Roy Anderson

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Independent investigation into
the death of Mr Roy Anderson,
a prisoner at HMP Ranby,
on 10 March 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, 2025
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 Roy Anderson died in hospital of oesophageal cancer on 10 March 2025, while a
prisoner at HMP Ranby. He was 77 years old. We offer our condolences to his
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Anderson received at
Ranby was of a good standard and was equivalent to that which he could have
expected to receive in the community.
5. The use of restraints on Mr Anderson when he was taken to hospital on 3 February
was inappropriate. We were told that restraints were used because the transfer took
place out of hours when staffing levels were much lower, but this is not a relevant
consideration. No one considered whether it was proportionate to use restraints on
a very unwell 77-year-old man.
6. Despite Mr Anderson being told on 7 February that he had only a few weeks left to
live, prison staff did not start an application for Early Release on Compassionate
Grounds (ERCG) for him.
Recommendation
• The Governor should:
• Review local policy on applying restraints to prisoners taken to hospital out of
hours to ensure it is compliant with the Graham Judgment.
• Ensure there is a robust quality assurance process in place to check that escort
risk assessments properly consider the appropriateness of restraints based on
the prisoner’s age, health and mobility.
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The Investigation Process
7. HMPPS notified us of Mr Anderson’s death on 10 March 2025.
8. NHS England commissioned an independent clinical reviewer to review Mr
Anderson’s clinical care at HMP Ranby.
9. The PPO investigator investigated the non-clinical issues relating to Mr Anderson’s
care.
10. The prison was unable to trace a next of kin for Mr Anderson, so the Ombudsman’s
office did not contact anyone regarding Mr Anderson’s death.
11. We shared our initial report with HMPPS and the prison’s healthcare provider,
Nottinghamshire Healthcare NHS Foundation Trust. HMPPS did not find any actual
inaccuracies and their action plan is annexed to this report.
Previous deaths at HMP Ranby
12. Mr Anderson was the eighth prisoner to die at HMP Ranby since March 2022. Of
the previous deaths, two were from natural causes, three were self-inflicted, and
two were drug related. There are no similarities between the findings in our
investigation into Mr Anderson’s death and the findings from our investigations into
the previous deaths.
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Key Events
13. On 1 November 1967, Mr Roy Anderson was sentenced to life in prison for murder.
On 25 October 2022, he was moved to HMP Ranby.
14. On 10 January 2025, Mr Anderson told a wing officer that he felt unwell and asked
to see healthcare staff. The officer phoned the healthcare unit and asked if they
could see him as he was short of breath, had a reduced appetite, and had a lump
on his stomach.
15. Later that day, a nurse saw Mr Anderson in the healthcare unit. He said he had
been feeling short of breath during exercise for the past week. The nurse took his
clinical observations, which were normal, and recorded that she saw no signs of
breathing problems at the time. She noted that a GP would review his case on
Tuesday (14 January) and told him to let officers know if he felt worse over the
weekend. (Mr Anderson was not seen by a GP on 14 January.)
16. On 23 January, wing officers again contacted healthcare staff because Mr
Anderson looked unwell, was pale, and was not eating. A nurse visited his cell, took
his 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.) Mr Anderson showed the nurse a lump on his
chest, which she thought was likely a small hernia (a bulge caused by tissue
pushing through a weak spot in the stomach area). She told him he had an
appointment booked with the GP and to contact healthcare again if he was feeling
unwell in the meantime.
17. On 30 January, a wing officer phoned healthcare staff again because Mr Anderson
still felt unwell, had shortness of breath and was “looking yellowish in colour”. A
nurse took Mr Anderson’s clinical observations, which were normal. She told him
that he had a GP appointment booked on 3 February and to contact healthcare staff
if his symptoms worsened.
18. On 31 January, a wing officer phoned the healthcare unit to ask if they had a
wheelchair so they could bring Mr Anderson there as he was not well. The nurse
told the officer that he had a GP appointment booked for the following Monday but if
they brought him to the healthcare unit, they would see him in the clinic.
19. Later that day, two nurses saw Mr Anderson in the clinic. He said he felt generally
unwell and had been feeling dizzy, had trouble swallowing, and was short of breath.
They took his clinical observations and calculated a NEWS2 score of 2 (low risk).
Mr Anderson had low blood pressure, so the nurses took a blood sample to run
urgent tests.
