Lisa Sherrington

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Independent investigation into
the death of Ms Lisa
Sherrington, a prisoner at HMP
Low Newton, on 26 August 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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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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Ms Lisa Sherrington died in hospital from herpes simplex encephalitis (brain inflammation
caused by the herpes virus) on 26 August 2022, while a prisoner at HMP Low Newton.
She was 50 years old. I offer my condolences to Ms Sherrington’s family and friends.
The clinical reviewer concluded that the care Ms Sherrington received at Low Newton was
equivalent to the care she could have expected to receive in the community.
While it appears to be unconnected to Ms Sherrington’s death, we are concerned that she
was able to smuggle drugs into Low Newton. The Governor will need to consider how
searching procedures can be improved to avoid similar incidents in future.
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 September 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 8
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Summary
Events
1. On 25 July 2022, Ms Lisa Sherrington was remanded in prison custody charged
with possession of class A drugs with intent to supply. She was sent to HMP Low
Newton.
2. Ms Sherrington had several health conditions and used a wheelchair. She also had
a history of drug misuse.
3. When Ms Sherrington arrived at Low Newton, a reception officer carried out a rub
down search of her while she remained in her wheelchair. The officer also
searched the wheelchair. Ms Sherrington was moved to a cell in the healthcare unit
so she could be monitored more easily.
4. On 26 July, Ms Sherrington had a seizure and was sent to hospital. While there, 18
packages of drugs were found in her rectum. Staff searched Ms Sherrington’s cell
and found four packs of antibiotics in the pouch at the back of her wheelchair.
5. Ms Sherrington returned to Low Newton on 27 July. On the morning of 2 August,
she again had a seizure and was sent to hospital.
6. Ms Sherrington died in hospital on 26 August. A hospital doctor recorded her cause
of death as herpes simplex encephalitis (brain inflammation caused by the herpes
virus).
Findings
7. The clinical reviewer concluded that the clinical care Ms Sherrington received at
Low Newton was of a good standard and equivalent to that which she could have
expected to receive in the community. He made no recommendations.
8. Ms Sherrington’s death was caused by a viral infection and there is no indication
that illicit drug use contributed to her death. Nevertheless, we are concerned that
Ms Sherrington was able to smuggle drugs into Low Newton. Body scanners,
which can detect drugs secreted internally, are not currently cleared for use in
women’s prisons. We therefore accept that it would have been difficult to detect the
drugs that Ms Sherrington had secreted internally. However, we are concerned that
Ms Sherrington was able to bring in four packs of antibiotics through reception.
Searching procedures for wheelchair users should be reviewed.
Recommendations
• The Governor should review the searching procedures for prisoners arriving in
wheelchairs and ensure that reception staff are fully aware of the procedures they
must follow in these circumstances.
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The Investigation Process
9. The investigator issued notices to staff and prisoners at HMP Low Newton informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
10. The investigator obtained copies of relevant extracts from Ms Sherrington’s prison
and medical records.
11. The investigator interviewed 11 members of staff at HMP Low Newton on 8, 9 and
10 November. He also interviewed two members of staff by telephone and by
video-link in October.
12. NHS England commissioned a clinical reviewer to review Ms Sherrington’s clinical
care at the prison. The investigator and clinical reviewer conducted joint interviews
with clinical staff on 10 November.
13. We informed HM Coroner for County Durham and Darlington of the investigation.
The Coroner provided us with the cause of death. We have sent the Coroner a
copy of this report.
14. The investigator contacted Ms Sherrington’s mother to explain the investigation and
to ask if she had any matters she wanted us to consider. Ms Sherrington’s mother
asked why her daughter was discharged from hospital on 28 July and sent back to
Low Newton. We have answered this question in our report.
15. We shared the initial report with Ms Sherrington’s mother and with HM Prison and
Probation Service (HMPPS). HMPPS commented upon the blister packs of
medication that were later discovered in Ms Sherrington’s wheelchair. HMPPS
argued that we could not be certain that the medication was in Ms Sherrington’s
wheelchair when she first arrived at Low Newton but might instead have been
secreted somewhere on her person. We have accepted this possibility, and this is
reflected in this version of the report and discussed further in paragraphs 49 and 50.
We also acknowledge in paragraph 50 that Ms Sherrington might have acquired the
medication while at Low Newton, although we consider that unlikely. We do not
accept it at all likely that Ms Sherrington had stored the four blister packs of
medication in her rectum as she had done with the packs of other drugs discovered
when she was transferred to hospital.
