Mark Apperley

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Independent investigation into
the death of Mr Mark Apperley,
a prisoner at HMP Long Lartin,
on 7 August 2023
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, 2026
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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 Mark Apperley died in a care home on 8 August 2023, while a prisoner at HMP
Long Lartin. He died from the respiratory complications of tetraplegia (paralysis
that affects all four limbs, plus the torso) caused by a post-traumatic cervical
paraspinal abscess. Mr Apperley was 52 years old. We offer our condolences to
his family and friends.
4. The clinical reviewers concluded that the clinical care Mr Apperley received at
Long Lartin was equivalent to that which he could have expected to receive in the
community. They made four recommendations which were not relevant to Mr
Apperley’s death but which the Head of Healthcare will need to address.
5. One of the clinical reviewers made a recommendation to NHS England’s health
commissioners about the lack of facilities in the prison estate for prisoners with
complex health needs. Mr Apperley did not meet the criteria for release on
temporary licence (ROTL) or early release on compassionate grounds (ERCG).
While his condition did not require him to remain in hospital indefinitely, his
medical needs were complex and required specialist care and equipment. As his
needs could not be met in the prison estate, Mr Apperley lived in a nursing home.
6. We did not identify any significant non-clinical learning.
Recommendation
The Director General of HMPPS should work with NHS England and the
Association of Directors of Adult Social Services with the aim of developing
a strategy to meet the needs of prisoners not suitable for release but who
need an adapted environment and specialist nursing and social care.
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The Investigation Process
7. HMPPS notified us of Mr Apperley’s death on 7 August 2023.
8. NHS England commissioned two independent clinical reviewers, to review Mr
Apperley’s clinical and mental health care at HMP Long Lartin. The clinical
reviewers’ report is attached as Annex 1.
9. The PPO investigator investigated the non-clinical issues relating to Mr Apperley’s
care. She obtained copies of relevant extracts from Mr Apperley’s prison and
medical records.
10. The investigator visited Long Lartin on 22 and 23 November 2023 and interviewed
six members of staff with the clinical reviewers.
11. The investigator carried out an interview on 10 November and conducted a further
three interviews with one of the clinical reviewers on 20 December and 16 January
2024. The investigator and the other clinical reviewer also interviewed one
member of staff on 1 December.
12. We informed HM Coroner for Worcestershire of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of the report.
13. The PPO wrote to Mr Apperley’s mother to explain the investigation and to ask if
she had any matters she wanted us to consider. She did not respond to our letter.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies. However, following feedback from
HMPPS a change was made to the wording of the recommendation.
15. Mr Apperley’s mother received a copy of the draft report. She did not make any
comments
Previous deaths at HMP Long Lartin
16. Mr Apperley was the eleventh prisoner to die at Long Lartin since 8 August 2020.
Of the previous deaths, eight were from natural causes and two were self-inflicted.
There are no similarities between our findings in these cases and those in our
investigation into Mr Apperley’s death.
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Key Events
17. On 17 March 1997, Mr Mark Apperley was sentenced to life imprisonment for
murder, with a minimum term of 15 years. He was diagnosed with antisocial and
borderline personality disorders, with features of paranoid personality disorder.
18. On 1 July 2021, Mr Apperley was transferred from HMP Swaleside to Long Lartin.
He lived in the segregation unit due to aggressive and abusive behaviour.
19. On 10 November, Nurse A saw Mr Apperley to give him his medications. She
recorded that he had blood on his forehead from what looked like an old wound
and his hand was bleeding. An officer told her that he had been annoyed earlier
and had head butted and punched the door in frustration.
20. On 23 November, Nurse B saw Mr Apperley to give him his medication. He told
her that he had collapsed earlier as his body felt numb. Nurse B told Mr Apperley
a doctor would see him the next day.
21. At 1.35pm on 24 November, Dr A, a GP operating at Long Lartin, examined Mr
Apperley in his cell. Mr Apperley told him that he was unable to use his arms and
legs and he had had a migraine for some time. Dr A noted that he saw Mr
Apperley move his arms. Because of Mr Apperley’s history of headbanging, Dr A
consulted the hospital and sent Mr Apperley to hospital.
22. Following tests, Mr Apperley was discharged from hospital and returned to Long
Lartin at 11.49pm. Officer A, an escort officer, told the investigator that Mr
Apperley was unable to walk or use his arms and had used a wheelchair to travel
to the prison van. He said that when they arrived at Long Lartin, they had to carry
him back to his cell. Nurse C saw Mr Apperley in reception when he returned to
Long Lartin. He told the investigator that the officers helped Mr Apperley off the
van into a wheelchair and then into his cell and onto his bed.
