
onto the wing landing to allow more room to deliver interventions. At this point, Mr
Johnson suffered a cardiac arrest. The nurse attached the defibrillator and staff
began CPR. The defibrillator could not find a shockable pulse.
48. At 6.35pm, paramedics arrived and took over Mr Johnson’s care. They continued to
deliver CPR. At 6.55pm, they stopped treatment and confirmed that Mr Johnson
had died.
Contact with Mr Johnson’s next of kin
49. Shortly after Mr Johnson’s death, the prison allocated a supervising officer (SO) as
the family liaison officer (FLO). As Mr Johnson’s next of kin was a prisoner who
lived in a different prison, the FLO contacted the prison but was told there was no
on-call FLO available there. He contacted the next of kin’s wing manager who told
Mr Johnson’s next of kin of his death.
50. The Coroner contacted a member of Mr Johnson’s family however they declined
any further involvement.
51. The prison paid for Mr Johnson’s funeral in line with national guidance.
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Support for prisoners and staff
52. After Mr Johnson’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues, and
to offer support. The staff care team also offered support.
53. The prison posted notices informing other prisoners of Mr Johnson’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 Johnson’s death.
Post-mortem report
54. The coroner gave Mr Johnson’s cause of death as ruptured atherosclerotic
abdominal aortic aneurysm (AAA).
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Findings
Clinical care
55. The clinical reviewer concluded that the care Mr Johnson received at Frankland
was of the required standard and equivalent to what he could have expected to
receive in the community.
56. She, did, however identify some concerns about recording keeping and medication
reviews. She found that the clinic letter following Mr Johnson’s consultation
appointment on 4 September 2019 about the management of his AAA was not in
his medical record as it should have been. The letter reflected that he was informed
of the potential consequence of his AAA diagnosis and that he could change his
mind and participate in the monitoring programme at any time.
57. There is no evidence that healthcare staff discussed Mr Johnson’s non-compliance
with his prescribed medication with him in order to understand why he was no
longer requesting and taking his medication.
58. The clinical reviewer made the following recommendations:
The Head of Healthcare at HMP Frankland should ensure clinic letters are
obtained and are available to view within the patient’s SystmOne medical
records. This will ensure continuity of care and support the ongoing
management of diagnosed health conditions.
The Head of Healthcare at HMP Frankland should ensure that a medication
review is undertaken when a patient does not request a repeat prescription of
critical medications. This will ensure that the patients reasoning for non-
concordance can be discussed and documented.
Emergency response
59. The local Medical Emergency Response protocol at Frankland states that the first
member of staff on the scene should make a dynamic risk assessment of the
situation and if they decide to enter the cell, the control room must be informed of
that decision.
60. When Mr Johnson pressed his cell bell for assistance, the prison was in patrol state.
The officer had just completed the routine check when she responded to Mr
Johnson’s cell bell. When the nurse asked the officer to open the cell door to enable
healthcare staff to conduct observations, she did not and instead radioed for a
custodial manager to attend the wing to open the cell.
61. The officer told us that at the time she was unaware that she could open a cell door
during patrol state. She said that even if she had been aware she would not have
opened the cell door as Mr Johnson had been swearing, which she assessed as
being aggressive.
62. Following Mr Johnson’s death, senior managers held a cold debrief on 26 January
2024 where they identified learning. They discussed staff authority to open cell
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doors in a medical emergency during patrol state and agreed to issue a notice to all
staff to reflect this.
63. Staff are expected to make dynamic risk assessments in complex and fast-moving
situations, and we accept that the officer might have decided not to unlock Mr
Johnson’s cell until senior staff were present. However, the fact that she did not
know that she had the authority to open the cell, and that we have previously noted
a similar issue at Frankland, suggests that the earlier Notice to staff issued by the
Governor, and the implementation of senior manager monthly audit checks in
response our recommendation in March 2023 has not been sufficient to change
staff practice. We therefore make the following recommendation:
The Governor should assure himself that senior managers are completing the
monthly audits checks of staff’s understanding of night procedures as stated
in the HMPPS action plan dated March 2023.
Inquest
At the inquest held on 10 January 2025, the Coroner concluded that Mr Johnson died of
natural causes.
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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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