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Background Information
HMP Low Newton
16. HMP Low Newton is located near Durham. It holds up to 344 women on remand
and serving short and long sentences including some high security prisoners.
Physical healthcare services are provided by Spectrum Community Healthcare CIC
and mental health provision is provided by Tees, Esk & Wear Valleys NHS
Foundation Trust. The prison has 24 hour a day nursing cover.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Low Newton was in June 2021. Inspectors
noted that 36% of women in the prisoner survey said it was easy to get drugs in the
prison, which was an improvement from the 64% response at the previous survey.
Inspectors had previously recommended that the prison should be equipped with a
body scanner to help prevent illicit items being smuggled in, but Low Newton said
that this technology had not been approved for use in women’s prisons. In
response, inspectors recommended that Low Newton should develop alternative
and effective ways of managing women suspected of secreting drugs and other
illicit items. Inspectors also noted that since the COVID-19 pandemic, staff in
reception no longer completed rub-down searches but instead asked women to
remove their clothing, which inspectors deemed disproportionate. Inspectors
recommended that rub down searches should be reinstated immediately, which the
prison accepted and implemented.
Independent Monitoring Board
18. 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 28 February 2022, the IMB
considered that the prison provided an environment that protected prisoners, so
levels of self-harm and violence were relatively low. The IMB reported that the Drug
and Alcohol Rehabilitation Team (DART) had developed in-cell work and
motivational materials to help reduce harm from substance misuse.
Previous deaths at HMP Low Newton
19. There were no deaths at Low Newton in the two years prior to Ms Sherrington’s
death.
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Key Events
20. On 25 July 2022, Ms Lisa Sherrington was remanded in prison custody, charged
with possession of class A drugs with intent to supply, and sent to HMP Low
Newton. This was her first time in prison.
21. Ms Sherrington had several physical health problems and used a wheelchair. She
also had a history of substance misuse.
22. A reception officer carried out a rub down search of Ms Sherrington while she
remained sitting in her wheelchair as she was unsure whether Ms Sherrington was
able to stand. She also carried out a rub down search of Ms Sherrington’s
wheelchair and checked the pockets. She found nothing of concern.
23. A nurse then saw Ms Sherrington for a reception health screen. The nurse noted
that Ms Sherrington had needed a wheelchair following a prolonged period in
hospital that included being in an induced coma for three to four months. She noted
that Ms Sherrington had a history of drug misuse and presently smoked drugs. She
noted that Ms Sherrington had recently been having seizures and possibly had
undiagnosed epilepsy. She also noted that Ms Sherrington had diabetes and was
insulin dependent.
24. Once the reception process was complete, the nurse located Ms Sherrington in a
cell in the healthcare unit so she could be checked more easily. Ms Sherrington
was prescribed insulin for diabetes and methadone (a heroin substitute) for opiate
dependency.
Events of 26 July
25. At 5.00pm on 26 July, an officer started an evening shift on the healthcare unit and
went to check the prisoners on the unit. She went to Ms Sherrington’s cell at
around 5.15pm and unlocked the door. Ms Sherrington was lying in bed and said
that she was okay.
26. Around five minutes later, a nurse went to check Ms Sherrington’s blood sugar
level. When she looked into the cell, she saw Ms Sherrington on the floor having a
seizure. The nurse was not carrying a radio, so she shouted for help and pressed
the emergency alarm bell. She went into the cell and officers and other nurses
arrived within a few seconds. She took clinical observations and gave Ms
Sherrington oxygen and rectal diazepam. She also gave naloxone in case the
seizures were drug related. One of the officers had radioed a Code Blue (a medical
emergency code to indicate that a prisoner is unconscious or having breathing
difficulties and that an ambulance is needed). Paramedics arrived at around
5.46pm, by which time the nurse noted that Ms Sherrington had had around seven
seizures. Ms Sherrington was taken to hospital and was accompanied by two
bedwatch officers (bedwatch officers accompany and remain with prisoners while
they are in hospital). Ms Sherrington’s mother was informed that evening that her
daughter had been taken to hospital.
27. At hospital, Ms Sherrington was sedated and placed in intensive care and during
examination was found to have 18 packages of drugs stored in her rectum. Staff
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thought one of the packages may have leaked, but it is unclear whether that was
the case.
Events of 27 and 28 July
28. On the morning of 27 July, Ms Sherrington’s sedation was stopped and at 11.49am,
she was noted to be awake and alert.