23. On 25 November, Officer B completed the escort debrief form. He stated that Mr
Apperley had been compliant, that he had said he could not use his arms and legs
and a CT scan had been completed. He had noted that when Mr Apperley was
discharged from hospital and returned to Long Lartin, he had jumped off the van
and walked unaided. He said that a concern had been raised about whether he
was feigning his symptoms. However, Officer B told the investigator that although
he had accompanied Mr Apperley to hospital, he had handed over the escort to
Officer A later that day and had not escorted Mr Apperley when he returned to
prison. He told the investigator that it was the escort officer’s responsibility to
complete the escort debrief. He confirmed that he had completed the debrief form
but could not recall why he had done this or who had told him that Mr Apperley
had jumped down from the van.
24. On 25 November, Mr Apperley was placed on the escape list based on the
information provided following his escort.
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25. At approximately 9.55am on 25 November, Nurse D and Nurse E visited Mr
Apperley in his cell. They saw that he looked pale and was hot to touch. They
carried out physical observations and calculated a NEWS2 score of thirteen.
(NEWS2 is a tool to detect and respond to clinical deterioration). A score of
thirteen meant that Mr Apperley was at a high risk of clinical deterioration/sepsis
and an emergency assessment by a critical care team was needed. Paramedics
were called and took Mr Apperley to hospital at 12.20pm. (His name was removed
from the escape list before he went to hospital.)
26. On 26 November, the hospital told the prison that Mr Apperley had been taken to
another hospital, that he had a spinal cord compression and was undergoing
surgery. Later that day, a neurosurgeon told the prison that Mr Apperley was very
unwell and may die. Despite the surgery Mr Apperley was left with paralysis that
affected his arms and his legs (tetraplegia) and he was placed on a ventilator and
admitted to the intensive care unit.
27. On 3 December, a multidisciplinary (MDT) meeting at Long Lartin discussed
whether Mr Apperley could be released on temporary licence (ROTL) or released
early on compassionate grounds (ERCG).
28. On 31 January 2022, an ERCG application was submitted to HMPPS’ Public
Protection Casework Team (PPCS, a specialist casework team). The application
was incomplete and the prison was asked to provide further evidence.
29. On 25 March, Mr Apperley’s application for early release was refused because he
did not meet the criteria. (He did not have a terminal illness and although he was
severely disabled, his prognosis was unclear. There was no evidence that further
imprisonment would reduce his life expectancy and the Secretary of State did not
consider that, on balance, his risk of reoffending was minimal.)
30. On 4 October 2022, an MDT meeting took place, with attendees from different
disciplines, including staff from HMPPS headquarters, the long-term high security
estate, HMPPS social care and strategic health partnerships, senior managers
from Long Lartin and HMPPS’ social care team. They considered Mr Apperley’s
clinical needs and his current and future accommodation needs. They noted that a
return to Long Lartin was not possible as they did not have a room large enough to
accommodate all the healthcare equipment needed and they did not have a
working lift. They also noted that there were no nursing home facilities in the
prison estate and the only viable options were to try to place Mr Apperley in a
different prison in the long-term and high security estate or in a category B prison.
In the meantime, they agreed that NHS England would continue to look for a
nursing home in the community as a short-term measure. Regular meetings
between stakeholders to progress finding suitable accommodation for Mr Apperley
continued during October.
31. On 24 November, a nursing home confirmed that they had a bed available for Mr
Apperley. In November and December, regular MDT meetings took place to
facilitate Mr Apperley’s move to the nursing home due to the specialist care he
needed. During this period, Mr Apperley developed infections which needed
hospital treatment so was unfit to be discharged.
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32. On 12 January 2023, Mr Apperley was discharged from hospital to the nursing
home. Mr Apperley had two officers with him at all times.
33. Between February and May 2023, Mr Apperley was re-admitted to hospital on
three occasions due to medical complications. Following his paralysis, Mr
Apperley’s behaviour continued to be anti-social. On occasions, he was verbally
abusive to hospital staff and visitors and spat at nursing staff.
34. On 8 February, an MDT meeting took place at HMP Five Wells. Staff from HMPPS
headquarters, NHS England and prison and healthcare staff from Five Wells
attended. An occupational therapist completed a suitability assessment which was
shared on 22 February. It concluded that Mr Apperley did not meet the criteria for
the prison and the accommodation could not be modified to meet his needs.
35. On 23 February, an MDT meeting took place with staff from the social care and
strategic health partnerships, the social care team, the long-term and high security
estate and NHS England. They agreed to explore a new ERCG application. They
noted that Mr Apperley needed a specialist nursing home, with mental healthcare
provision. They recorded that although Mr Apperley was already in a nursing
home, it was conditional on him remaining a serving prisoner.
36. In the following months, there were a number of MDT meetings which discussed
the ERCG application and whether any other prisons were viable options.
Consideration of the ERCG application included discussion about how to manage
Mr Apperley’s risks (because of his outbursts and spitting) and whether a care
home or nursing home was appropriate.
