Rebecca Parkinson

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into the
death of Ms Rebecca Parkinson,
a prisoner at HMP Styal,
on 31 July 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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.
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.
Ms Rebecca Parkinson died in hospital on 31 July 2022, two days after she was found
unresponsive in her cell at HMP Styal. She was 43 years old. I offer my condolences to Ms
Parkinson’s family and friends.
Ms Parkinson had been at Styal for only around 24 hours when she was found
unresponsive on the floor of her cell. She had suffered a cardiac arrest, but the post-
mortem examination was unable to ascertain the cause.
My investigation identified some issues with the emergency response, though we cannot
say whether they affected the outcome for Ms Parkinson.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman September 2024
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 28 July 2022, Ms Rebecca Parkinson was remanded to HMP Styal charged with
assaulting a police officer. It was her first time in prison.
2. Before she arrived at Styal, the community mental health team told the prison’s
mental health team that Ms Parkinson was at risk of harming herself (she self-
harmed by punching herself or banging herself off objects with force). She had a
history of mental health problems including anxiety, depression and psychosis.
When she arrived at Styal, staff started suicide and self-harm prevention
procedures (known as ACCT) and set observations at one an hour.
3. During her initial health screen, Ms Parkinson told the nurse that she was anxious
about being in prison for the first time. She said that she had last self-harmed by
banging her head on 25 July. Staff placed Ms Parkinson on the Valentina Unit (for
women who need higher levels of care) due to her history of self-harm.
4. The next day, staff held an ACCT case review with Ms Parkinson. She said she was
anxious about being in prison but had not self-harmed. She refused lunch but had
hot water. She also had a call to her father to let him know where she was.
5. Shortly after 6.00pm, an officer saw Ms Parkinson climbing onto her bed and
thought she was going to have a rest as she had not eaten much all day and had
just taken her medication. When the officer returned at around 6.45pm, she saw Ms
Parkinson lying face down on a quilt on the floor of her cell. She thought that she
could see Ms Parkinson breathing, however, she got no response when she
knocked on the door and shouted her name. She radioed for staff assistance.
6. A healthcare support worker, who was in a nearby cell, overheard and went to help.
She looked through Ms Parkinson’s cell door and thought that she was not
breathing. She then went to the healthcare unit (attached to the Valentina Unit) to
ask nursing colleagues for urgent assistance.
7. The healthcare support worker returned to the cell with two nurses. The officer and
the nurses entered and started CPR. At 6.52pm, a second officer arrived at the cell
and called a medical emergency code, which prompted the control room to call an
ambulance.
8. Nurses attached a defibrillator which showed Ms Parkinson did not have a
shockable heart rhythm. They then inserted an airway and gave her oxygen. A
nurse also gave two injections of adrenaline.
9. At 7.09pm, the ambulance arrived at the Valentina Unit and paramedics took over
Ms Parkinson’s care. The paramedics continued CPR and gave Ms Parkinson more
adrenaline. They attached their defibrillator to Ms Parkinson which showed
pulseless electrical activity (PEA – a form of cardiac arrest where there is no pulse,
but the heart’s electrical activity is present). The paramedics continued CPR and
moved her to the ambulance. She was taken to hospital at 7.39pm.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
10. Ms Parkinson was admitted to intensive care where she remained in a coma. On 31
July, doctors confirmed that she was brain stem dead. They stopped all treatment
and at 5.49pm, confirmed her death.
11. The post-mortem examination was unable to establish the cause of Ms Parkinson’s
death. The pathologist found no natural disease that could have caused Ms
Parkinson to have a cardiac arrest but also found no compelling evidence that her
death had been caused by a head injury.
Findings
12. There was a delay in calling the medical emergency code which resulted in a delay
in calling an ambulance. We have previously made recommendations to Styal about
ensuring staff follow the medical emergency procedures by promptly calling the
appropriate code.
13. The clinical reviewer found that the nurse who administered adrenaline during the
emergency response used the dose and method for a severe allergic reaction
instead of a cardiac arrest. She concluded that Ms Parkinson’s clinical care was
partially equivalent to that which she could have expected to receive in the
community.