29. Due to the discovery of the secreted drugs, Ms Sherrington’s cell was searched on
27 July. The investigator viewed body worn video recordings of the search. The
search was thorough and systematic and covered the bedding material, towels and
curtains, Ms Sherrington’s clothing and other possessions. The search also
covered the cell furniture and staff checked behind and beneath it. The search
discovered around 36 tablets of clindamycin (an antibiotic) in four blister packs that
were in the pouch at the back of Ms Sherrington’s wheelchair (she had been
prescribed this medication while in the community).
30. At 12.15pm on 28 July, one of the bedwatch officers started Prison Service suicide
and self-harm monitoring (known as ACCT) after Ms Sherrington made comments
about having “nothing to live for” and that she “did not want to be here”. He set
observations at four an hour.
31. Ms Sherrington was discharged from hospital and returned to Low Newton at
around 4.25pm on 28 July. One of Low Newton’s nurses subsequently noted that
the reason for Ms Sherrington’s discharge was that the hospital had no available
‘step down beds’. The nurse told the investigator that the usual practice would be
for a hospital patient to move from intensive care to a medical ward for their
progress to be monitored before being discharged. However, the nurse did not
have any particular concerns about Ms Sherrington’s discharge back to Low
Newton.
32. The hospital discharge summary noted Ms Sherrington’s diagnosis to be ‘epilepsy
generalised’.
Events of 29 July to 1 August
33. On the morning of 29 July, an officer saw Ms Sherrington for an ACCT assessment
interview. The officer noted that Ms Sherrington appeared very confused and kept
jumping from one thought to another. She told the investigator that that was the
first time she had met Ms Sherrington, so she did not know if this was usual for her
or whether it was due to the circumstances that led to her hospitalisation. She said
that during ACCT assessments she typically asked prisoners, on a scale of zero to
ten, whether they wanted to die, and she noted that Ms Sherrington had answered
ten. However, Ms Sherrington also spoke about her family and going to education
and said that her main concern was that she was losing weight and needed help
with that.
34. In the early afternoon, a Supervising Officer (SO) chaired an ACCT case review.
Ms Sherrington, the officer who carried out the assessment interview and a mental
health nurse also attended. The review was held on the healthcare exercise yard
as Ms Sherrington wanted some fresh air. The SO noted that Ms Sherrington was
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a little confused when answering questions and when asked if she knew where she
was, said she was in HMP Holme House (a male prison). She also said that she
remembered nothing about being in hospital. He noted that Ms Sherrington had
self-harmed in the past by cutting and noted that as Ms Sherrington was unknown
at Low Newton, she should continue to be observed four times an hour. He
scheduled the next ACCT review for 5 August. The nurse did not note any concerns
in Ms Sherrington’s medical record after the ACCT review.
35. Officers made entries in Ms Sherrington’s records to show that from the afternoon
of 29 July, she began to engage more with staff. She was noted to be in good
spirits on 30 July and on 31 July, and she said that she felt much better physically.
On 1 August, the records indicate that Ms Sherrington had been feeling unwell that
day although she told a nurse in the afternoon that she was no longer feeling sick.
Events on 2 and 3 August
36. At around 8.00am on 2 August, a nurse went to Ms Sherrington’s cell and briefly
chatted to her before going to collect equipment to check her blood sugar level.
Before the nurse had returned, an officer went to make an ACCT check on Ms
Sherrington and saw her having a seizure on her bed. The officer shouted for nurse
assistance and the nurse ran from the staff office, which was around 20 yards
away. The nurse said that she went into Ms Sherrington’s room and was joined by
another nurse and the Head of Healthcare. The nurse said that they put Ms
Sherrington on her side to make sure she was safe, and they took her observations.
Ms Sherrington had several seizures, but they were not as severe as the seizure on
26 July, and she was able to talk in between seizures. After around two to three
minutes the nurses decided Ms Sherrington would need to go back to hospital, so
they radioed a Code Blue. Ambulance paramedics arrived at 8.57am and took Ms
Sherrington to hospital.
37. Communications room records show that the Code Blue call was made at 8.42am
and an emergency ambulance was called at 8.44am. An Officer Support Grade
(OSG) who was working in the communications room that day said that the practice
at that time was that an ambulance would only be called when the most senior
uniformed officer on duty had confirmed that one was needed. However, the
practice had since been updated so ambulances were requested immediately on
hearing a Code Blue.
