Matthew Xavier

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Matthew Xavier,
a prisoner at HMP Highpoint, on
16 December 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. If my office is to best assist HM 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 Matthew Xavier died in hospital on 16 December 2022, of lung cancer while a
prisoner at HMP Highpoint. He was 65 years old. We offer our condolences to his
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Xavier received at HMP
Highpoint was equivalent to what he could have expected to receive in the
community. The clinical reviewer made no recommendations.
5. The decision to keep Mr Xavier restrained until the day before he died was not
justified given his deterioration in health and mobility.
Recommendations
• The Governor and Head of Healthcare should ensure that all staff
undertaking risk assessments for prisoners taken to hospital understand the
legal position on the use of restraints and that, in all cases:
• healthcare staff complete the medical information section of the escort risk
assessment, accurately reflecting how the prisoner’s current health and
medical condition affects their risk of escape; and
• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk.
• The Operational Security Group Director for HMPPS should monitor, over
the next three months, how many prisoners at HMP Highpoint are escorted
to hospital without restraints (for inpatient admissions and outpatient
appointments) and report back to the Ombudsman.
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The Investigation Process
6. On 16 December 2022, HMPPS informed us of Mr Xavier’s death.
7. NHS England commissioned an independent clinical reviewer to review Mr
Xavier’s clinical care at Highpoint.
8. The PPO investigator investigated the non-clinical issues relating to Mr Xavier’s
care.
9. The PPO family liaison officer wrote to Mr Xavier’s wife to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond
to our letter.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Xavier’s family received a copy of the initial report. They pointed out some
factual inaccuracies and/or omissions. This report has been amended accordingly.
Mr Xavier’s family also raised a number of issues/questions that do not impact on
the factual accuracy of this report and have been addressed through separate
correspondence.
Previous deaths at HMP Highpoint
12. Mr Xavier was the sixth prisoner to die at Highpoint since December 2019. Of the
previous deaths, three were from natural causes, and two were self-inflicted.
13. In a previous investigation into the death of a prisoner at Highpoint in 2021, we
identified the inappropriate use of restraints and made a recommendation.
Highpoint accepted our recommendation and said that they would ensure all
escorts and bed watches had appropriate and adequate medical input and
disclosure within the medical section of the risk assessment, and staff were
reminded of these requirements in February 2022.
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Key Events
14. On 23 March 2018, Mr Matthew Xavier was sentenced to 12 years in prison for
grievous bodily harm. He was sent to HMP Norwich.
15. On 9 May 2022, Mr Xavier was transferred to HMP Highpoint.
16. On 21 November, a GP at the prison saw Mr Xavier after he reported a lump in the
left side of his neck. The GP examined him and diagnosed ‘likely malignancy’ and
referred him for further tests under the two-week wait referral process. (The two-
week appointment system was introduced so that any patient with symptoms that
might indicate cancer, or a serious condition such as cancer, could be seen by a
specialist as quickly as possible).
17. On 1 December, an officer attended Mr Xavier’s cell because two prisoners
pressed Mr Xavier’s emergency cell bell. They told the officer that Mr Xavier was
unresponsive, they had shaken him to rouse him, and he then took a sharp intake
of breath. The officer radioed a code blue (indicating a prisoner is unconscious or
is having breathing difficulties) and healthcare staff attended. Mr Xavier said that
he was having difficulty breathing and complained of a sharp pain to his left
shoulder, radiating through to his chest. Mr Xavier was taken to hospital with a
possible diagnosis of sepsis (the body's extreme response to an infection, which
can be a life-threatening medical emergency). Mr Xavier was escorted to hospital
by two officers and was restrained using single handcuffs and an escort chain (a
long chain with a handcuff at each end, one of which is attached to the prisoner
and the other to an officer).
18. On 2 December, the hospital informed healthcare staff at the prison that Mr Xavier
was being cared for in the ‘Rapid Assessment Unit’ and had a possible new
diagnosis of pneumonia. A few days later, the hospital informed healthcare staff at
the prison that Mr Xavier had been diagnosed with stage four lung cancer. Mr
Xavier remained restrained.