37. On 7 June, Mr Apperley was taken to hospital as staff had noticed blood in his
urine.
38. On 3 July, a suitability assessment was carried out at HMP Stafford.
39. On 13 July, an MDT took place. Staff from the social care and strategic health
partnerships, the social care team, NHS England and Long Lartin attended. They
discussed the suitability assessment which had concluded that HMP Stafford was
not suitable for Mr Apperley due to his complex health needs. They agreed a letter
would be sent to the Executive Directors of HMPPS and NHS England, outlining
the current situation and acknowledging that a prison space was needed to meet
his environmental needs and where specialist services could be brought in to meet
his medical needs.
40. On 28 July, Mr Apperley was discharged from hospital and he returned to the
nursing home.
41. At 4.44am on 7 August, a nurse at the nursing home checked on Mr Apperley and
found that he had died. An order was in place not to resuscitate him if his heart or
breathing stopped so no resuscitation attempt was made.
Post-mortem report
42. The post-mortem report concluded that Mr Apperley died from the respiratory
complications of tetraplegia caused by a post-traumatic cervical paraspinal
abscess.
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43. In his report the pathologist set out his consideration of the findings from the
toxicology report, in regards to the presence of mono-acetyl morphine (a
substance which the body produces following heroin use) and the level of
morphine identified, and how he reached his conclusion.
Inquest into the death of Mr Apperley
44. The inquest into Mr Apperley’s death was held on 27 January 2025 and a verdict
of natural causes was recorded.
45. The coroner concluded that Mr Apperley’s death was due to respiratory
complications of tetraplegia caused by a cervical paraspinal abscess (treated).
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Clinical Findings
46. The clinical reviewers concluded that the clinical care Mr Apperley received was
equivalent to what he could have expected to receive in the community. They
made four recommendations which were not relevant to his death but which the
Head of Healthcare at Long Lartin will need to address.
47. However, the clinical review also identified a lack of facilities in the prison estate
for prisoners who do not meet the ROTL/ERCG criteria due to their complex
health and treatment needs.
48. Mr Apperley’s circumstances were complex and challenging. He was severely
disabled and needed 24-hour specialist nursing care and specialist equipment to
maintain his health. Although he needed nursing care, he did not always need a
hospital bed.
49. Mr Apperley also had an antisocial and borderline personality disorder, with
features of paranoid personality disorder and a history of anti-social and
aggressive behaviour. Following his paralysis, Mr Apperley’s behaviour continued
to be anti-social. On occasion, he had been verbally abusive to hospital staff and
visitors and spat at nursing staff. Mr Apperley had been in prison since 1997
serving a life sentence, with a minimum tariff of fifteen years. Due to his offence,
Mr Apperley was subject to the parole process and he could not be considered for
ROTL.
50. An ERCG application was submitted in January 2022, but was refused on the
basis that Mr Apperley did not meet the criteria: his prognosis was unclear; he was
in hospital (so imprisonment was not reducing his life expectancy) and there was
still a risk of re-offending (as he had not undertaken risk reduction work since
2004). While it later became clear that Mr Apperley’s condition was not going to
improve, the other two criteria remained unresolved.
51. We note that the various stakeholders involved in Mr Apperley’s case considered
making a second ERCG application but this was not progressed because a
suitable alternative placement for Mr Apperley had not been identified (as he could
not have remained in the nursing home) and his risk of reoffending remained a
concern, even though it was reduced due to his physical condition.
52. The various stakeholders in HMPPS and NHS England met regularly to discuss
Mr Apperley’s situation and a number of alternative locations within the prison
estate were explored. However, they were unable to identify a prison which could
cater for Mr Apperley’s custodial requirements, as well as his environmental and
medical needs.
53. While Mr Apperley was outside the prison estate, he was not accessing the parts
of the regime that would have allowed him to participate in risk reduction work and
he was not receiving support to address his antisocial/borderline personality
disorder. Without progress in these areas, Mr Apperley was unlikely to succeed in
any application for parole or ERCG. Given this, it was in his best interests to
remain in the prison estate.
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54. We appreciate the clear tensions between looking after an elderly, frail or severely
disabled prisoners and holding them in secure conditions when they are not
suitable for release. It seems inevitable that HMPPS will need to consider the
option of establishing what would amount to a secure care home, but appreciate
the resources and complications that would be involved, and therefore that
progress is likely to be slow. We therefore make the following recommendation:
The Director General of HMPPS should work with NHS England and the
Association of Directors of Adult Social Services with the aim of developing
a strategy to meet the needs of prisoners not suitable for release but who
need an adapted environment and specialist nursing and social care.
Governor to note
55. The officer who escorted Mr Apperley back to the prison did not complete the
appropriate escort form and the information contained in the form was incorrect.
Staff completing forms should make it clear if they are completing documents on
behalf of a colleague.
Adrian Usher
Prisons and Probation Ombudsman November 2025
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