Recommendations
• The Governor and Head of Healthcare should review how staff are trained on the
use of medical emergency codes and satisfy themselves that all staff are aware of
their responsibilities during medical emergencies.
• The Head of Healthcare should ensure that staff understand how and when to
administer adrenaline in medical emergencies and that they have received the
appropriate training to do so.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
14. HMPPS notified us of Ms Parkinson’s death on 31 July 2022.
15. The investigator issued notices to staff and prisoners at HMP Styal informing them
of the investigation and asking anyone with relevant information to contact him. No
one responded.
16. The investigator obtained copies of relevant extracts from Ms Parkinson’s prison
and medical records.
17. NHS England commissioned an independent clinical reviewer to review Ms
Parkinson’s clinical care at the prison. The investigator and clinical reviewer
interviewed four members of staff at Styal on 5 September 2022.
18. We informed HM Coroner for Cheshire of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
19. The Ombudsman’s family liaison officer contacted Ms Parkinson’s parents to
explain the investigation and to ask if they had any matters they wanted us to
consider. They wanted to know more about the circumstances leading up to Ms
Parkinson’s death, which we have covered in this report.
20. We shared our initial report with HMPPS. They pointed out a minor factual
inaccuracy in this report and in one of the interview transcripts, which have been
corrected. They provided an action plan which is annexed to this report.
21. We sent a copy of our initial report to Ms Parkinson’s parents via their legal
representative. They did not notify us of any factual inaccuracies.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Styal
22. HMP Styal is a prison and young offender institution (YOI) in Wilmslow, Cheshire,
for women aged 18 and over. It holds up to 486 women. Spectrum community
health CIC provides healthcare and substance misuse services. Mental health
services are contracted from Greater Manchester Mental Health NHS Foundation
Trust.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Styal was in October 2021. Inspectors found
that outcomes for women at Styal were reasonably good across healthy prison
outcomes (safety, respect, purposeful activity, rehabilitation and release planning).
They found there was good oversight of medicines management, however some
dispensing practices were unsafe and required immediate attention.
Independent Monitoring Board
24. 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 30 April 2022, the IMB reported
despite operational difficulties, most women received primary care that was at least
as good as that provided in the community. They were concerned that healthcare
had not consistently provided a timely, safe process for administering medication.
Previous deaths at HMP Styal
25. Ms Parkinson was the fifth prisoner at Styal to die since July 2019. Of the previous
deaths, two were from natural causes and two were self-inflicted.
26. We have previously made recommendations about ensuring staff use the
appropriate code when they discover a medical emergency. In September 2021, we
were told that staff were being provided with Emergency Response Information
Cards (ERIC) to provide information on calling emergency response codes, along
with further training at morning briefings.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
27. On 28 July 2022, Ms Rebecca Parkinson was remanded in prison, charged with
assaulting a police officer, and sent to HMP Styal. It was her first time in prison.
28. Before Ms Parkinson arrived at Styal, a member of the community mental health
team (CMHT) spoke to a member of the prison’s mental health team to tell them
that Ms Parkinson was at risk of self-harm (she self-harmed by punching herself or
banging herself off objects with force). The CMHT also advised that staff should see
Ms Parkinson in pairs as she posed a risk of assault. They said there was a working
diagnosis of depression with psychosis and possible emotionally unstable
personality disorder (EUPD). Ms Parkinson was also diagnosed with attention
deficit hyperactivity disorder (ADHD). She was on a range of medication including
antipsychotics and antidepressants.
29. Ms Parkinson arrived at Styal shortly after 5.00pm. Staff started suicide and self-
harm prevention procedures (known as ACCT) and set observations at one an
hour. During her initial health screening, Ms Parkinson told the nurse that she had
last self-harmed by banging her head on 25 July. She said she had not lost
consciousness and the nurse found no signs of injury. The nurse asked prison staff
to place Ms Parkinson on the Valentina Unit (used for women who need higher
levels of care) as she was concerned about her history of self-harm and her anxiety
about being in prison.
30. Staff checked on Ms Parkinson hourly through the night. They noted that she was
upset because she had been unable to contact her parents who did not know she
was in prison.
