Leon Cadman

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Independent investigation into
the death of Mr Leon Cadman,
a prisoner at HMP Peterborough,
on 12 July 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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© 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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Leon Cadman died in hospital of cirrhosis of the liver on 12 July 2022, while a
prisoner at HMP Peterborough. This was caused by alcohol and hepatitis C
infection (liver failure). He also had previous intravenous opiate drug dependency
which contributed to but did not cause his death. He was 51 years old. We offer our
condolences to Mr Cadman’s family and friends.
4. The clinical reviewer concluded that the clinical care Mr Cadman received at
Peterborough was mostly of the required standard and partially equivalent to that
which he could have expected to receive in the community. She was concerned that
there was no timely escalation when Mr Cadman’s health deteriorated on 12 July
2022, National Early Warning Scores (NEWS2, a clinical tool to identify and
address clinical deterioration) were not calculated correctly and healthcare staff
were not offered appropriate support after his death.
5. We are concerned that the early compassionate release process was not managed
effectively or efficiently. We saw no evidence that an application was completed
after 27 June 2022, as it should have been.
6. We were also concerned that, despite requests, Peterborough did not provide the
investigator with all the documentation about the use of restraints when Mr Cadman
went to hospital. This meant that we could not determine whether the decision to
restrain Mr Cadman on 24 June 2022 was appropriate.
Recommendations
• The Head of Healthcare should ensure that healthcare staff:
• are fully competent in using the National Early Warning Score (NEWS2)
effectively;
• complete full and accurate clinical observations;
• follow protocols for clinical escalation in line with NEWS2 and sepsis
pathways; and
• make accurate, timely and contemporaneous notes in prisoners’ medical
records, in line with the Nursing and Midwifery Council’s guidance.
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• The Governor at HMP Peterborough should ensure that a manager holds a hot
debrief promptly after a death in custody and that all those involved in the incident,
including healthcare staff, are invited to attend, in line with PSI 64/2011.
• The Governor and Head of Healthcare should ensure that applications for early
release on compassionate grounds for prisoners with terminal illnesses are
prioritised, and that a record is kept of action taken.
• The Governor should ensure that all evidence about a death in custody, including
electronic evidence, is retained and promptly made available to the Prisons and
Probation Ombudsman, in line with PSI 58/2010.
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The Investigation Process
7. NHS England and NHS Improvement (NHSE&I) commissioned an independent
clinical reviewer to review Mr Cadman’s clinical care at Peterborough.
8. The PPO investigator investigated the non-clinical issues relating to Mr Cadman’s
care, including Mr Cadman’s location, the security arrangements for his hospital
escorts, liaison with his family and whether compassionate release was considered.
9. The PPO family liaison officer wrote to Mr Cadman’s next of kin, his wife, to explain
the investigation. She did not respond to our letter.
10. The solicitor representing Mrs Cadman, received a copy of the initial report. They
wrote to us raising a number of issues that do not impact on the factual accuracy of
this report. We have provided clarification by way of separate correspondence to
the solicitor.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Peterborough
12. Mr Cadman was the sixth prisoner to die at Peterborough since July 2020. The
majority of the previous deaths were from natural causes, and one was drug-
related. There have been ten deaths since.
13. Following a death in April 2022, our investigation found that although clinical
observations were taken, NEWS2 scores were not always assessed at
Peterborough. HM Prison and Probation Service’s (HMPPS) action plan following
our investigation report had not been completed at the time of this report.
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Key Events
14. On 26 July 2021, Mr Leon Cadman was sentenced to seven years in prison for drug
offences. He was sent to HMP Lincoln and transferred to HMP Stocken the
following day.
15. On 3 August, Mr Cadman was sent to hospital, where he was treated for alcohol-
related liver disease, ascites (a build-up of fluid in the abdomen, often due to severe
liver disease), bilateral pleural effusions (an excessive build-up of fluid in the space
between the lungs and chest cavity), sepsis (an infection of the blood stream) and
resolved hepatic encephalopathy (a loss of brain function as a result of toxins not
being removed from the blood due to liver damage).
