Peter Coulthard

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Independent investigation into
the death of Mr Peter Coulthard,
a prisoner at HMP Whatton,
on 23 March 2021
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. We carry out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
3. Mr Peter Coulthard died in hospital on 23 March 2021, while a prisoner at HMP
Whatton. He was 61 years old. The cause of his death was COVID-19 pneumonitis.
I offer my condolences to Mr Coulthard’s family and friends.
4. The clinical reviewer concluded that Mr Coulthard’s clinical care at Whatton was
equivalent to that he could have expected to receive in the community. However,
she found that there were no care plans in place to manage his hypertension and
some of the clinical checks after he contracted COVID-19 were not documented in
his medical record.
5. Mr Coulthard was at high risk of complications from COVID-19. Due to a lack of
documentary evidence of actions taken, we are not satisfied that he was managed
in line with the COVID-19 national policy at the time. He seems to have contracted
the virus at Whatton, as he had not left the prison for some time.
6. We consider that clinically high-risk prisoners should have a personal risk
assessment if they are employed in roles such as cleaning, which potentially places
them at greater risk of exposure to COVID-19. This would increase awareness and
enable staff to consider adjustments to help mitigate the risks.
Recommendations
• The Governor and Head of Healthcare should ensure that staff manage prisoners at
high risk of complications from COVID-19 in line with national guidance. Key actions
and decisions should be fully documented in prisoners’ medical and personal
records.
• The Head of Healthcare should ensure that all clinical assessments are fully
documented in the patient’s medical record.
• The Head of Healthcare should ensure that care plans are in place for patients with
hypertension and other chronic conditions.
• The Director General of Prisons should issue national guidance on risk
assessments for clinically high-risk prisoners, to ensure that protective measures
are fully considered for those employed as cleaners, or in other roles which
significantly increase the possibility of exposure to COVID-19.
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The Investigation Process
7. NHS England commissioned an independent clinical reviewer to review Mr
Coulthard’s clinical care at HMP Whatton.
8. The PPO investigator investigated the non-clinical issues, including aspects of the
prison’s response to COVID-19 and shielding prisoners; Mr Coulthard’s location; the
security arrangements for his journey and admission to hospital; liaison with his
family; and whether early release was considered.
9. The Ombudsman’s family liaison officer contacted Mr Coulthard’s next of kin, his
sister, to explain the investigation. Mr Coulthard’s sister asked for the following
matters to be considered during the investigation.
• Why was Mr Coulthard kept in his cell between 5 and 9 March, and should he
have been sent to hospital sooner?
• Did he receive the correct PPE for his job as a cleaner and were there clear
procedures, given the increased risks of the role?
• Why had he not received a COVID-19 vaccination?
10. We shared our initial report with HMPPS and the prison’s healthcare provider. They
found no factual inaccuracies. They provided an action plan which is annexed to
this report.
11. We sent a copy of our report to Mr Coulthard’s sister. She did not notify us of any
factual inaccuracies.
Previous deaths at HMP Whatton
12. Mr Coulthard was the 16th prisoner at Whatton to die since March 2019. All the
previous deaths were from natural causes and COVID-19 had caused or
contributed to five of them. There have since been 16 further deaths, 15 due to
natural causes and one self-inflicted. None appear to be related to COVID-19. We
have previously raised concerns about the need to document clinical interventions.
COVID-19 (coronavirus)
13. COVID-19 is an infectious disease that affects the lungs and airways. It is mainly
spread through droplets when an infected person coughs, sneezes, speaks or
breathes heavily. On 11 March 2020, the World Health Organisation (WHO)
declared COVID-19 a worldwide pandemic.
14. COVID-19 can make anyone seriously ill, but some people are at higher risk of
severe illness and developing complications from the infection. People at high risk
(clinically extremely vulnerable) include those who have had an organ transplant;
have severe lung or kidney disease; or are having certain types of cancer or other
treatment which significantly increases the risk of infection. Examples of those at
moderate risk (clinically vulnerable) are people over 70; people under 70 with an
underlying health condition, such as diabetes, or chronic respiratory, heart, liver or
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kidney disease; those with a weakened immune system; or who are very
overweight. (These lists are not exhaustive.)
15. In response to the initial pandemic outbreak, HM Prison and Probation Service
(HMPPS) introduced several measures to try and contain the outbreak - to be
implemented at local level, depending on the needs of individual prisons. (An
outbreak is defined as two or more prisoners, or staff, who are clinically suspected,
or have tested positive for COVID-19 within 14 days.) A key strategy is
‘compartmentalisation’ to cohort and protect prisoners at high and moderate risk;
isolate those who are symptomatic; and separate newly-arrived prisoners from the
main population. Other measures include social distancing and the use of personal
protective equipment (PPE).
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Key Events
16. Mr Peter Coulthard was remanded to prison on 8 April 2002. He was later convicted
of sexual and violent offences and sentenced to life imprisonment, with a minimum
period to serve of eight years and nine months. After moving between several
prisons, Mr Coulthard transferred to HMP Whatton on 20 December 2011.
