Michael Tate

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Independent investigation into
the death of Mr Michael Tate,
a prisoner at HMP Gartree,
on 6 February 2025
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 Michael Tate died in a hospice of lung cancer on 6 February 2025, while a
prisoner at HMP Gartree. He was 83 years old. We offer our condolences to his
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Tate received at Gartree
was equivalent to that which he could have expected to receive in the community.
She made two recommendations relating to wider care Mr Tate received, which the
Head of Healthcare will wish to address.
5. We found that an application for Mr Tate’s Early Release on Compassionate
Grounds (ERCG) was not resubmitted when his condition deteriorated in December
2024. In addition, no consideration was given to granting him Release on
Temporary Licence (ROTL) when he was admitted to a hospice.
Recommendations
• The Governor should ensure that a robust process is in place to review Early
Release on Compassionate Grounds (ERCG) refusals and resubmit applications
where an individual’s health has deteriorated.
• The Governor should ensure that staff understand the requirements for Release on
Temporary Licence for medical purposes and a robust process is implemented to
ensure applications are made when appropriate.
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The Investigation Process
6. HMPPS notified us of Mr Tate’s death on 6 February 2025.
7. NHS England commissioned an independent clinical reviewer to review Mr Tate’s
clinical care at HMP Gartree.
8. The PPO investigator investigated the non-clinical issues relating to Mr Tate’s care.
9. The Ombudsman’s office wrote to Mr Tate’s son to explain the investigation and to
ask if he had any matters he wanted us to consider. He asked for a copy of the
report and wanted to know why he was given different answers by the prison and
hospice about when his father would be put on a syringe driver to deliver
medication. We have addressed this in our report.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. HMPPS provided an
action plan which is annexed to this report.
11. We sent a copy of our initial report to Mr Tate’s son. He did not notify us of any
factual inaccuracies.
Previous deaths at HMP Gartree
12. Mr Tate was the eleventh prisoner to die at HMP Gartree since February 2022. Of
the previous deaths, seven were from natural causes, two were self-inflicted and
one was drug related. Our investigation into a previous death in September 2024,
found delays in applying for Early Release on Compassionate Grounds (ERCG).
The prison told us that they had arranged monthly meetings between the healthcare
provider, safer custody and the offender management unit, to discuss all issues
relating to end of life care including the progression of ERCG applications.
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Key Events
13. On 12 May 2015, Mr Michael Tate was sentenced to life in prison for murder. On 25
July 2022, he was moved to HMP Gartree.
14. On 14 March 2024, a nurse saw Mr Tate to review his medication. During the
appointment, she found a small lesion on his forehead. Mr Tate said he had a
cancerous lesion removed in 2020. She referred him to a dermatologist for further
investigation.
15. On 24 May, doctors diagnosed Mr Tate with cell carcinoma (a type of skin cancer)
on his face.
16. On 18 June, Mr Tate visited the clinic with shortness of breath, which he said had
been going on for two months. A nurse did an ECG, listened to his chest, took blood
samples, and requested a chest X-ray. She also booked a follow-up appointment
with a GP to review his blood test results.
17. The next day, a GP reviewed Mr Tate’s blood test results, which showed he had
higher levels of B-type Natriuretic Peptide (BNP, a hormone released by the heart
when under stress or working harder than usual). The GP arranged a follow up
appointment with Mr Tate.
18. On 8 July, a GP saw Mr Tate to discuss his blood test results. Mr Tate said his
symptoms had not changed. The GP prescribed blood pressure medication and
recommended referring him to a cardiologist, but Mr Tate declined the referral.
19. On 17 July, Mr Tate went to hospital for a chest X-ray. It showed a mass on his
lungs, which suggested cancer.
20. On 24 July, Mr Tate went to hospital to have the lesion on his forehead removed.
He returned to Gartree the same day.
21. On 16 August, officers radioed a code blue (a medical emergency code used when
a prisoner is unconscious or having breathing difficulties that alerts healthcare staff
and tells the control room to call an ambulance immediately) as Mr Tate had chest
pain and shortness of breath. A nurse took Mr Tate’s clinical observations and
calculated a NEWS2 score of 1. (The National Early Warning Score (NEWS2) is a
tool used to assess clinical deterioration. A score is calculated from the clinical
observations taken and the higher the score, the higher the risk. A score of 1 is low
risk.) The nurse cancelled the ambulance. She spoke with a GP and arranged for
them to review his medication. The GP prescribed morphine.
22. On 31 August, the healthcare team referred Mr Tate for a social care assessment.
He was struggling with his mobility and told staff he was feeling dizzy due to the
morphine.
23. On 11 September, Mr Tate went to hospital for a lung biopsy. He stayed in hospital
until 17 September, when he was discharged back to Gartree. Doctors told him that
he likely had terminal lung cancer, but they needed the biopsy results to confirm the
prognosis.
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24. On 19 September, a nurse from a local hospice assessed Mr Tate to see what
support he needed. During the assessment, Mr Tate felt unwell as he was unable to
pass urine. A nurse at Gartree fitted him with a catheter.
25. On 16 October, an oncologist told Mr Tate that his biopsy results confirmed he had
terminal cancer. Mr Tate said that he did not want to be resuscitated in the event his
heart stopped beating and signed a Do Not Attempt Cardiopulmonary Resuscitation
(DNACPR) form.
26. On 30 October, staff at Gartree submitted an application for Mr Tate’s Early
Release on Compassionate Grounds (ERCG) to the Public Protection Casework
Section (PPCS) of HMPPS.
27. On 29 November, PPCS refused Mr Tate’s ERCG application due to ongoing risk,
and because Gartree could still meet his care needs. PPCS advised the Governor
to monitor his condition and reapply if it worsened.
