Michael Higginbottom

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Independent investigation into the
death of Mr Michael Higginbottom,
a prisoner at HMP Stafford,
on 5 June 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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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 Higginbottom died in hospital from a bleed on the brain on 5 June 2022, while
a prisoner at HMP Stafford. He was 79 years old. I offer my condolences to his family and
friends.
Mr Higginbottom was admitted to hospital with a stroke on 1 February 2022. He was
discharged on 11 February and spent the next three months in the prison’s Specialist Care
Unit (SCU). Mr Higginbottom was returned to a standard wing on 11 May, where prison
staff struggled to meet his care needs. On 24 May, staff found Mr Higginbottom
unresponsive and sent him to hospital, where he died less than two weeks later.
The clinical reviewer found that the care Mr Higginbottom received in the prison’s SCU
was good and was equivalent to that which he could have expected to receive in the
community. However, I am concerned that Mr Higginbottom’s care needs were not met
when he returned to a standard wing and I consider that the prison could have done more
to explore alternative options for him.
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 November 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 7
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Summary
Events
1. In July 2019, Mr Michael Higginbottom was sentenced to 18 years imprisonment for
sexual offences. On 24 September, he was moved to HMP Stafford.
2. Mr Higginbottom had several long-term health conditions, including high blood
pressure and heart disease. He also had poor mobility and signs of memory loss.
3. On 1 February 2022, Mr Higginbottom was admitted to hospital after a stroke. On
11 February, he was discharged to the prison’s Specialist Care Unit (SCU), which
provided a specialist rehabilitation programme.
4. On 11 May, Mr Higginbottom was moved to a standard wing because his declining
cognitive function meant he could no longer engage with the rehabilitation
programme offered by the SCU. The lead dementia nurse noted that Mr
Higginbottom’s needs remained complex as he was incontinent of urine and at high
risk of falling. His social care package of four visits a day continued but the prison
could not accommodate a live-in carer as requested by healthcare staff.
5. On the evening of 23 May, healthcare staff attended to Mr Higginbottom after wing
staff had found him on the floor of his cell, which was covered in urine and faeces.
The next morning, a nurse fully assessed Mr Higginbottom. She noted multiple
bruises and that the cell floor and bed were soaked in urine. She escalated her
concerns to the Clinical Team Leader.
6. On 24 May, at approximately 8.09am, prison staff found Mr Higginbottom
unconscious and unresponsive on his bed and called a medical emergency code
blue. Healthcare staff attended and checked Mr Higginbottom’s clinical observations
until paramedics arrived and took him to hospital. A hospital doctor diagnosed Mr
Higginbottom with subarachnoid (surface of the brain) and subdural (space between
the skull and the brain) bleeding. He died in hospital on 5 June.
Findings
7. The clinical reviewer concluded that the care Mr Higginbottom received in the SCU
was equivalent to the care he could have expected to receive in the community.
However, Mr Higginbottom’s care needs were not met when he was returned to a
standard wing. The prison should have considered alternative options for Mr
Higginbottom given that his care needs were not being met on a standard wing.
8. The clinical reviewer highlighted several concerns. She found that there was no
policy or procedure for prisoners who were prescribed blood-thinning medication
and experienced a fall.
9. The clinical reviewer found a few occasions where staff had taken vital observations
but not recorded a National Early Warning Score (NEWS2, a tool used to assess
clinical deterioration in adult patients).
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10. When Mr Higginbottom was discharged from hospital to Stafford on 31 January,
discharge information was not given to the escorting officers.
Recommendations
• The Governor and Head of Healthcare should explore alternative options for
meeting a prisoner’s care needs when they cannot be met on a standard wing.
• The Head of Healthcare should ensure that the falls assessment includes a
procedure for patients who are prescribed blood-thinning medication based on the
National Institute for Health and Care Excellence (NICE) Head Injury guidance.
• The Head of Healthcare should ensure that when healthcare staff complete vital
observations, they use the NEWS2 scoring system as a standard procedure.
• The Head of Healthcare should engage with a senior clinical hospital colleague in
order to improve the discharge information process between the hospital provider
and HMP Stafford.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Stafford informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Higginbottom’s prison
and medical records.