17. Mr Coulthard’s significant physical health conditions were obesity and high blood
pressure. He was monitored by nurses at the hypertension clinic, but did not take
his medication regularly and disregarded advice about his diet.
18. In March 2020, COVID-19 was confirmed as a pandemic. On 29 June, an entry in
Mr Coulthard’s medical record noted that he had been identified as at high risk of
complications from the virus. (A similar entry for 12 August was entered
retrospectively on 11 January 2021.) There was no record of whether he was
notified either time.
19. Mr Coulthard lived on C1 wing, where he worked as a cleaner. He was responsible
for public areas, showers and the disabled toilet. He had also been trained to deal
with biohazards. An entry in his personal records noted that his role was particularly
demanding all day. This was partly due to an increased number of prisoners from
other wings using the facilities on C1, as those in other areas were out of action.
20. In October 2020, HMP Whatton had an outbreak of COVID-19. The prison was
placed in lockdown with a restricted regime; limited movement; meals delivered to
cells; and no unnecessary contact. On 31 October, Mr Coulthard tested negative for
COVID-19.
21. The COVID-19 risk criteria changed during the pandemic. However, on 12 January
2021, Mr Coulthard was again assessed as high risk, due to obesity. On 14
January, a letter was sent advising him to shield.
22. On 22 January, following a mass screening at the prison, Mr Coulthard tested
negative for COVID-19.
COVID-19 infection
23. The national COVID-19 vaccination programme for people aged 61-63 years old
began on 21 February. Whatton received their first delivery of the vaccine on 3
March and Mr Coulthard’s vaccination appointment was scheduled for 30 March.
24. Early on 5 March, Mr Coulthard gave a wing officer a note stating that he felt ill, with
symptoms of COVID-19. A nurse assessed him and found that he was lethargic,
with a high temperature, but no cough or loss of taste or smell. She took a swab to
be tested and advised him to take paracetamol and keep hydrated. Mr Coulthard
stayed in isolation on his wing and declined the offer of a phone call. (The test result
was confirmed as COVID-19 positive on 9 March.)
25. Healthcare staff reviewed Mr Coulthard daily. On 6 March, it was noted that he had
developed a cough. The medical records contained no references to clinical checks
on 7 and 8 March, but entries in Mr Coulthard’s personal records and his COVID-19
isolation log confirmed that they had been completed on both days. It was noted
that he still felt unwell.
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26. Just after 3.00pm on 9 March, a nurse was on the wing swabbing prisoners. As she
was passing Mr Coulthard’s cell, she asked through the hatch if he needed more
paracetamol. Although he responded, the nurse was concerned about his
demeanour and asked an officer to open his cell door. The nurse described Mr
Coulthard as pale and vague, with a very dry mouth, sore throat and shallow
breathing. Clinical observations indicated very low blood oxygen saturation levels.
The nurse called a code blue emergency and gave him oxygen while waiting for the
ambulance. Mr Coulthard was initially reluctant to go to hospital, but was told that
he was likely to die if he refused treatment.
27. Mr Coulthard was taken to Queen’s Medical Centre, Nottingham, escorted by two
prison officers. No restraints were used in the ambulance, but an escort chain was
applied for a few minutes at the hospital. Mr Coulthard was admitted to the intensive
care unit around 20 minutes after his arrival. He was then sedated and placed on a
ventilator.
28. On 10 March, the prison appointed a family liaison officer. Before he was sedated,
Mr Coulthard had said he did not want his family to be notified that he was unwell.
However, in view of his diagnosis and serious condition, the family liaison officer
informed Mr Coulthard’s sister and offered support. She asked to be informed
immediately, day or night, if Mr Coulthard’s condition worsened.
29. On 17 March, Mr Coulthard was granted release on temporary licence and the
escort was reduced to one officer. He died on 23 March.
30. The family liaison officer supported Mr Coulthard’s sister over the following weeks.
In line with national policy, the prison contributed to the costs of Mr Coulthard’s
funeral, which was held on 26 April.
31. A prison manager debriefed the escort officer and offered support. Notices were
issued to other staff and prisoners, informing them of Mr Coulthard’s death and
reminding them of the support available.
Cause of death
32. No post-mortem examination was held as the coroner accepted the cause of death
certified by a hospital doctor as COVID-19 pneumonitis.
33. The inquest, held on 3 June 2021, concluded that Mr Coulthard died from natural
causes.
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Findings
Clinical Findings
34. The clinical reviewer concluded that Mr Coulthard received timely and appropriate
care at Whatton, at least equivalent to that he could have expected to receive in the
community. However, she was concerned there was no care plan in place to
monitor and review his hypertension; and there were lapses in recording clinical
monitoring when he contracted COVID-19. We reflect these issues and her
recommendations in this report.