16. On 2 November, Mr Cadman was discharged from hospital to HMP Peterborough to
access twenty-four-hour healthcare. He was located on the prison healthcare wing.
17. On 4 November, a nurse noted that he had turned down a liver transplant and was
on a palliative care pathway. Appropriate palliative care plans were put in place.
18. On 11 November, Mr Cadman said he did not want to be resuscitated if his heart or
breathing stopped and signed an order to that effect.
19. On 12 November, the Head of Safety appointed a Senior Officer as Mr Cadman’s
family liaison officer (FLO). The FLO agreed with the Head of Safety, that she would
not contact the family until after an upcoming palliative care meeting.
20. On 1 December, the FLO telephoned Mr Cadman’s wife to introduce herself to the
family and talk about Mr Cadman’s health.
21. On 22 December, Mr Cadman was released on temporary licence to continue
medical treatment in hospital without escorting prison officers by his side.
22. That day, the FLO told Mr Cadman’s wife that the Director of Peterborough had
approved Mr Cadman’s early compassionate release application and that it would
be submitted that week. She told her that the application may take six to eight
weeks to progress.
23. On 3 February 2022, the FLO told Mr Cadman’s wife that there were no updates
about the compassionate release application as the prison was still waiting for a
hospital consultant’s letter about Mr Cadman’s prognosis.
24. On 10 February, Mr Cadman retracted his decision not to be resuscitated if his
heart or breathing stopped. He asked to be added to the waiting list for a liver
transplant. The Operational Healthcare Manager told him that he would not be
eligible for early compassionate release if he was seeking active treatment. Mr
Cadman confirmed that he still wanted a transplant.
25. On 20 May, Mr Cadman said he did not want to be resuscitated if his heart or
breathing stopped and signed a new order to that effect.
26. On 31 May, the FLO met Mr Cadman’s wife when she visited Mr Cadman at
Peterborough. Mr Cadman’s wife asked her about early compassionate release and
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the FLO said a new application would be needed and she would ask if it was an
option.
27. On 24 June, Mr Cadman attended the local hospital for a planned blood test and to
have the swelling in his legs drained. No documentation was provided to the
investigator about the arrangements for this escort, so we do not know whether any
restraints were applied.
28. On 27 June, a nurse noted that both Peterborough and Leeds hospitals had
confirmed that Mr Cadman was not a candidate for a liver transplant. She emailed
the liver specialist nurse at the local hospital to ask for a letter from the hospital
consultant to establish Mr Cadman’s prognosis to support an early compassionate
release application.
Events of 12 July 2022
29. At 9.34am, a Healthcare Assistant (HCA) attended Mr Cadman’s cell to carry out
physical observations. She recorded that his blood pressure was low (at
77/52mmHg) and that his heart rate was high (at 130bpm). His temperature and
oxygen saturation levels were within normal range. She did not complete a NEWS2
score. (A clinical tool to identify and address clinical deterioration. A score above
seven indicates the need for an emergency response.) If she had calculated a
NEWS2 score using the recorded observations, it would have been at least nine.
There is no record of the abnormal observation results being escalated or further
action being taken.
30. At 10.07am, the HCA left Mr Cadman to continue with her ward observations. She
walked into the corridor past, a prison GP, who was carrying out the weekly ward
round, but did not mention the abnormal observations. The GP noted that she had
seen Mr Cadman for the weekly ward round in the healthcare unit. She said that Mr
Cadman was tearful and said he felt better when he had company.
31. The HCA told the investigator at interview that at approximately 10.30am she
completed her ward observations and recorded them on the computer. She said
she then told a senior nurse about the low blood pressure result but not the heart
rate result. There is no clinical record about this. The nurse said that she did not
recall anyone escalating Mr Cadman’s observations to her.
32. At 10.34am, two nurses saw Mr Cadman because an officer reported to them that
Mr Cadman was uncomfortable. They attended to his legs as they were leaking fluid
and made him comfortable. This was reported at interview but was not documented
in the medical records.