13. NHS England commissioned an independent clinical reviewer to review Mr
Higginbottom’s clinical care at the prison.
14. We informed HM Coroner for South Staffordshire of the investigation. He gave us
the results of the post-mortem examination. We have sent him a copy of this report.
15. The PPO family liaison officer wrote to Mr Higginbottom’s next of kin, his sister, to
explain the investigation and to ask if she had any matters she wanted us to
consider. She did not respond to our letter.
16. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. HMPPS and Practice Plus
Group provided an action plan which is annexed to this report.
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Background Information
HMP Stafford
17. HMP Stafford holds approximately 750 men who have been convicted of sexual
offences. Practice Plus Group provides a 24-hour healthcare service.
HM Inspectorate of Prisons
18. The most recent inspection of Stafford was in January 2020. Inspectors reported
that overall, the prison provided a safe environment in which prisoners were
respected. They reported that healthcare provision had improved since their
previous inspection in February 2016. They also found that their recommendation
from their previous inspection report - that HMP Stafford should develop an equality
strategy and that action planning should be informed by a periodic analysis of need
and advice from care specialists for elderly people - had not been achieved.
Independent Monitoring Board
19. 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 Stafford for the year to 30 April 2022, the IMB
reported that during the COVID-19 restrictions, those delivering social and
associated care (e.g. dementia nurse, occupational therapists) continued wherever
possible, with some residents requiring multiple social care visits each day.
20. The Board said it had been hoped that the opening of the Special Care Unit (SCU)
would have alleviated some of the problems, especially for officers who were not
trained as carers but often left to resolve the issues. This was not found to be the
case. For example, a resident diagnosed with severe dementia, doubly incontinent
and frequently falling was expected to cope in a standard cell when multiple beds
were available in the SCU. The Board said they had been asked about the sense
and humanity of this situation by both residents and staff but had no answer.
Previous deaths at HMP Stafford
21. Mr Higginbottom was the fourteenth prisoner to die at Stafford since June 2020. All
the previous deaths were from natural causes. We have previously made
recommendations about falls risk assessments and the use of the NEWS2 tool.
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Key Events
22. In July 2019, Mr Michael Higginbottom was sentenced to 18 years imprisonment for
sexual offences. On 24 September, he was moved to HMP Stafford.
23. Mr Higginbottom had several long-term health conditions, including hypertension
(high blood pressure), type 2 diabetes, ischaemic heart disease (reduced blood flow
within the heart) and atrial fibrillation (irregular heartbeat). He also had poor mobility
and signs of memory loss.
24. On 31 January 2022, prison staff sent Mr Higginbottom to hospital as he had
symptoms of a possible stroke. He returned to Stafford later that evening after
hospital staff assessed that he did not need treatment.
25. On 1 February, prison staff again sent Mr Higginbottom to hospital with symptoms
of a possible stroke. A hospital doctor diagnosed Mr Higginbottom with a stroke
caused by a blood vessel blockage in the brain and admitted him for treatment and
monitoring. Mr Higginbottom was discharged on 11 February. He returned to the
prison’s Specialist Care Unit (SCU), which provided a specialist rehabilitation
programme.
26. On 18 February, prison staff sent Mr Higginbottom to hospital as he had abdominal
pain. A hospital doctor diagnosed him with cholecystitis (an inflammation of the
gallbladder) and admitted him for treatment. Mr Higginbottom returned to the
prison’s SCU on 3 March.
27. On 11 May, Mr Higginbottom was moved to a standard wing as his declining
cognitive function meant he could no longer engage with the rehabilitation
programme offered by the SCU. The healthcare team requested an accessible
ground floor cell that could accommodate Mr Higginbottom’s hospital bed, mobility
lift aid and a live-in carer. His social care package of four visits a day continued but
the cell provided did not have the space for a live-in carer. The lead dementia nurse
noted that Mr Higginbottom’s needs remained complex as he was incontinent of
urine and at high risk of falling. She completed an incident form to highlight the
potential risk of standard location being unable to provide the level of social care
that she thought Mr Higginbottom needed.