Management of Mr Coulthard’s risk of infection from COVID-19
35. In line with national guidance for the general population, HMPPS’ cohorting policy
required prisons to identify prisoners at high risk of serious illness if they contracted
COVID-19 and provide the opportunity to shield. Staff were expected to support
prisoners to make an informed decision by discussing the benefits of shielding and
the possible consequences of not doing so. They were also required to record
decisions about shielding in prisoners’ NOMIS personal records and the defensible
decisions log.
36. The prison said that all men considered at risk were given the option to shield on
either a dedicated unit, or in their existing cell and they were visited by the
psychology team to discuss this. They were also sent a shielding letter giving
details of the precautions necessary to reduce their risk. Disclaimers for those who
opted not to shield were supposed to be signed and scanned to individual records.
The Head of Healthcare said that information leaflets were provided and updates
were broadcast on the prison’s television channel.
37. Entries in Mr Coulthard’s medical record, in June and August 2020 and January
2021, confirmed that he had been assessed as at high risk of complications from
COVID-19. However, there was no record that he was notified of this until the latter
occasion. His NOMIS personal records contained no references to discussions
about risk or shielding and there were no disclaimers. As there is no evidence that
relevant information was communicated to Mr Coulthard, we cannot be sure his risk
was managed appropriately.
38. The guidance for those previously considered clinically extremely vulnerable from
COVID-19 has since changed and the shielding programme is no longer
mandatory. However, it is important that healthcare and prison staff comply with
current and future policies on managing those at risk and ensure that records are
appropriately documented. We recommend:
The Governor and Head of Healthcare should ensure that staff manage
prisoners at high risk of complications from COVID-19 in line with national
guidance. Key actions and decisions should be fully documented in
prisoners’ medical and personal records.
39. At the time Mr Coulthard became unwell, several measures were in place to limit
contact with others, including restricted movement within the prison and delivery of
meals to cells. In spite of this, Mr Coulthard almost certainly contracted COVID-19
at Whatton, as he had not left the prison for a long time.
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Monitoring Mr Coulthard after he contracted COVID-19
40. When Mr Coulthard became unwell, he was immediately isolated and healthcare
staff reviewed him daily. The outcome of the checks on 7 and 8 March were not
recorded in his medical record, but the NOMIS record and COVID-19 isolation log
verifies that they took place.
41. While we are satisfied that Mr Coulthard was appropriately monitored, we share the
clinical reviewer’s concern that the checks were not entered in his medical record
on two successive days. Documenting clinical monitoring is important to detect
deterioration and ensure continuity of care. We recommend:
The Head of Healthcare should ensure that all clinical assessments are fully
documented in the patient’s medical record.
Management of Mr Coulthard’s hypertension
42. Mr Coulthard’s blood pressure fluctuated, as he was not always compliant with
monitoring and taking his medication. Although he was managed by the
hypertension clinic, there was no care plan in place. The clinical reviewer considers
that a care plan would have enabled consistent measurement of Mr Coulthard’s
blood pressure and might have helped him to comply with his treatment. We
recommend:
The Head of Healthcare should ensure that care plans are in place for patients
with hypertension and other chronic conditions.
Risks associated with Mr Coulthard’s employment as a cleaner
43. The investigation explored whether Mr Coulthard’s job as a cleaner might have
placed him at higher risk of exposure to COVID-19 and if sufficient action was taken
to mitigate the risks given his vulnerability.
44. The prison issued notices to staff and prisoners throughout the pandemic, outlining
the mandatory health and safety requirements, the essential clothing to be worn
and the consequences of failing to comply with the instructions.
45. All wing cleaners were provided with protective clothing and footwear, gloves and
masks. They were trained to take precautionary measures and to follow infection
prevention control guidelines to avoid cross contamination. To further reduce the
risk, the other men would be locked in their cells while cleaning took place.
46. The HMPPS COVID-19 policy team clarified that for biohazard cleaning, cleaners
wear a white sterile suit, plastic shoe covers, rubber arm gauntlets, goggles and, for
some tasks, an FFP mask (which protects against very fine particles). They
considered that, in some instances, cleaning public spaces, such as the showers
and toilets, might present a slightly lower risk as the cleaners used long reach poles
and swabbing, rather than sprays.
47. We are satisfied that the prison provided appropriate training, guidance and
equipment for cleaners. We are not critical of the decision to allow Mr Coulthard to
continue this work if he chose to do so. However, we consider that if a high-risk
prisoner is employed to perform tasks that would potentially put them at even
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greater risk of contracting COVID-19, it would be prudent to conduct an auditable
personal risk assessment. As far as we aware, this is not currently mandated by the
Prison Service, but we consider it would help staff to determine whether any
adjustments need to be made and ensure that the prisoner is aware of the
increased risk. We recommend:
The Director General of Prisons should issue national guidance on risk
assessments for clinically high-risk prisoners, to ensure that protective
measures are fully considered for those employed as cleaners, or in other
roles which significantly increase the possibility of exposure to COVID-19.
Sue McAllister CB
Prisons and Probation Ombudsman December 2024
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