Michael Grimes

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Independent investigation into
the death of Mr Michael Grimes,
a prisoner at HMP Isle of Wight,
on 26 February 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, 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.
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.
Mr Michael Grimes died of congestive cardiac failure (where the heart is unable to pump
blood around the body properly) caused by an enlarged heart, ischaemic heart disease
and high blood pressure, on 26 February 2022, at HMP Isle of Wight. He was 74 years
old. I offer my condolences to his family and friends.
Mr Grimes had a number of significant long-term health conditions, and I am satisfied that
these were managed appropriately by prison healthcare staff. However, I am concerned
that the officers who found Mr Grimes unresponsive on 26 February did not commence
cardiopulmonary resuscitation in the minutes before healthcare staff arrived at his cell.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Kimberley Bingham
Acting Prisons and Probation Ombudsman March 2023
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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 27 September 2017, Mr Michael Grimes was sentenced to 28 years in prison for
sex offences. On 20 February 2019, he was transferred to HMP Isle of Wight.
2. Mr Grimes had many long-term health conditions including Type 2 diabetes, high
blood pressure, atrial fibrillation (an irregular and often fast heartbeat) and heart
failure. On arrival at Isle of Wight, healthcare staff recorded that his blood sugar
levels were too high and that he was obese. Mr Grimes declined to participate in
the prison’s healthy lifestyle programme.
3. On 28 August, a vascular nurse specialist reviewed Mr Grimes because he had a
long history of pain in his calves and his mobility had deteriorated. The nurse found
that Mr Grimes was likely to have superficial femoral artery disease caused by
atherosclerosis (a condition where arteries become clogged with fatty substances).
4. On 17 January 2020, a consultant vascular surgeon reviewed Mr Grimes. He noted
that further tests confirmed that Mr Grimes had atherosclerosis. The consultant
suggested that the best options for treatment were weight loss with a gradual
increase in exercise.
5. On 2 February 2022, a pharmacist, noted that she had a higher than expected stock
of insulin pens which suggested that Mr Grimes was not taking his insulin as
prescribed or at the dose recommended. The pharmacist asked for details of Mr
Grimes’ glucose levels and the administering of his insulin doses to enable a review
and dose optimisation of his insulin.
6. On 22 February, a nurse saw Mr Grimes who arrived in healthcare in a wheelchair.
The nurse noted that Mr Grimes had unstable diabetes, increased anxiety and
digestion and abdominal issues possibly related to poor and reduced mobility. The
nurse asked for a GP to review him in a week’s time.
Events of 26 February 2022
7. At 10.18am on 26 February, an officer found Mr Grimes lying on the floor of his cell
with his head and torso partially under the bed. He went into the cell and found that
Mr Grimes was not breathing. The officer radioed a medical emergency code blue
(which indicates that a prisoner is unconscious or having difficulty breathing).
8. A custodial manager and another officer went to Mr Grimes’ cell. The officers
moved Mr Grimes out from under the bed and turned him onto his back. They
attached a defibrillator but did not begin cardiopulmonary resuscitation.
9. A healthcare assistant and a nurse arrived at Mr Grimes’ cell three minutes later.
The healthcare assistant began chest compressions, and the nurse gave Mr Grimes
oxygen.
10. Paramedics arrived and chose to transfer Mr Grimes to hospital. They moved Mr
Grimes to the ambulance but at 11.36am, before they had left the prison, they
confirmed that Mr Grimes had died.
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Findings
Clinical care
11. The clinical reviewer found that the clinical care that Mr Grimes received at Isle of
Wight was of a good standard and was equivalent to that which he could have
expected to receive in the community.
Emergency response
12. The officer who found Mr Grimes unresponsive promptly radioed a medical
emergency code blue. Officers applied a defibrillator but did not commence
cardiopulmonary resuscitation (CPR) including chest compressions in the three
minutes before healthcare staff arrived at the cell.
Recommendations
• The Governor should ensure that all staff are aware of the importance of starting
cardiopulmonary resuscitation at the earliest opportunity and that staff first on
the scene of an emergency provide basic life support until qualified health
professionals arrive.
2 Prisons and Probation Ombudsman
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The Investigation Process
13. The investigator issued notices to staff and prisoners at HMP Isle of Wight informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
14. The investigator obtained copies of relevant extracts from Mr Grimes’ prison and
medical records.
15. The investigator interviewed seven members of staff at HMP Isle of Wight on 18
and 19 May 2022, and a member of staff by video on 27 June.
16. NHS England commissioned a clinical reviewer to review Mr Grimes’ clinical care at
the prison.
17. We informed HM Coroner for the Isle of Wight of the investigation. She gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
18. The Ombudsman’s family liaison officer wrote to Mr Grimes’ stepdaughter to explain
our investigation. Mr Grimes’ stepdaughter asked what time he should have been
released from his cell on the day that he died and asked if prison staff had
completed a personal emergency evacuation plan (PEEP).
19. We shared the initial report with the Prison Service. There were no factual
inaccuracies.