20. On 3 February, Mr Anderson’s blood tests results came back as abnormal (they
indicated poor liver function) and the laboratory advised he go to hospital
immediately. At around 8.00pm, prison staff took Mr Anderson to A&E. Mr Anderson
was double cuffed for the journey (the prisoner’s hands are handcuffed together
and a second pair of handcuffs is used to attach the prisoner’s wrist to a prison
officer’s wrist).
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21. On 4 February, at around 2.35am, Mr Anderson was moved to a hospital ward. The
escorting officer switched him to an escort chain (a long cable with a cuff at one end
attached to the prisoner and at the other to a prison officer).
22. On 5 February, Mr Anderson had an endoscopy (a test using a camera to look
inside the body), which showed he had cancer in his oesophagus (the tube that
carries food from the mouth to the stomach).
23. On 7 February, a hospital doctor told Mr Anderson that he had cancer, and it had
spread to his liver and probably to other parts of his body. He was told he likely had
only a few weeks to live.
24. On 8 February, at 10.00am, Mr Anderson’s escort chain was removed by bed watch
officers, after approval from the authorising manager.
25. On 14 February, a nurse at Ranby phoned the hospital to ask how Mr Anderson
was doing. She wrote in his medical notes that he was now a ‘fast-track patient’
because of his diagnosis but was not eligible for Early Release on Compassionate
Grounds (ERCG). (This was based on incorrect information from Mr Anderson’s
community offender manager.)
26. On 9 March, Mr Anderson deteriorated. The doctors agreed that if he did not
improve, they would remove all active treatment.
27. On 10 March, at around 8.40am, Mr Anderson died in hospital.
Cause of death
28. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave the cause of death as
metastatic oesophageal cancer (cancer which has spread to other parts of the
body).
29. At the inquest, held on 25 September 2025, the Coroner concluded that Mr
Anderson died from natural causes.
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Findings
Clinical findings
30. The clinical reviewer concluded that the care Mr Anderson received at Ranby was
of a good standard and was equivalent to that which he could have expected to
receive in the community.
31. The clinical reviewer made four recommendations not directly related to Mr
Anderson’s death which the Head of Healthcare will wish to address.
Use of restraints
32. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. It said that medical opinion about the prisoner’s ability to escape
must be considered as part of the assessment process and kept under review as
circumstances change.
33. The investigator asked the Head of Security at Ranby about the decision to double
cuff Mr Anderson when he was taken to hospital on 3 February. He said it was
typical for prisoners going to hospital out of hours to be double cuffed due to
reduced staffing levels. He said as Mr Anderson left the prison at around 8.00pm,
was mobile and was not going to hospital as an emergency, he considered the
cuffing level was reasonable.
34. We disagree. Mr Anderson was 77 years old, was unwell and had required a
wheelchair to get to the healthcare unit on 31 January. It is difficult to imagine how
he could possibly have escaped from two escorting prison officers. We are
concerned at the apparent blanket approach to double cuffing prisoners who are
taken to hospital out of hours. This is not in line with policy which says that a
prisoner’s age, health, and mobility must be taken into account when assessing the
appropriateness of restraints. We recommend:
The Governor should:
• Review local policy on applying restraints to prisoners taken to hospital
out of hours to ensure it is compliant with the Graham Judgment.
• Ensure there is a robust quality assurance process in place to check that
escort risk assessments properly consider the appropriateness of
restraints based on the prisoner’s age, health and mobility.
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Early release on compassionate grounds
35. 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.
36. The ERCG Policy Framework says applications may be considered for prisoners
suffering from a terminal illness who are in the last few months of life.
37. We found that an application for ERCG was not started for Mr Anderson, despite
him having a terminal diagnosis and a short prognosis in February.
38. The investigator spoke with the current interim Head of Offender Management Unit
(OMU) at Ranby. While she was in a different role at the time of Mr Anderson’s
death, she told the investigator that an application for ERCG was not formally
started for Mr Anderson as at a multidisciplinary team (MDT) meeting, Mr
Anderson’s community offender manager said that he was not eligible. This was not
further looked into by staff at the time.
39. The interim Head of OMU said she would set up an internal process to ensure that
anyone who is given a terminal diagnosis will automatically be assessed for ERCG,
which will be managed by OMU hub managers. She will also create and share
guidance across all relevant departments to prevent any future delays. In light of
this, we make no recommendation.
Adrian Usher
Prisons and Probation Ombudsman November 2025
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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