Paul David Horrocks

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Independent investigation into the
death of Mr Paul David Horrocks,
a prisoner at HMP Thorn Cross,
on 30 June 2019
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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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 Paul David Horrocks died on 30 June 2019 at HMP Thorn Cross after being found
unresponsive in his cell. The cause of his death is unknown. He was 43 years old. I offer
my condolences to Mr Horrocks’ family and friends.
Mr Horrocks had a long history of drug misuse in the community and he had regular
contact with the prison’s substance misuse and mental health teams. The clinical reviewer
concluded that, overall, Mr Horrocks’ care at Thorn Cross was of a good standard and
equivalent to that which he could have expected to receive in the community.
However, the clinical reviewer found that healthcare staff did not follow up on his high
blood pressure reading when he arrived at Thorn Cross in April 2019 or arrange a
secondary health screen.
l am concerned that when Mr Horrocks was found unresponsive in his cell on 30 June,
prison staff did not immediately use a medical emergency code, meaning that healthcare
staff were not aware of the nature of the medical emergency and an emergency
ambulance was not called immediately. I am also concerned that there were no first aid
trained prison staff who attended Mr Horrocks’ cell on that day. I am satisfied, however,
that this did not affect the outcome for Mr Horrocks.
Communication between the control room and the emergency services was unclear, and
as a result the emergency services advised staff to continue with CPR despite a nurse
already concluding that any attempts at resuscitation would be futile.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister CB
Prisons and Probation Ombudsman March 2021
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
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Summary
Events
1. On 5 September 2018, Mr Paul David Horrocks was sentenced to two years and
eight months in prison for burglary. He was initially sent to HMP Forest Bank and
transferred to HMP Thorn Cross in April 2019.
2. Mr Horrocks had a long history of substance misuse in the community and was
prescribed methadone (a synthetic opiate used to treat heroin addiction) during his
time in prison. When he arrived at Thorn Cross, Mr Horrocks continued with a
methadone detoxification programme he had already started at his previous prison.
He engaged with the prison’s substance misuse team and prison’s mental health
team. He was prescribed antipsychotic and antidepressant medications.
3. On the evening of 29 June, prisoners described Mr Horrocks as being under the
influence of illicit drugs. They did not inform prison staff.
4. At around 7.30am, on 30 June, Mr Horrocks did not attend the healthcare unit for his
methadone medication. An officer went to his room and found him unresponsive on
his bed. The officer called for healthcare assistance. A nurse attended and
considered that Mr Horrocks had clearly been dead for some time and that any
attempts at resuscitation would be futile, so she did not attempt cardiopulmonary
resuscitation (CPR). Paramedics arrived and, at 8.15am, they confirmed that Mr
Horrocks had died.
5. The post-mortem was unable to determine the cause of Mr Horrocks’ death.
Findings
Management of Mr Horrocks’ substance misuse and mental health
6. The clinical reviewer concluded that the substance misuse and mental health care Mr
Horrocks received was of a good standard and equivalent to that which he could
have expected to receive in the community. He had regular support from the prison’s
drug and mental health teams and had daily contact with healthcare staff.
Clinical care
7. The clinical reviewer concluded that the care Mr Horrocks received at Thorn Cross
was good and equivalent to that which he could have expected to receive in the
community.
8. However, the clinical reviewer was concerned that during his initial health screen, Mr
Horrocks had high blood pressure. Healthcare staff did not complete further tests or
arrange any follow up action. She was also concerned that healthcare staff did not
arrange a secondary health screen for Mr Horrocks to ensure continuity of care.
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Emergency response
9. Prison staff did not use a medical emergency code, as they should have done when
Mr Horrocks was found unresponsive in his cell on 30 June. This meant that
healthcare staff were not aware of the nature of the medical emergency, and there
was a delay in calling an ambulance. However, this did not affect the outcome for Mr
Horrocks.
10. Prison staff who responded to the emergency response on 30 June, did not have
basic first aid training. Also, prison staff did not update control room staff about the
nature of the medical emergency, meaning they were unable to relay accurate
information to the ambulance emergency services. We are satisfied however, that
this did not affect the outcome for Mr Horrocks.
Recommendations
• The Head of Healthcare should ensure that any prisoners with elevated blood
pressure readings are monitored in accordance with NICE guidelines.
• The Head of Healthcare should ensure that all new prisoners receive secondary
health screens within seven days, in line with NICE guidelines and PSO 3050,
Continuity of Healthcare for Prisoners.