20. We shared the initial report with Mr Grimes’ stepdaughter. She did not respond.
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Background information
HMP Isle of Wight
21. HMP Isle of Wight is an amalgamation of two former prisons, Parkhurst and Albany,
and holds approximately 1,100 men, mainly convicted of sex offences. Practice
Plus Group provides healthcare services at the prison. There is an inpatient
healthcare unit (IHU) at the former Albany site, providing 24-hour care for prisoners.
There are two palliative care suites on the IHU to accommodate end of life
prisoners. The prison is opposite the island’s hospital.
HM Inspectorate of Prisons
22. The most recent full inspection of HMP Isle of Wight was in May 2019. Inspectors
reported that healthcare was very good at the prison, and that health services were
delivered by a conscientious team who knew their patients well. They said there
was good oversight of the implementation of healthcare recommendations from
deaths in custody reports and evidence of learning from serious incidents. The
inspectors reported that in-possession medication risk assessments were
completed and reviewed, and spot checks of in-possession medication took place
according to the policy. They also said that relationships between prison staff and
prisoners were good. The report noted that 40 per cent of the prison population
were over 50 years old and that a significant proportion were elderly.
Independent Monitoring Board
23. 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 31 December 2020, the IMB
found that the health provision had been excellent. They noted that prisoner
representatives spoke positively about the role of healthcare.
Previous deaths at HMP Isle of Wight
24. There have been thirteen deaths from natural causes at HMP Isle of Wight in the
two years before Mr Grimes’ death, four of which were related to COVID-19. There
have also been three self-inflicted deaths and a drug related death. There are no
significant similarities between our findings in this investigation and those of the
other deaths.
4 Prisons and Probation Ombudsman
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Key Events
25. On 27 September 2017, Mr Michael Grimes was sentenced to 28 years in prison for
sex offences. On 20 February 2019, he was transferred to HMP Isle of Wight.
26. Mr Grimes had Type 2 diabetes, which caused diabetic neuropathy (nerve damage
caused by high levels of sugar in the blood). He was also diagnosed with high
blood pressure, atrial fibrillation, heart failure, high cholesterol, peripheral vascular
disease (a blood circulation disorder), cellulitis (a skin infection), chronic obstructive
pulmonary disease (COPD - a lung disease), obesity, obstructive sleep apnoea and
depression. In 2016, Mr Grimes experienced a ‘mini stroke’.
27. On 21 February 2019, a prison nurse recorded that Mr Grimes’ blood sugar levels
were too high and that he was obese. Healthcare staff created care plans for high
blood pressure and heart concerns, diabetes, asthma/COPD, anxiety and
depression. Mr Grimes declined to participate in the healthy lifestyle programme
and refused an abdominal aortic aneurysm screening (to check if there is a bulge or
swelling in the aorta blood vessel).
28. On 28 August, a vascular nurse specialist reviewed Mr Grimes because he had a
long history of pain in his calves and his mobility had deteriorated. She found that
Mr Grimes was likely to have superficial femoral artery disease caused by
atherosclerosis (the thickening or hardening of the arteries). She said that further
tests should be carried out.
29. On 17 January 2020, a consultant vascular surgeon reviewed Mr Grimes. He noted
that further tests showed that Mr Grimes had atherosclerosis. He suggested that
the best options for treatment were weight loss with a gradual increase in exercise.
30. On 23 November, prison staff completed a Personal Emergency Evacuation Plan
(PEEP) for Mr Grimes.
31. Over the following months, healthcare staff frequently saw and reviewed Mr Grimes.
32. On 24 April 2021, a consultant cardiologist reviewed Mr Grimes and suggested a
change in his medication to treat heart disease, high blood pressure and heart
failure.
33. On 18 October, a nurse saw Mr Grimes in his cell because he said that he had
shortness of breath and a chesty cough with sputum. A prison GP noted that Mr
Grimes looked a little grey and sweaty but that he had no chest pain and was
maintaining his blood oxygen saturation. The GP and a nurse decided that he
should be sent to the healthcare inpatient unit for observation and treatment for an
acute exacerbation of COPD.
34. On 26 October, a prison GP noted that Mr Grimes had recovered well and was able
to return to a normal prison wing.
35. On 22 November, a nurse saw Mr Grimes, who said that he felt horrible, was
breathless on the slightest exertion, pale, had difficulty in breathing and intermittent
chest pains. She noted that Mr Grimes had some oedema (fluid in the limbs) and
that she was unable to perform an ECG. She sent him to hospital as a non-urgent
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admission. Later that day, Mr Grimes returned to the prison having been prescribed
antibiotics.
36. On 2 February 2022, a pharmacist noted that she had a greater stock of insulin
pens than expected, which suggested that Mr Grimes was not taking his insulin as
prescribed or at the dose recommended. She asked for Mr Grimes to provide
regular glucose levels to enable a review and dose optimisation of his insulin.
37. On 22 February, a nurse saw Mr Grimes, who arrived in healthcare in a wheelchair.
He noted that most of Mr Grimes’ symptoms were likely to be linked to unstable
diabetes, increased anxiety, and digestion and abdominal issues possibly related to
poor and reduced mobility. He asked for a GP review in a week’s time.