28. The lead dementia nurse recorded on 19 May that wing officers had told her they
were struggling to care for Mr Higginbottom and thought he should return to the
SCU. (This was not possible as Mr Higginbottom no longer met the criteria.) Mr
Higginbottom was now doubly incontinent, had had multiple falls, had lost his
inhibitions and was removing his clothes. When the lead dementia nurse saw Mr
Higginbottom, he was sitting in his wheelchair, was bright in mood and had no
concerns.
29. On the evening of 23 May, wing staff contacted healthcare staff after finding Mr
Higginbottom on the floor of his cell, which was covered in urine and faeces. Staff
cleaned Mr Higginbottom and his cell and helped him back to bed.
30. The next morning, at around 6.20am, a nurse fully assessed Mr Higginbottom. The
nurse noted multiple bruises and that the cell floor and bed were soaked in urine.
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The nurse escalated her concerns to the Clinical Team Leader who requested a
multidisciplinary team meeting and a review by the dementia nurse, including a
review of Mr Higginbottom’s risk of falling.
31. On 24 May, at approximately 8.09am, prison staff found Mr Higginbottom
unconscious and unresponsive on his bed. They called a medical emergency code
blue. Healthcare staff attended and checked his clinical observations until
paramedics arrived and took him to hospital. A hospital doctor then diagnosed Mr
Higginbottom with subarachnoid (surface of the brain) and subdural (space between
the skull and the brain) bleeding. He died in hospital on 5 June.
Contact with Mr Higginbottom’s family
32. On 24 May, at around 9.15am, the prison appointed a family liaison officer (FLO).
The FLO told Mr Higginbottom’s sister that he was in hospital. On 5 June, at around
8.39am, the FLO informed her of Mr Higginbottom’s death by phone and offered her
condolences. The prison offered to contribute to the funeral costs in line with policy.
Support for prisoners and staff
33. After Mr Higginbottoms’s death, the duty governor debriefed the staff involved in the
bedwatch to ensure they had the opportunity to discuss any issues arising, and to
offer support. The staff care team also offered support.
Post-mortem report
34. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Higginbottom's
cause of death as spontaneous intracerebral haemorrhage as a result of
hypertension. Stroke and atrial fibrillation were listed as contributory factors.
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Findings
Clinical care
35. The clinical reviewer noted that Mr Higginbottom had complex health conditions that
would have been difficult to manage in any healthcare setting. She concluded that
the care Mr Higginbottom received in the prison’s SCU after his stroke was good
and equivalent to the care he could have expected to receive in the community.
36. However, she noted that Mr Higginbottom’s care needs were not met when he
returned to a standard wing. We were told that the SCU had strict criteria for the few
beds available and as Mr Higginbottom did not meet the criteria, it was not possible
for him to return there. We are concerned that the prison did not consider
alternative options for Mr Higginbottom given that staff were struggling to meet his
care needs when he was on a standard wing. We recommend:
The Governor and Head of Healthcare should consider alternative options for
meeting a prisoner’s care needs when they cannot be met on a standard
wing.
37. The clinical reviewer highlighted several other concerns.
38. Mr Higginbottom was on a blood-thinning medication for his heart condition and
therefore at high risk of bleeding should he fall. The SCU team acknowledged that
they did not have a policy or procedure for patients who were prescribed blood-
thinning medication and experienced a fall. We recommend:
The Head of Healthcare should ensure that the falls assessment includes a
procedure for patients who are prescribed blood-thinning medication based
upon the NICE Head Injury guidance.
39. The clinical reviewer found a few occasions where staff had taken vital observations
but not recorded a NEWS2 score. We recommend:
The Head of Healthcare should ensure that when healthcare staff complete
vital observations, they use the NEWS2 scoring system as a standard
procedure.
40. When Mr Higginbottom was discharged from the Stafford County Hospital
Emergency Department on 31 January, discharge information was not given to the
escorting officers when Mr Higginbottom returned to HMP Stafford. We recommend:
The Head of Healthcare should engage with a senior clinical hospital
colleague in order to improve the discharge information process between the
hospital provider and HMP Stafford.
Inquest
41. At the inquest, held on 17 October 2024, the Coroner concluded that Mr
Higginbottom died from natural causes.
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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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