29 July
31. The next day, staff noted that Ms Parkinson was feeling down but there were no
signs of self-harm. They noted that Ms Parkinson had called her father that morning
and that she was anxious and upset. She refused lunch but had hot water.
32. Staff held an ACCT case review with Ms Parkinson. A member of the mental health
team attended. Staff noted that she engaged well but was anxious about being in
prison. She said that she self-harmed in the community, usually by banging her
head, but had managed not to while she had been in prison.
33. A mental health nurse carried out a mental health assessment with Ms Parkinson.
The nurse noted that Ms Parkinson was willing to engage but that it was hard to
build a rapport with her as she was staring intently, spoke in a monotone voice and
was facially flat. The nurse noted that Ms Parkinson was being supported using
ACCT and would be referred to the Single Point of Contact in the mental health
team to be placed on the caseload.
34. At approximately 5.30pm, an officer walked Ms Parkinson back to the Valentina Unit
after collecting her medication. She noticed that Ms Parkinson was slightly unsteady
on her feet and asked if she was okay. Ms Parkinson told the officer that she was
not okay and needed to speak to her. The officer said she had some duties to do
and would come back to her cell to speak to her.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
35. The officer returned to Ms Parkinson’s cell at approximately 6.05pm and saw Ms
Parkinson climbing onto her bed. At interview, she said she thought Ms Parkinson
was tired as she had not eaten much and had just taken her medication. She
decided to leave Ms Parkinson to get some rest and go back later.
36. At approximately 6.45pm, the officer saw Ms Parkinson lying face down on a quilt
on the floor of her cell. She looked through the observation panel in the cell door
and thought that she could see Ms Parkinson breathing, but she did not respond
when she knocked on the door and shouted her name. She radioed for officer
assistance as she needed a second officer with her before unlocking the cell door
as the prison was in patrol state (when fewer staff are on the units). A second
officer responded and confirmed they were on their way. At interview, the officer
said that she risk assessed in the moment that she would wait for a second officer
to unlock the cell as she did not know Ms Parkinson and had seen from her record
that she had a history of assault.
37. A healthcare support worker overheard the officer asking for assistance on the radio
and went to the cell to help. She looked through the cell door and could not see any
obvious signs of breathing from Ms Parkinson. She went to the healthcare unit
(connected to the Valentina Unit) to ask for urgent assistance.
38. The healthcare support worker arrived back at the cell with two nurses. The officer
opened the door and entered with the nurses. At 6.52pm, another officer arrived
and radioed a code blue (a medical emergency code used when a prisoner is
unconscious or having breathing difficulties that alerts staff in the control room to
call an ambulance).
39. The nurses found that Ms Parkinson was unresponsive and not breathing. They
started CPR and then Nurse A returned to the healthcare unit to get the emergency
bags and the defibrillator (shocks the heart to restore a normal heartbeat).
40. The nurses then attached the defibrillator which did not advise any shocks to be
delivered. They then inserted an airway device and gave Ms Parkinson oxygen.
41. Nurse A gave Ms Parkinson two injections of adrenaline. However, the dose and
route by which she gave the adrenaline was to treat anaphylaxis (injected into a
muscle at a low dose), not cardiac arrest (injected into a vein at a high dose).
42. At 7.01pm, the ambulance arrived at Styal. The control room initially sent the
ambulance to the Waite Wing where there was another code blue. Once staff
realised, they redirected the ambulance to the Valentina Unit.
43. At 7.09pm, the ambulance arrived at the Valentina Unit and paramedics took over
Ms Parkinson’s care. The paramedics continued CPR and gave Ms Parkinson more
adrenaline (using the correct dose and route). They attached their defibrillator which
showed pulseless electrical activity (PEA – a form of cardiac arrest where there is
no pulse, but the heart’s electrical activity is present). The paramedics continued
chest compressions and moved her to the ambulance. She was taken to hospital at
7.39pm.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
44. While in hospital, Ms Parkinson remained in a coma. She had a CT scan which
showed that she had a hypoxic brain injury (when the brain does not get enough
oxygen and the brain cells die).
45. Ms Parkinson did not regain consciousness and on 31 July, doctors confirmed that
she was brain stem dead. All treatment was stopped, and at 5.49pm, doctors
confirmed her death. Her family were present.