28. On 5 December, after Mr Tate fell in his cell, staff assessed that he needed full-time
care that the prison could no longer provide. The next day, the prison held an
urgent meeting with NHS England to discuss his care needs.
29. On 6 December, a nurse visited Mr Tate in his cell. She found him very weak,
struggling to swallow, and unable to pass urine. She took his clinical observations
and calculated a NEWS2 score of 5 (indicating moderate risk). After discussing his
condition with a GP, they agreed he needed to go to hospital. An ambulance took
Mr Tate to A&E, where he was admitted.
30. On 11 December, a nurse from Gartree visited Mr Tate in hospital. She told ward
staff that he could not return to Gartree as his condition had worsened and they
were no longer able to meet his care needs.
31. On 17 December, Mr Tate was discharged from hospital to a hospice for palliative
care.
32. On 15 January 2025, doctors at the hospice gave Mr Tate an updated prognosis of
only a few weeks to live.
33. On 3 February, doctors at the hospice told staff at Gartree that Mr Tate would be
put on a syringe driver (a machine that gives continuous pain relief) the next day as
he was nearing the end of his life.
34. On 4 February, a family liaison officer (FLO) at Gartree phoned Mr Tate’s son to
advise that the hospice would be starting Mr Tate on a syringe driver, and he was in
his final days. The hospice later decided not to start the syringe driver until Mr Tate
could no longer eat.
35. At around 6.00pm on 5 February, Mr Tate’s condition worsened, and he could no
longer eat. The doctor stopped his oral medication and started the syringe driver.
36. On 6 February, at around 8.55am, Mr Tate died. A local doctor attended the
hospice and pronounced life extinct at 11.52am.
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Cause of death
37. The Coroner accepted the cause of death provided by a hospice doctor and no
post-mortem examination was carried out. The doctor gave the cause of death as
metastatic lung cancer (cancer which has spread to other parts of the body).
Inquest
38. At the inquest held on 22 April 2025, the Coroner concluded that Mr Tate died of
natural causes.
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Findings
Clinical findings
39. The clinical reviewer concluded that the majority of care Mr Tate received at
Gartree was of a good standard and was equivalent to that which he could have
expected to receive in the community.
40. While the clinical reviewer made two recommendations, about medication
administration and peer support processes, she did not find any elements of
healthcare delivery that would have impacted Mr Tate’s cause of death.
41. We do not repeat the clinical reviewer’s recommendations here, but the Head of
Healthcare will wish to address them.
Early Release on Compassionate Grounds (ERCG)
42. Release on compassionate grounds is a means by which prisoners who are
seriously ill, usually with a life expectancy of less than three months, can be
permanently released from custody before their sentence has expired. A clear
medical opinion of life expectancy is required. The criteria for early release are set
out in the Early Release on Compassionate Grounds (ERCG) Policy Framework.
An application for ERCG must be submitted to the Public Protection Casework
Section (PPCS) of HMPPS.
43. Prison staff at Gartree submitted an application for Mr Tate’s ERCG on 30 October
2024. On 29 November, PPCS refused the application as they considered Mr Tate
still posed a risk to the public and his care needs could still be met by the prison. In
their refusal letter, they advised the Governor to monitor Mr Tate’s condition and
submit another application in the event he deteriorated.
44. On 5 December, Mr Tate was assessed by staff at Gartree as needing full-time care
that the prison could not provide. An emergency multidisciplinary (MDT) meeting
was arranged for the next day to discuss his care with NHS England. As Mr Tate
deteriorated, he was taken to hospital.
45. While we recognise that staff at Gartree appropriately applied for Mr Tate’s ERCG
in October, when he was given a prognosis of short months, we are concerned that
staff did not submit an updated application for Mr Tate when his condition
deteriorated.
46. We recommend:
The Governor should ensure that a robust process is in place to review Early
Release on Compassionate Grounds (ERCG) refusals and resubmit
applications where an individual’s health has deteriorated.
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Release on Temporary Licence (ROTL)
47. The Release on Temporary Licence (ROTL) Policy Framework sets out how a
Special Purpose Licence (SPL) can be issued in response to a specific event or
circumstances that would not usually require release on a regular basis.
48. Section 6.31 of the ROTL Policy Framework says that a SPL may be granted for
offenders to attend medical out-patient appointments, or inpatient requirements.
49. Section 6.26 says if an offender is subject to a Restricted ROTL (which sets
limitations on ROTL due to their sentence, offence, or risk) they are still eligible for a
SPL for medical treatment, providing:
• the offender needs essential medical treatment in the community; and
• a senior manager chaired ROTL board has sat; and
• the governor or deputy governor has agreed SPL is appropriate in all the
circumstances.
50. On 6 December, Mr Tate was admitted to hospital, where he remained until he
moved to a hospice on 17 December. After this he did not return to Gartree.
51. A prison manager told the investigator that staff at Gartree did not apply for ROTL
for Mr Tate during this period because the refusal for ERCG cited continued risk
and that while frail, Mr Tate was not totally physically incapacitated. They
considered that they would be unlikely to satisfy the conditions for the medical
element of Special Purpose Licence available for restricted ROTL.
52. Given Mr Tate’s health had significantly deteriorated by the time he was admitted to
a hospice on 17 December, it is our view that ROTL should have been explored
with him at this stage.
53. We recommend:
The Governor should ensure that staff understand the requirements for
Release on Temporary Licence for medical purposes and a robust process is
implemented to ensure applications are made when appropriate.
Adrian Usher
Prisons and Probation Ombudsman December 2025
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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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