38. On 3 August, following Ms Sherrington’s additional seizures, a further search was
made of her cell and a package of brown powder was found concealed in a sock
inside a cupboard. (The investigator noted that when staff checked the cell on 27
July, they checked Ms Sherrington’s clothing by turning the items inside out and
they emptied the cupboards before placing checked items back inside the
cupboards.)
Ms Sherrington’s deterioration and death
39. Bedwatch officers remained with Ms Sherrington while she was at hospital and
prison healthcare staff maintained contact with the hospital for updates on her
progress. Ms Sherrington had various hospital tests and had seizures from time to
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time, but also had periods when she was lucid and talkative. On 15 August, Ms
Sherrington was able to leave her bed to wash herself in the bathroom.
40. In the early hours of 16 August, Ms Sherrington had continuous seizures for three
hours and was moved from a general ward to the intensive treatment unit (ITU). Ms
Sherrington remained sedated from that time, with machines assisting her
breathing. Doctors performed various tests and diagnosed Ms Sherrington with
herpes simplex encephalitis, a rare neurological disorder causing inflammation of
the brain. They gave her a five percent chance of survival. Ms Sherrington was
disconnected from all life support equipment on 26 August and died at 4.10pm that
day.
Contact with Ms Sherrington’s family
41. One of Low Newton’s family liaison officers (FLOs) had attempted without success
to contact Ms Sherrington’s mother on the afternoon of 2 August to inform her that
her daughter had been sent to hospital again. The FLO was not able to speak to
Ms Sherrington’s mother until 5 August, as she had been away from home for
several days. Ms Sherrington’s mother visited her daughter in hospital and was
later present when the life support machine was switched off and Ms Sherrington
died.
42. Low Newton contributed to the cost of Ms Sherrington’s funeral in line with national
instructions.
Support for prisoners and staff
43. After Ms Sherrington’s death, a member of the prison care team debriefed the staff
who had been on bedwatch to ensure they had the opportunity to discuss any
issues arising, and to offer support.
44. The prison posted notices informing other prisoners of Ms Sherrington’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 Ms Sherrington’s death.
Cause of death
45. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor recorded Ms Sherrington’s
cause of death as herpes simplex encephalitis (inflammation of the brain caused by
the herpes virus). There were no toxicological tests for the presence of drugs or
other substances.
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Findings
Clinical care
46. The clinical reviewer concluded that the healthcare Ms Sherrington received at Low
Newton was of a good standard and equivalent to that which she could have
expected to receive in the community. The clinical reviewer found no areas for
concern, and he made no recommendations.
47. The clinical reviewer did not identify anything that the prison could have done
differently that might have prevented Ms Sherrington’s death.
Drug finds
48. When Ms Sherrington was sent to hospital on 26 July, several drug packages were
found in her rectum. Further medication and drugs were subsequently found during
cell searches on 27 July and 3 August.
49. Body scanners, which can identify items secreted internally, are not used in
women’s prisons and strip searches are carried out at Low Newton only if there is
intelligence that a woman might be carrying drugs. We therefore accept that it
would not have been possible for staff to identify that Ms Sherrington had secreted
drugs internally and the drugs discovered on 3 August might also have been stored
internally when Ms Sherrington arrived. However, we are concerned that four
blister packs of medication were later found in the pouch at the back of Ms
Sherrington’s wheelchair, which were not found during the reception searching
procedures. It is probable that these were somewhere upon her person or in or on
her wheelchair when she arrived. We accept that staff must be sensitive when
conducting rub down searches, especially when checking intimate areas of the
body, but we are surprised that Ms Sherrington was apparently able to successfully
conceal four packs of medication.
50. It is possible that Ms Sherrington acquired the drugs, including the medication,
while in Low Newton, but that seems unlikely. We do not know where the
medication was when Ms Sherrington arrived and whether it was in her wheelchair
or concealed under her clothing. We accept that a full search would have been
inappropriate and that there are limitations with rub down searches. Nevertheless,
we consider that it would be advisable for the searching arrangements for
wheelchair users to be reviewed to ensure they are sufficiently robust. We
recommend:
The Governor should review the searching procedures for prisoners arriving
in wheelchairs and ensure that reception staff are fully aware of the
procedures they must follow in these circumstances.
Inquest
An inquest into Ms Sherrington’s death held on 21 October 2024 concluded that her
cause of his death was herpes simplex encephalitis.
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