Contact with Ms Parkinson’s family
46. The Deputy Governor contacted Ms Parkinson’s parents on 29 July to tell them that
she was being taken to hospital. The next day, the prison appointed the duty
governor as the interim family liaison officer. The duty governor spoke to Ms
Parkinson’s family the same day to introduce herself, explain her role, and offer
support.
47. The prison offered to pay towards Ms Parkinson’s funeral, but the family declined.
Support for prisoners and staff
48. After Ms Parkinson’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support.
49. The Head of Healthcare attended Styal the next day, which was her non-working
day, to support the nursing staff who were involved in the emergency response.
Post-mortem report
50. The post-mortem report concluded that Ms Parkinson died following a
cardiorespiratory arrest but the cause of that was unascertained. There was no
evidence of natural disease and toxicology tests showed that Ms Parkinson had
taken only her prescribed medication. The pathologist also found no compelling
evidence suggestive of a traumatic head injury including of brain injury being
implicated in the cause of death. The pathologist concluded that the cause of death
was unascertained.
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Managing Ms Parkinson’s risk of suicide and self-harm
51. The cause of Ms Parkinson’s death is unclear. There is no evidence that she self-
harmed while she was at Styal and on the evidence available, it does not appear
that her death was self-inflicted. Nevertheless, we have considered the care she
received at Styal with regard to her history of self-harm.
52. Staff correctly started ACCT procedures for Ms Parkinson when she arrived at
Styal. They placed her on Valentina Unit for extra support and checked on her
hourly. The day after she arrived, Ms Parkinson had an ACCT case review and a
mental health assessment. We consider that she received appropriate support.
Clinical care
53. The clinical reviewer found that the clinical care Ms Parkinson received at Styal was
partially equivalent to that which she could have expected to receive in the
community. She found that Ms Parkinson received a thorough initial health screen
to assess her needs and received a prompt mental health assessment. However,
there were issues with the emergency response.
Emergency response
54. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
says that staff discover a prisoner who is unresponsive must call the appropriate
code (code blue for unconsciousness or code red for severe blood loss) without
delay. The code alerts healthcare staff to the nature of the emergency and tells the
control room to call an ambulance immediately.
55. There was a delay of approximately seven minutes between Ms Parkinson being
found unresponsive on her cell floor and the code blue being called. This meant that
initially the nurses who responded did not bring the correct equipment with them
(because the healthcare support worker simply asked for urgent assistance, which
did not make clear the nature of the emergency) and there was also a delay in
calling the ambulance. We cannot say whether this affected the outcome.
56. We have previously made several recommendations to Styal about ensuring staff
efficiently communicate the nature of a medical emergency using the appropriate
code to avoid delays.
57. In September 2021, the prison told us that all staff would be issued with Emergency
Response Information Cards (ERIC) which provide information on calling the
appropriate medical codes in an emergency. Monthly integrity tests were also to be
introduced, along with training delivered at morning briefings. However, this same
issue has arisen again. We recommend:
The Governor and Head of Healthcare should review how staff are trained on
the use of medical emergency codes and satisfy themselves that all staff are
aware of their responsibilities during medical emergencies.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Use of adrenaline
58. The clinical reviewer found that adrenaline was not administered correctly to Ms
Parkinson during the emergency response. She found that Nurse A administered a
lower dose of adrenaline used for a severe allergic reaction, not a cardiac arrest,
and that she gave the adrenaline by an injection into the muscle instead of into a
vein, which was not in line with the Resuscitation Council UK guidance.
59. The clinical reviewer also noted that Nurse A was not trained in advanced life
support. Resuscitation Council UK guidance says that adrenaline should only be
given by clinicians who have undergone advanced life support training.
60. We recommend:
The Head of Healthcare should ensure that staff understand how and when to
administer adrenaline in medical emergencies and that they have received the
appropriate training to do so.
Inquest
61. The inquest, held on 17 March 2025, reached a narrative verdict as follows:
Rebecca Parkinson died as a result of hypoxic brain injury, caused by cardiac
arrest. The cause of the cardiac arrest was hyponatraemia which was most likely
caused by drinking excess water. The amount of water or the timing of the ingestion
cannot be determined.
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE