Salim Sakaria

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Independent investigation into
the death of Mr Salim Sakaria,
a prisoner at HMP Risley, on 14
December 2018
A report by the Prisons and Probation Ombudsman
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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 Salim Sakaria died in hospital on 14 December 2018 following heart surgery, while a
prisoner at HMP Risley. He was 48 years old. I offer my condolences to Mr Sakaria’s
family and friends.
Mr Sakaria had complex health needs. I am satisfied that he received a standard of
care at Risley equivalent to that he could have expected to receive in the community.
I am concerned, however, that Risley was unable to provide us with an escort risk
assessment to justify the need for Mr Sakaria to be restrained for five weeks after he
was taken to hospital for the final time on 24 October.
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 July 2019
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Contents
Summary ........................................................................................................................ 1
The Investigation Process ............................................................................................... 2
Background Information .................................................................................................. 3
Key Events ...................................................................................................................... 4
Findings .......................................................................................................................... 9
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Summary
Events
1. On 9 October 2014, Mr Salim Sakaria was sentenced to 15 years in prison for fraud
and assault and sent to HMP Manchester. On 11 January 2017, he was moved to
HMP Risley.
2. When Mr Sakaria arrived at Risley, a nurse noted that he had been treated
successfully for lymphoma (cancer of the lymphatic system), which was in
remission. She also noted that he had previously had a heart attack and undergone
gastric band surgery to treat his obesity.
3. In February 2017, Mr Sakaria’s lymphoma returned. It was treated successfully and
by May 2018, it was in remission again. While receiving cancer treatment in
hospital, Mr Sakaria had another heart attack.
4. Between May and October 2018, Mr Sakaria was taken to hospital on four
occasions with chest pains. Tests showed that his arteries had narrowed due to a
build-up of fatty deposits.
5. On 24 October, he was admitted to hospital and on 23 November, he had triple
heart bypass surgery and two valves replaced. However, his condition deteriorated
after the operation and 14 December, he died from multiple organ failure.
Findings
6. We are satisfied that the care Mr Sakaria received at HMP Risley was equivalent to
that he could have expected to receive in the community.
7. The prison was unable to provide the escort risk assessment for Mr Sakaria’s final
hospital admission on 24 October, but other documents show that he was
restrained with an escort chain that remained in place for five weeks until it was
removed on 29 November. Given Mr Sakaria’s very poor state of health at the time,
we consider that restraints would only have been justifiable if he was assessed as a
significant escape risk. In the absence of the risk assessment paperwork, we do
not know if this was the case.
Recommendations
• The Governor should ensure that escort risk assessments are completed for every
hospital transfer and the documentation retained.
• The Governor should ensure that:
• bedwatch staff understand the need to treat prisoners’ visitors sensitively;
and
• escort risk assessments cover the use of languages other than English
where this is relevant to the individual’s risk.
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The Investigation Process
8. The investigator issued notices to staff and prisoners at HMP Risley informing them
of the investigation and asking anyone with relevant information to contact her. No
one responded.
9. The investigator obtained copies of relevant extracts from Mr Sakaria’s prison and
medical records.
10. NHS England commissioned a clinical reviewer to review Mr Sakaria’s clinical care
at the prison.
11. We informed HM Coroner for Cheshire, Halton and Warrington of the investigation.
The coroner gave us the cause of death. We have sent the coroner a copy of this
report.
12. Mr Sakaria’s family’s solicitors contacted the investigator with matters they wanted
the investigation to consider. These included restraints, visiting rights, Mr Sakaria’s
location within the prison and the diet provided. Other matters were also raised
which are outside the remit of this investigation and have been addressed in
separate correspondence.
13. Mr Sakaria’s family received a copy of the initial report. They did not raise any
further issues which impact upon this report or have not already been addressed.
14. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly.
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Background Information
HMP Risley
15. HMP Risley is a medium security training prison, which holds over 1,000 convicted
men. Bridgewater Community Healthcare NHS Trust provides healthcare services
in the prison. There is 24-hour healthcare cover. There is a doctor in the prison
during the day and at night there are nurses on duty. Prisoners who need inpatient
treatment are referred to other prisons (usually HMP Preston) or to hospital.
Lifeline provides substance misuse services.
HM Inspectorate of Prisons
16. The most recent inspection of HMP Risley was in June 2016. Inspectors reported
that health services were reasonable but governance and oversight were
underdeveloped. The range of primary care services was adequate, although
prisoners waited too long to see a GP. Inspectors noted that there were not enough
custody staff with basic life support skills and there were no automated external
defibrillators on the wings.
Independent Monitoring Board
17. 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 31 March 2018, the IMB
reported that staffing levels had improved which had enabled attendance at
healthcare appointments. The Board noted that the healthcare centre was clean
and well-equipped, and the latest infection control audit was 96% (green).
Previous deaths at HMP Risley
18. Mr Sakaria was the seventh prisoner to die at Risley since December 2016. One
death was from natural causes, three were drug related, one was self-inflicted and
one awaits classification. There are no similarities with Mr Sakaria’s case.
19. There have been three deaths at Risley since Mr Sakaria’s. One was from natural
causes, one was a homicide and one awaits classification.
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Key Events
20. On 10 October 2014, Mr Sakaria was sentenced to 15 years in prison for fraud and
assault. He was sent to HMP Manchester.
21. On 11 January 2017, Mr Sakaria was moved to HMP Risley. He had previously
been treated for lymphoma (cancer of the lymphatic system) which was in
remission. He had previously had a heart attack and undergone gastric band
surgery to treat his obesity. He was under the care of a haematologist and a
cardiologist.
22. In February 2017, Mr Sakaria’s cancer returned. He underwent chemotherapy
between April and August and then on 15 November, was admitted to hospital for
an intensive course of treatment. He remained in hospital until 22 May 2018. He
had a heart attack during that admission and was also treated for sepsis. His
cancer was in remission although he was told that it would return and, when that
happened, only palliative treatment would be offered.
23. A healthcare manager, an occupational therapist, and an unnamed social worker
visited Mr Sakaria in hospital before his discharge back to Risley. The healthcare
manager recorded that he was self-caring in terms of washing and dressing but
should be put in a disability cell at the prison. She noted that a special bed and
shower chair were ready, and a telecare pendant and box would be installed. She
considered Mr Sakaria would need a wheelchair.
24. Mr Sakaria was moved to a disability cell at Risley which incorporated all the
healthcare manager recommendations and he had his own kettle and television.
The prison told us that the hospital did not recommend a special diet, but we note
from other records that Mr Sakaria was frequently provided with salads as he
requested.
25. A nurse assessed Mr Sakaria on his return to Risley on 22 May 2018. She
recorded that Mr Sakaria was scheduled to have an echocardiogram (a scan that
gives a detailed view of the structures of the heart), lung function tests and a
cardiology review in three months’ time. Weekly blood rests were also required. A
prison GP saw Mr Sakaria the next day. He prescribed Mr Sakaria’s medication.
26. On 26 May 2018, Mr Sakaria was admitted to hospital with chest pain and
discharged the next day with a diagnosis of angina.
27. On 20 July 2018, the Public Protection Casework Section of HM Prison and
Probation Service (HMPPS) refused Mr Sakaria’s application for release on
compassionate grounds. Mr Sakaria did not have a prognosis of less than three
months and they did not accept that Mr Sakaria’s health was not being managed
properly in custody. They cited numerous examples of good care, diet and adapted
living conditions.
28. On 22 August, Mr Sakaria was taken to A&E with chest pain and was admitted until
26 August. Specialists considered he needed a perfusion scan (which shows how
well blood is flowing through the heart muscle) and an urgent assessment for a
coronary artery bypass graft.
29. On 16 September, Mr Sakaria was taken to A&E after telling a nurse that he had
chest pain. He returned to prison that evening. He did not see a nurse when he got
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back, and the hospital had not provided a discharge summary. The prison
eventually received one (it is not clear when) which said a scan showed that Mr
Sakaria’s heart was enlarged with some evidence of inflammation. The hospital
recommended that he be given antibiotics and a further X-ray in four weeks’ time.
The Head of Healthcare has confirmed that the antibiotics were provided.
30. On 4t October, Mr Sakaria underwent a Low Dobutamine Stress test (which
measures how the heart copes with exercise without the need for actual exercise -
dobutamine mimics it).
31. On 8 October, a prison GP saw Mr Sakaria. Mr Sakaria complained he had a
bubbly feeling in his chest. The doctor diagnosed a lower respiratory tract infection
and prescribed antibiotics.
32. On 11 October, Mr Sakaria was sent to hospital after complaining of chest pain. He
stayed overnight but returned to the prison the next day. The hospital thought he
had suffered an angina attack.
33. On 19 October, a nurse recorded that she received a call from someone at a
hospital who said that test results indicated that Mr Sakaria required urgent
admission to hospital. The nurse questioned what the test results were and
whether an emergency ambulance was required but the caller did not know. The
caller could not tell the nurse if Mr Sakaria needed monitoring in case of a cardiac
arrest.
34. The nurse spoke to a nurse at the hospital who said that Mr Sakaria’s arteries were
severely narrowed (due to a build-up of fatty deposits) but that the hospital did not
have any beds. Conversations between the hospital, including Mr Sakaria’s
specialist, and the prison continued and eventually the hospital said the admission
could wait. Mr Sakaria was admitted on 24 October. (The prison has told us that
they subsequently received a letter dated 26 October 2018 from a doctor requesting
Mr Sakaria’s urgent admission ‘for assessment and discussion with the Cardio
Thoracic Team for consideration of a Bypass and Aortic Valve Replacement
Surgery’.)
35. The prison has not been able to supply a risk assessment for Mr Sakaria’s
admission to hospital on 24 October. The Person Escort Record shows that when
he first went to hospital he was restrained by an escort chain (a long chain with a
handcuff at each end, one of which is attached to the prisoner and the other to an
officer). The bedwatch records show that from 29 November, he was not restrained.
36. The records indicate that as Mr Sakaria was considered to be stable, he was initially
allowed visits in hospital in line with general prison protocol of five a month. After
his operation these were increased to every day.
37. Specialists assessed that Mr Sakaria required bypass surgery (at a hospital) and
this was scheduled for 23 November. On 24 November, a nurse from prison
healthcare phoned the hospital for an update and was told that Mr Sakaria had had
triple heart bypass surgery and two valves replaced. Prison healthcare staff made
regular calls to the hospital from this point for progress reports.
38. On 29 November, Mr Sakaria was treated for pericardial effusion (fluid around the
heart) and was on a ventilator. On 6 December, a nurse was informed he had
developed sepsis, his liver was failing, and he was on dialysis.
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39. On 10 December, a prison GP contacted the hospital and was told Mr Sakaria’s
condition was improving, he was being weaned off ventilation and was not sedated.
The prison GP recorded that he was told Mr Sakaria was not deteriorating further
and was not considered palliative.
40. On 13 December, a nurse contacted the hospital and was told Mr Sakaria was
awake and alert but still on ventilation. They planned to perform a tracheostomy (in
which an opening is created in the neck to aid breathing) later that day.
41. On 14 December, a nurse was told by hospital staff that Mr Sakaria had suddenly
deteriorated and was in a critical condition. It was thought highly likely that he
would die. A prison GP, probation officer and the deputy governor completed Early
Release on Compassionate Grounds paperwork, but Mr Sakaria died later that day
at 6.25pm.
1. Contact with Mr Sakaria’s family
42. On 14 December at approximately 1.30pm, the prison appointed a prison chaplain,
as the family liaison officer (FLO). He went to the hospital and met Mr Sakaria’s
family to explain his role and the assistance the prison could give when Mr Sakaria
died. The Governor took over the FLO role after this point.
43. Mr Sakaria’s funeral was on 16 December. No representatives from the prison
attended as it was arranged by the family quickly and the prison were not informed.