• The Governor should ensure that all prison staff are made aware of and understand
their responsibilities during medical emergencies including that staff:
• use an emergency code immediately where there are serious concerns about
the health of a prisoner to alert control room staff to call an ambulance
automatically; and
• efficiently communicate the nature of a medical emergency so that there is no
delay in directing or discharging ambulances.
• The Governor should ensure there are a sufficient number of radios available to
officers on each Unit.
• The Governor should ensure that this report is shared with Officer A and that a senior
manager discusses the Ombudsman’s findings with him.
• The Governor and the Head of Healthcare should liaise with the local Ambulance
Service to ensure that an effective protocol is in place so that the Ambulance Service
understands the nature of medical emergencies in a prison context and that staff who
request ambulances might not be able to provide detailed information about a
prisoner’s medical condition immediately.
• The Governor should ensure there are sufficient numbers of first aid trained staff on
duty at all times, in line with PSI 29/2015.
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The Investigation Process
11. The investigator issued notices to staff and prisoners at HMP Thorn Cross 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 Horrocks’ prison and
medical records.
13. NHS England commissioned a clinical reviewer to review Mr Horrocks’ clinical care at
the prison.
14. The investigator and clinical reviewer jointly interviewed five staff and two prisoners
at Thorn Cross on 20 August 2019.
15. We informed HM Coroner for Cheshire of the investigation. We suspended our
investigation from 22 August 2019 until 27 April 2020, while we waited for the post-
mortem report. The coroner gave us the results of the post-mortem examination. We
have sent him a copy of this report.
16. One of the Ombudsman’s family liaison officers contacted Mr Horrocks’ next of kin,
his sister and niece, to explain the investigation and to ask if they had any matters
they wanted the investigation to consider. They did not have any specific questions
for the investigation to consider, but they requested a copy of our report.
17. Mr Horrocks’ family received a copy of the initial report. The solicitor representing Mr
Horrocks’ family wrote to us pointing out a factual inaccuracy. The report has been
amended accordingly.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out one factual inaccuracy and this report has been amended
accordingly.
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Background Information
HMP & YOI Thorn Cross
19. HMP & YOI Thorn Cross is an open prison holding up to 400 Category D adult male
prisoners and young male offenders. Bridgewater Community Healthcare Foundation
Trust provide healthcare services. Greater Manchester West Mental Health Care
Foundation Trust provide mental health services. The integrated clinical and
psychosocial substance misuse services are delivered by Change, Grow, Live (CGL).
The healthcare centre is open from 7.30am to 5.30pm on Monday to Friday and from
7.30am to 12.15pm on weekends and bank holidays.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Thorn Cross was in August 2016. Inspectors
reported that Thorn Cross was a good prison. They found that it was a well-led and
confident prison that delivered very good outcomes for prisoners. Inspectors noted
that good support was provided for new arrivals and there were few violent incidents.
Integrated drug services were excellent. Inspectors assessed Thorn Cross as a
respectful prison and the environment and accommodation were good. Health
outcomes for prisoners were very good and appreciated by prisoners.
Independent Monitoring Board
21. 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 April 2019, the IMB reported that prisoners at
Thorn Cross were treated fairly and the governors and staff provided a fair and
reasonable environment for the prisoners. The Board noted that although there was
an increasing availability of psychoactive substances (PS) in the community, this had
not been mirrored at Thorn Cross. However, a worrying trend was the counterfeiting
of tablets and capsules. The Board found that prisoners were led to believe that the
substances were genuine and were bought in that belief. However, the drugs were
rarely genuine and often contained harmful and addictive active substances and the
risks to prisoners were apparent.
Previous deaths at HMP Thorn Cross
22. Mr Horrocks is only the second prisoner ever to die at Thorn Cross. The other death
was a homicide which occurred while the prisoner was out of the prison on day
release in October 2018. There are no similarities between our findings in the
investigation into Mr Horrocks’ death and our investigation findings for the previous
death.
Psychoactive Substances (PS)
23. Psychoactive substances (formerly known as ‘new psychoactive substances’ or ‘legal
highs’) are a fundamental problem across the prison estate. They are difficult to
detect and can affect people in a number of ways including increasing heart rate,
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raising blood pressure, reducing blood supply to the heart and vomiting. Prisoners
under the influence of PS can present with marked levels of disinhibition, heightened
energy levels, a high tolerance of pain and a potential for violence. Besides emerging
evidence of such dangers to physical health, there is potential for precipitating or
exacerbating the deterioration of mental health with links to suicide or self-harm.