33. At 12.50pm, a nurse saw Mr Cadman to give him his medication. She noted that he
had visibly deteriorated physically and noted that his observations were ‘abnormal’.
She did not calculate a NEWS2 score and did not call a medical emergency code.
34. At 1.15pm, the nurse repeated the physical observations and noted a NEWS2 score
of 11. She asked an officer to request an emergency ambulance.
35. At 1.19pm, the officer telephoned to request an emergency ambulance and
ambulance paramedics arrived at 1.42pm. The ambulance left at 2.27pm to take Mr
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Cadman to hospital. Prison staff did not apply restraints to Mr Cadman when they
escorted him to hospital.
36. At approximately 2.45pm, the deputy FLO telephoned Mr Cadman’s wife to inform
her that Mr Cadman was in a critical condition. She agreed to meet her at the
hospital.
37. At 4.51pm, Mr Cadman died with his family by his side.
38. The following day, a debrief meeting was held with the two officers who escorted Mr
Cadman to hospital. There are no records of whether anyone else was invited to
attend this meeting.
Post-mortem report
39. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Cadman’s cause of death
as cirrhosis of the liver. This was caused by alcohol and hepatitis C infection. He
also had previous intravenous opiate drug dependency which contributed to but did
not cause his death.
Inquest into Mr Cadman’s death
40. The inquest into Mr Cadman’s death was concluded on 18 March 2024 and a
verdict of natural causes was recorded. The coroner concluded that Mr Cadman’s
death was due to acute chronic liver failure, sepsis of an unknown cause and
alcohol and hepatitis C virus related liver cirrhosis. He also had previous
intravenous drug use and opioid dependency.
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Clinical Findings
Clinical care
41. The clinical reviewer concluded that the clinical care Mr Cadman received at
Peterborough was mostly of the required standard and partially equivalent to that
which he could have expected to receive in the community. She said there was
evidence of appropriate care planning, timely transfers to hospital when required
and ongoing monitoring of his health needs. However, she was concerned that
there was no timely escalation when Mr Cadman’s health deteriorated on 12 July
2022, NEWS2 scores were not calculated correctly, and healthcare staff were not
offered appropriate support after his death.
Events of 12 July 2022
42. The clinical reviewer was concerned about the events of 12 July and the different
reports of how and when healthcare staff escalated concerns. There were no
records of escalation documented in Mr Cadman’s medical records, other than
those of a nurse, who requested an emergency ambulance at 1.15pm.
43. The HCA completed her observations at 9.34am. She recorded Mr Cadman’s low
blood pressure and high heart rate. The clinical reviewer reported that the
observations and open leg wounds were high-risk factors for sepsis. There was no
indication in the medical records that sepsis was considered. The HCA did not
complete a NEWS2 score.
44. The clinical reviewer found that Mr Cadman’s physical observations were monitored
regularly during his time at Peterborough. However, NEWS2 scores were often not
calculated. At interview, the Head of Healthcare reported that all staff had received
NEWS2 training in November 2020, and that scores should be recorded either
manually on a scoring sheet or in the medical records. The HCA reported at
interview that she had only been trained on NEWS2 in August 2022 after Mr
Cadman’s death. Training records suggest she attended training in December
2019. It is clear that NEWS2 scoring was not embedded in practice at Peterborough
at the time of Mr Cadman’s death.
45. Following a death in April 2022, our investigation found that although clinical
observations were taken, NEWS2 scores were not always assessed at
Peterborough. We await HM Prison and Probation Service’s action plan at the time
of issuing this report.
46. After the HCA completed the observations on 12 July, she walked out of Mr
Cadman’s room and past a prison GP, who was completing a ward round on the
wing. She did not tell the GP about Mr Cadman’s abnormal observation results. The
GP said at interview that she did not require observation results for the ward round.
However, in the case of a deteriorating patient, we would expect to see an
immediate escalation to senior healthcare staff or the use of a medical emergency
code to call for help.