Events of 26 February 2022
38. At about 9.10am on 26 February, Officer A spoke to Mr Grimes in his cell. He saw
Mr Grimes wrapped up with blankets. Mr Grimes told him that he was “all right”.
39. At 10.18am, Officer A went back to Mr Grimes cell to unlock his cell door for his
domestic period. He found Mr Grimes lying on the floor with his head and torso
partially under the bed. He tried to gain a response from Mr Grimes, who did not
respond. He went into the cell and checked for signs of life. Mr Grimes was not
breathing. He radioed a medical emergency code blue and called for assistance.
40. A Custodial Manager (CM) and Officer B went to Mr Grimes’ cell. Officer A and
Officer B moved Mr Grimes out from under the bed and turned him onto his back.
Officer A saw that his face was purple, that his blood had pooled and that his face
and body were cold. The CM passed a defibrillator to Officer B, who attached it to
Mr Grimes. No one began cardiopulmonary resuscitation.
41. Around three minutes after the code blue message, a Healthcare Assistant (HCA)
and a nurse arrived at Mr Grimes’ cell. The HCA inserted an airway and
commenced chest compressions. The nurse gave Mr Grimes oxygen. The nurses
changed positions and continued life support. The defibrillator advised not to
shock.
42. At around 10.28am, ambulance paramedics arrived at the cell and asked the prison
staff to move Mr Grimes onto the landing. Ambulance paramedics gave Mr Grimes
adrenalin and amiodarone (given as an attempt to reverse a cardiac arrest). The
paramedics also delivered shocks from their defibrillator. The paramedics
recognised some cardiac output so decided to transfer Mr Grimes to hospital.
43. The paramedics lifted Mr Grimes onto a stretcher and carried him to the ambulance
which was outside the wing. At 11.36am, in the ambulance before leaving the
prison, they confirmed that Mr Grimes had died.
Contact with Mr Grimes’ family
44. A family liaison officer (FLO) was appointed. After Mr Grimes died, the FLO
telephoned his stepdaughter and left a message. Later that day, Mr Grimes’
stepdaughter telephoned the FLO, who told her that he had died. Mr Grimes’
funeral took place on 28 April. The prison contributed to its cost in line with national
instructions.
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Support for prisoners and staff
45. After Mr Grimes’ death, the Head of Security and Intelligence debriefed the staff
involved in the emergency response to ensure they had the opportunity to discuss
any issues arising, and to offer support. The staff care team also offered support.
46. Prison staff posted notices informing other prisoners of Mr Grimes’ 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 Grimes’ death.
Post-mortem report
47. A post-mortem examination established that Mr Grimes died from congestive
cardiac failure (heart failure) as a result of cardiomegaly (an enlarged heart),
ischaemic heart disease and hypertension (high blood pressure).
Inquest
48. The inquest into Mr Grimes’ death concluded on 25 July 2025, and returned a
verdict of natural causes.
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Findings
Clinical care
49. The clinical reviewer found that the clinical care that Mr Grimes received at HMP
Isle of Wight was of a good standard and was equivalent to that which he could
have expected to receive in the community.
50. The clinical reviewer found that Mr Grimes was well supported by healthcare staff
for his long-term conditions and underlying co-morbidities. She found that Mr
Grimes made choices about engagement with healthy lifestyle options which were
not always conducive to good diabetes control and his other health needs.
51. The clinical reviewer has made two recommendations which are not directly related
to Mr Grimes’ death which the Head of Healthcare will need to address.
Emergency response
52. When Officer A found Mr Grimes unresponsive, he promptly radioed a medical
emergency code blue. Officer B applied a defibrillator, but the officers did not
commence cardiopulmonary resuscitation (CPR) or chest compressions. When the
HCA and nurse arrived at Mr Grimes cell, around three minutes later, they
commenced chest compressions and inserted an airway. The HCA said that she
would have expected the officers to have commenced CPR and did not know why
they hadn’t.
53. Officer B told us that after they had applied the defibrillator “it started to count down
or it was telling [us] to wait”. He said that Officer A told him that he thought that
they should carry out chest compressions and as he was “sinking into the situation”
the healthcare staff arrived. He agreed that chest compressions should have been
carried but that healthcare staff then arrived at the cell.
54. Officer A said that he did not know why they did not start chest compressions but
said that “healthcare staff were there pretty quickly”.
55. There was a delay of around three minutes from when the officers went into Mr
Grimes’ cell until healthcare staff began CPR. We recognise that it can be difficult
for staff in such situations to make instant decisions but when there is a potentially
life-threatening situation, it is essential to act quickly. We cannot say that earlier
intervention would have made a difference to the outcome for Mr Grimes, but there
is a chance that it might. We make the following recommendation:
The Governor should ensure that all staff are aware of the importance of
starting cardiopulmonary resuscitation at the earliest opportunity and that
staff first on the scene of an emergency provide basic life support until
qualified health professionals arrive.
8 Prisons and Probation Ombudsman
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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