24. In July 2015, we published a Learning Lessons Bulletin about the use of PS (still at
that time NPS) and its dangers, including its close association with debt, bullying and
violence. The bulletin identified the need for better awareness among staff and
prisoners of the dangers of PS; the need for more effective drug supply reduction
strategies; better monitoring by drug treatment services; and effective violence
reduction strategies.
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Key Events
25. On 5 September 2018, Mr Paul David Horrocks was sentenced to two years and
eight months in prison for burglary. He was sent to HMP Forest Bank. He transferred
to Thorn Cross on 2 April 2019.
26. On his arrival at Thorn Cross, prison staff submitted an intelligence report which
recorded that Mr Horrocks was overheard asking other prisoners how to obtain drugs
in the prison.
27. A nurse carried out Mr Horrocks’ reception health screen. She checked his blood
pressure and it was high. She noted his history of schizophrenia, depression, anxiety
and substance misuse (cocaine, opiates, amphetamines and cannabis) and noted no
significant physical concerns. Mr Horrocks was already on a methadone
detoxification programme when he arrived at Thorn Cross. The reception nurse
referred him to the prison’s substance misuse team, DART (Drug and Alcohol
Recovery Team), and the prison’s mental health team. He continued with his
methadone therapy and healthcare staff reviewed him regularly. They also completed
a prescription for his mental health medication.
28. On 5 April, a mental health counsellor saw Mr Horrocks. She referred him for one to
one counselling because he had talked about his past anxiety. He would either fail to
attend these sessions or walk out of them. On 23 April, he attended his appointment
with a psychological wellbeing practitioner and continued to attend the sessions
frequently to help him address his anxiety.
29. On 1 May, a prison GP saw Mr Horrocks. It was agreed that Mr Horrocks could start
methadone reduction therapy.
Events of 29 June 2019
30. Mr Horrocks had a single room on the second floor of Unit 1 at Thorn Cross. His
neighbours on either side of him were Prisoner A and Prisoner B. Prisoners have
their own room keys and can move around the unit at any time. A roll check (a count
of all prisoners) is completed by the evening staff around 8.00pm, and the next roll
check is completed by the night staff at around 6.00am.
31. On the evening of 29 June, Prisoner A said that he saw Mr Horrocks outside his
room at about 8.10pm, while the other prisoners waited for the roll check to be
completed. He said that he saw Mr Horrocks again at 8.45pm. He told the
investigator that Mr Horrocks was not “in control of himself, walking funny” and
wearing one flip flop and one sock. He said that Mr Horrocks dropped his crockery
and he appeared to be under the influence of something.
32. Prisoner A said that at approximately 10.30pm, he heard a commotion from Mr
Horrocks’ room. He looked out into the corridor and saw Prisoner B also looking to
see what had happened. Prisoner B said that he went outside Mr Horrocks’ door and
shouted to ask if he was ok, but there was no response. Both prisoners returned to
their rooms. CCTV footage showed no one leaving or entering Mr Horrocks’ room
during that time.
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Event of 30 June 2019
33. At 5.10am, an Operational Support Grade (OSG) started the morning roll check on
Unit 1. When he reached Mr Horrocks’ room, he opened the observation panel and
saw Mr Horrocks sleeping. He told the investigator that he did not notice anything
unusual and continued with his duties until the end of his shift.
34. Officer A arrived on Unit 1 and began his duties in the office. He said that at
approximately 7.30am, a nurse telephoned him asking for Mr Horrocks to attend the
healthcare unit for his methadone medication.
35. Officer A went to Mr Horrocks’ room and opened the observation panel. He saw Mr
Horrocks lying on his front on the bed, apparently asleep. He called Mr Horrocks’
name but got no response. Prisoner B asked the officer if he needed help. The officer
asked him to hold the door open as he walked over to the bed. He touched Mr
Horrocks and said that he was cold and stiff. He ran to the unit office to get a radio to
summon help.
36. Officer A radioed for the duty nurse, duty manager and orderly officer to attend Unit 1
and ran back to the room. He removed the quilt from Mr Horrocks’ body and noticed
that there was a small amount of blood on his pillow.
37. A nurse heard a radio call for the duty nurse to come to Unit 1. She did not bring any
emergency equipment as the radio message had not indicated the nature of the call.