19. On 8 December, Mr Xavier’s condition began to deteriorate, and he was much
more breathless. The Head of Healthcare at Highpoint emailed the Head of Safer
Custody and suggested that they remove Mr Xavier’s handcuffs due to his decline
in health and consider making an application for compassionate release. However,
it was agreed that handcuffs would remain, as Mr Xavier was still mobile and there
was no confirmed treatment plan.
20. That day, due to a deterioration in Mr Xavier’s condition, the hospital put in place a
Do not Attempt Cardiopulmonary Resuscitation order on Mr Xavier’s behalf, which
meant that in the event his heart or breathing stopped, he would not be
resuscitated.
21. On 9 December, prison staff started the compassionate release process.
However, this had not been completed before Mr Xavier died.
22. That day, an officer was on bedwatch duty at the hospital and called a prison
manager at Highpoint to ask if he could remove Mr Xavier’s handcuffs on
compassionate grounds. The prison manager said that the handcuffs needed to
remain as they were until a further risk assessment was completed.
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23. On 13 December, the Head of Healthcare confirmed that she had had a
discussion with a prison manager about removing Mr Xavier’s handcuffs. They
decided that Mr Xavier’s restraints could be removed due to him becoming less
independent and his movements were restricted due to needing more oxygen. The
necessary processes began for this to happen.
24. The next day, a doctor at the hospital told prison staff that Mr Xavier’s health had
deteriorated, he had very limited mobility and was reliant on a permanent supply of
oxygen. On the 15 December, the Head of Security at Highpoint completed a new
risk assessment, and the restraints were then removed, following the agreement
already made on 13 December and information provided by the hospital.
25. On the morning of 16 December, doctors at the hospital said Mr Xavier had hours
to live, and he was placed on end-of-life care. At 1.15pm, it was confirmed that Mr
Xavier had died.
Cause of death
26. The coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Xavier’s cause of
death as metastatic small cell lung cancer (an aggressive form of lung cancer that
grows and spreads rapidly).
27. At the inquest held on 23 April 2024, the coroner concluded that Mr Xavier died
from metastatic small cell lung cancer.
4 Prisons and Probation Ombudsman
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Non-Clinical Findings
Restraints, security and escorts
28. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need
to distinguish between a prisoner’s risk of escape when fit (and the risk to the
public in the event of an escape) and the prisoner’s risk when suffering from a
serious medical condition. It said that medical opinion about the prisoner’s ability
to escape must be considered as part of the assessment process and kept under
review as circumstances change.
29. The nurse who completed the risk assessment paperwork for the escort on 1
December 2022, wrote ‘medical in confidence’ in the medical section of the
paperwork and provided no information about Mr Xavier’s current medical
condition. This meant that the authorising manager was not fully aware of Mr
Xavier’s state of health and how this affected his risk of escape. As a result, the
level of restraints authorised for Mr Xavier was not proportionate to the risk he
posed.
30. Prison staff asked prison managers to remove Mr Xavier’s restraints on
compassionate grounds on 9 December as his health was rapidly declining. The
risk assessment should have been reviewed when his circumstances changed on
2, 9 and 13 December. In fact, the risk assessment was not reviewed until 15
December, the day before Mr Xavier died, after a doctor at the hospital told prison
staff that Mr Xavier’s mobility was limited, and he needed continuous oxygen. It
was at this point that prison managers approved the removal of restraints.
31. We make the following recommendations:
The Governor and Head of Healthcare should ensure that all staff
undertaking risk assessments for prisoners taken to hospital understand the
legal position on the use of restraints and that, in all cases:
• healthcare staff complete the medical information section of the escort
risk assessment, accurately reflecting how the prisoner’s current health
and medical condition affects their risk of escape; and
• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk.
The Operational Security Group Director for HMPPS should monitor, over
the next three months, how many prisoners at HMP Highpoint are escorted
to hospital without restraints (for inpatient admissions and outpatient
appointments) and report back to the Ombudsman.
Prisons and Probation Ombudsman 5
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Adrian Usher
Prisons and Probation Ombudsman August 2024
6 Prisons and Probation Ombudsman
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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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