47. The HCA said at interview that she did not notice Mr Cadman’s high heart rate. Had
she completed the NEWS2 scoring template, it would have highlighted to her that
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Mr Cadman’s health was deteriorating. She said she passed on the information
about Mr Cadman’s low blood pressure to a senior nurse at approximately
10.30am. There is no record of this escalation within the records and no record of
any action taken. The nurse said in a statement that she did not recall any
observations escalated to her. She was on extended leave from the prison and was
unavailable for interview.
48. We are unable to say whether the observations were escalated by the HCA to the
senior nurse. However, we know that there is no record of escalation and no clear
actions taken. There were a number of opportunities to escalate these results.
While we cannot say that escalation would have changed the outcome for Mr
Cadman, it is possible that he would have been sent to hospital for treatment
sooner and in other emergencies, it could be critical. We make the following
recommendation:
The Head of Healthcare should ensure that healthcare staff:
• are fully competent in using the National Early Warning Score (NEWS2)
effectively;
• complete full and accurate clinical observations;
• follow protocols for clinical escalation in line with NEWS2 and sepsis
pathways; and
• make accurate, timely and contemporaneous notes in prisoners’
medical records, in line with the Nursing and Midwifery Council’s
guidance.
Staff support
49. PSI 64/2011 sets out the actions that should be taken following a death in custody.
This includes holding a hot debrief immediately after a death in custody and inviting
all staff directly involved in the incident, including healthcare staff, to attend.
50. A hot debrief took place the day after Mr Cadman’s death. It was attended by two
officers who had escorted Mr Cadman to hospital, however there is no record that
any of the other staff involved in the incident, including healthcare staff were invited
to attend. During interview, a nurse, who was involved in the emergency response,
reported that she did not receive any support and that she was not invited to the hot
debrief. We are concerned that healthcare staff involved were given no opportunity
to discuss any concerns that arose and were not offered support services. We
make the following recommendation:
The Governor at HMP Peterborough should ensure that a manager holds a hot
debrief promptly after a death in custody and that all those involved in the
incident, including healthcare staff, are invited to attend, in line with PSI
64/2011.
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Non-Clinical Findings
Compassionate release
51. Release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from prison 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 (ERCG) 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.
52. In December 2021, the prison approved an application for early compassionate
release for Mr Cadman. This was appropriately withdrawn when Mr Cadman
subsequently decided to seek active treatment and to apply to go on the liver
transplant waiting list.
53. On 27 June 2022, a nurse emailed the hospital consultant for a letter to confirm Mr
Cadman’s prognosis to support a compassionate release application. This was
because the hospital had confirmed Mr Cadman was not a suitable candidate for a
liver transplant. However, there is no evidence that the compassionate release
process was followed up or that the application was started, and the investigator
was unable to identify why this did not progress.
54. Mr Cadman died fifteen days later. While the ERCG Policy Framework gives no
specific timescales for making an application, it states that it is imperative that
applications are expedited as far as possible. We are concerned that the
compassionate release process was not managed efficiently. We have seen no
evidence that the compassionate release application was completed after 27 June,
and we are concerned that no prison manager took effective control of the process.
We make the following recommendation:
The Governor and Head of Healthcare should ensure that applications for
early release on compassionate grounds for prisoners with terminal illnesses
are prioritised, and that a record is kept of action taken.
Providing the PPO with relevant documents
55. PSI 58/2010 requires prisons to provide evidence to the Ombudsman’s office for the
purpose of our investigation. Peterborough did not give us all the escort risk
assessment documentation. This adversely affected our investigation and meant
that we could not determine whether the decision-making process when Mr
Cadman was escorted to hospital on 24 June 2022 was appropriate. We make the
following recommendation:
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The Governor should ensure that all evidence about a death in custody,
including electronic evidence, is retained and promptly made available to the
Prisons and Probation Ombudsman, in line with PSI 58/2010.
Kimberley Bingham
Deputy Prisons and Probation Ombudsman May 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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