She went to Mr Horrocks’ room and an officer told her that he thought that Mr
Horrocks was dead. She entered the room and told the officer she needed help to roll
Mr Horrocks over on his back. She said that when they rolled him over his eyes were
fixed and he felt warm. She checked for a pulse and noted that Mr Horrocks’ body
was stiff, so she did not attempt CPR.
38. The nurse said that a prison senior manager had told them that they needed to
telephone an ambulance so that they could confirm Mr Horrocks’ death. In his written
statement, a Senior Officer (SO) said that the nurse had told him that an ambulance
was needed to confirm Mr Horrocks’ death so he asked the gate staff to call an
ambulance.
39. The nurse told the investigator that a prison manager said that she could return to the
healthcare unit to lock up. When she got there, she heard a radio message
instructing staff to start CPR. She locked up the healthcare unit and returned to Mr
Horrocks’ room. She waited outside the room because paramedics had just arrived.
40. At 8.15am, paramedics confirmed that Mr Horrocks had died. The nurse said that she
asked a paramedic if her actions in not attempting CPR had been correct and the
paramedic told her that they were correct.
Information received after Mr Horrocks’ death
41. After Mr Horrocks’ death, staff submitted intelligence reports suggesting that two
prisoners on another unit had supplied Mr Horrocks with pregabalin tablets the night
before he died. (Pregabalin is prescribed medication for epilepsy, anxiety and nerve
pain and is traded illicitly and abused in prisons for its euphoric effects.) Intelligence
reports recorded that Mr Horrocks had told other prisoners that he was high because
he had taken five pregabalin tablets, medication he had not been prescribed. The
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intelligence reports were assessed, and an analyst concluded that the claims were
unsubstantiated.
42. Police retrieved vials of liquids and a mobile telephone from Mr Horrocks’ room and
sent them for testing. The police said that the vials tested negative for drugs and
were consistent with fragrance oils. The mobile telephone had four text messages,
but they were not related to drugs or threats.
Contact with Mr Horrocks’ family
43. On 30 June, the prison appointed a family liaison officer (FLO). Later that day, the
FLO and a prison manager visited Mr Horrocks’ next of kin, his sister, at her address
and told her that her brother had died. They maintained contact with Mr Horrocks’
family, offering support and information.
44. Mr Horrocks’ funeral was held on 19 July. The prison contributed to the costs of Mr
Horrocks’ funeral in line with national policy.
Support for prisoners and staff
45. After Mr Horrocks’ death, a duty manager 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. The prison posted notices informing other prisoners of Mr Horrocks’ 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 Horrocks’ death.
Post-mortem report
47. The post-mortem was unable to establish the cause of Mr Horrocks’ death.
48. There was no evidence of drug or alcohol misuse, although the pathologist said that
the use of PS could not be completely ruled out as there are so many different types.
Toxicology results showed the presence of Mr Horrocks’ prescribed medication at
therapeutic levels which did not contribute to his death.
49. There was no evidence of any natural disease or injury that would have been the
cause of Mr Horrocks’ death. The pathologist found that Mr Horrocks had an
enlarged heart (possibly caused by high blood pressure or cocaine use) and dilated
mitral valve, but neither were severe, and it could not be certain that these were
factors in the cause of his death.
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Findings
Management of Mr Horrocks’ substance misuse and mental health
50. The clinical reviewer found that healthcare staff offered Mr Horrocks opportunities to
engage with support services to address his substance misuse and mental health,
and that this support was offered in a timely manner. DART staff and healthcare staff
who had regular contact with Mr Horrocks had no suspicion that he was under the
influence of drugs or using illicit substances in addition to his methadone.
51. The clinical reviewer concluded that the care Mr Horrocks received for his substance
misuse and mental health was of a good standard and equivalent to that which he
could have expected to receive in the community.
Clinical care
52. The clinical reviewer concluded that, overall, the care Mr Horrocks received at Thorn
Cross was equivalent to that which he could have expected to receive in the
community.
53. The clinical reviewer did, however, identify some concerns.
Follow up care and secondary reception screen
54. Prison Service Order (PSO) 3050, Continuity of Healthcare, emphasises the
importance of continuity in clinical interventions and treatment. It says that:
“In the week following first reception, every prisoner must be offered a general health
assessment. This assessment is equivalent to a primary care assessment when
registering with a new practice in the community…”
55. The secondary screen is an opportunity for care planning and a more in-depth
assessment and investigation of healthcare issues. During his initial health screen on
2 April 2019, a nurse noted that Mr Horrocks’ blood pressure was high. The clinical
reviewer found that the nurse had not made any arrangements for follow up checks
and had not arranged a secondary health screen. We make the following
recommendations:
The Head of Healthcare should ensure that any prisoners with elevated blood
pressure readings are monitored in accordance with NICE guidelines.
The Head of Healthcare should ensure that all new prisoners receive secondary
health screens within seven days, in line with NICE guidelines and PSO 3050,
Continuity of Healthcare for Prisoners.
Emergency response
56. Prison Service Instruction (PSI) 03/2013, requires prisons to have a medical
emergency response code protocol, which ensures an ambulance is called
automatically in a life-threatening emergency. It says that all prison staff must be
made aware of and understand the protocol and their responsibilities during medical
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emergencies. The PSI makes it clear that there should be no delay in admitting and
discharging an ambulance.
57. Thorn Cross has local guidance for medical emergencies which is in line with
national instructions. The local guidance says that in the event of a life-threatening
situation the first member of staff on scene is responsible for requesting an
ambulance prior to the attendance of any healthcare staff or prison managers.
58. When Officer A found Mr Horrocks unresponsive in his cell on 30 June, he did not
have his radio with him to summon help. He ran to the unit office to use a radio. He
told the investigator that although there were two officers working on Unit 1, only one
radio was allocated to the Unit. He used the radio to ask a nurse and duty managers
to attend Mr Horrocks’ room. He should have immediately called an emergency
medical code blue to indicate that Mr Horrocks was unresponsive. Because an
emergency medical code blue was not called, the nurse did not bring an emergency
medical bag and there was a delay between him first seeing Mr Horrocks lying
unresponsive on his bed and the ambulance being called.
59. Although this did not affect the outcome for Mr Horrocks, who had clearly been dead
for some time when he was found, it could make a significant difference in other
medical emergencies. We make the following recommendations:
The Governor should ensure that all prison staff are made aware of and
understand their responsibilities during medical emergencies including that
staff:
• use an emergency code immediately where there are serious concerns
about the health of a prisoner to alert control room staff to call an
ambulance automatically; and
• efficiently communicate the nature of a medical emergency so that there
is no delay in directing or discharging ambulances.
The Governor should ensure there are a sufficient number of radios available
to officers on each Unit.
The Governor should ensure that this report is shared with Officer A and that a
senior manager discusses the Ombudsman’s findings with him.
60. PSI 3/2013 also requires prisons to agree written emergency response protocols with
the local Ambulance Trust so that they understand medical emergencies within a
prison context and to help eliminate any confusion.
61. When control room staff called an ambulance, the emergency services told them to
start CPR. There were then repeated radio calls for staff to continue with CPR. A
nurse had already attended Mr Horrocks’ room and, after checking for signs of life,
she considered that he had clearly been dead for some time and so she did not
attempt CPR. This information was not communicated to the Ambulance Service and
caused confusion. The clinical reviewer noted that this was very upsetting for the
nurse, as she had made the correct decision not to attempt resuscitation. We make
the following recommendation:
The Governor and the Head of Healthcare should liaise with the local
ambulance service to ensure that an effective protocol is in place so that the
ambulance service understands the nature and context of medical
emergencies in prison and that staff who request ambulances might not be
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able to provide detailed information about a prisoner’s medical condition
immediately.
First Aid Training
62. PSI 29/2015, First Aid, requires there to be suitably trained first aiders available to
treat anyone who becomes ill in the prison. The PSI says that ‘first aid provision must
be adequate and appropriate in the circumstances’. This means that sufficient first
aid equipment, facilities and personnel need to be available at all times.
63. HMP Thorn Cross does not have 24-hour healthcare cover. The investigation found
that there was no list of trained first aid staff at Thorn Cross.
64. None of the custodial staff on duty who attended were first aid trained when they
found Mr Horrocks unresponsive in his room on 30 June. It was fortunate on this
particular occasion that a nurse was on duty that day to provide medical assistance.
Although this did not affect the outcome for Mr Horrocks, we consider that there
should be at least one first aid or basic life support trained member of staff on every
shift, able to attend to any medical emergency and that it is imperative that Thorn
Cross complies with national guidance and ensures there is first aid cover at all
times. We make the following recommendation:
The Governor should ensure there are sufficient first aid trained staff, at all
times, in line with PSI 29/2015.
Inquest
65. At the inquest, held on 28 to 30 October 2024, the Coroner concluded that on the
evidence available, it was not possible to ascertain how Mr Horrocks came by his
death.
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