Governor Williams told us that someone from the prison told the family that they
would make a contribution towards the funeral costs but, at the time of writing, she
had not received an invoice for the costs from Mr Sakaria’s family.
Support for prisoners and staff
44. After Mr Sakaria’s death, one of the escorting officers went straight home and the
other stayed on duty at the hospital. The prison has confirmed that both officers
were offered support.
45. The prison posted notices informing other prisoners of Mr Sakaria’s 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 Sakaria’s death.
2. Cause of death
46. A post-mortem examination was not carried out because the coroner accepted the
cause of death provided by the hospital. The hospital recorded that Mr Sakaria died
from multiple organ failure, which had been caused by aortic valve and coronary
disease. Mr Sakaria’s compromised clinical background (previous chemotherapy
for non-Hodgkin lymphoma, obesity treated with gastric band, and hypertension)
was a contributing factor.
Events after Mr Sakaria’s death
47. After Mr Sakaria’s death, his brother complained to the prison about the behaviour
of prison staff when he visited Mr Sakaria in hospital on the evening of 28
November 2018. Mr Sakaria’s brother said:
• he was refused entry as he was told the visit had not been booked in the
proper way;
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• after some lengthy discussion, the visit was eventually allowed but was soon
terminated as he was praying with his brother in a language other than
English and was told by prison staff this was not allowed;
• as he left his brother’s room, a Custodial Manager (CM) (who was one of two
prison staff on duty that evening) called him a “Paki”.
48. The complaint was investigated by the prison’s Equalities Manager, who provided a
report to the Deputy Governor on 26 April 2019, saying:
• He had spoken to prison and hospital staff;
• The hospital’s ward log recorded that there had been an incident on 28
November, when Mr Sakaria’s brother had initially been refused entry to his
private room and later emerged shouting that he had been called a “Paki”
and was escorted out by hospital staff;
• An un-named prison officer subsequently wrote an entry in the log about
‘manipulation techniques’ being used by Mr Sakaria’s family;
• The only people in Mr Sakaria’s room at the time were his brother and other
family members, and two prison officers: a CM and an officer;
• The CM was on sick leave but had denied using racist language when
questioned shortly after the incident;
• The officer said that Mr Sakaria’s family had been speaking in what he
thought was Urdu and the CM had politely asked them not to, but Mr
Sakaria’s brother had continued to do so, had displayed “a poor attitude” and
had said he could do what he liked; CM Grieve then asked him to leave;
• The officer denied that he or CM had used racist language.
49. The prison’s Equalities Manager concluded that he had found no discrimination on
the basis of race. However, he said he had reminded the officer of the need for an
understanding of other cultures and faiths and for empathy when dealing with the
family of a seriously ill prisoner. He had also reminded him of the need to seek
clarification from a senior manager at the prison when doing a bed watch if he was
concerned about family members speaking in a language other than English. He
would also remind the CM when he returned to work.
50. He noted that Prison Service Instruction (PSI) 33/2015 External Escorts – External
Prisoner Movements – did not provide guidance on this point and that it would need
to be looked at at local level with an update on the Local Security Strategy (LSS) if
necessary.
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Findings
Clinical care
51. The clinical reviewer found that the care Mr Sakaria received at HMP Risley was of
a high standard and at least equivalent to that he could have expected to receive in
the community. She considered staff responded appropriately to his acute health
needs and that when his health deteriorated he was referred to secondary care.
Healthcare staff maintained communication with hospital staff during admissions to
ensure they were prepared when he was discharged.
52. Mr Sakaria was assessed by a social worker and an occupational therapist and
subsequently placed in a disability cell with equipment to aid his everyday living.
Care plans were in place to cover social care.
Restraints, security and escorts
53. 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.
54. 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. The judgment indicated 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.
55. On 24 October, Mr Sakaria was taken to hospital for heart surgery. The prison has
not been able to supply the escort risk assessment which should have informed the
restraint and escort decision. They have supplied a copy of the Person Escort
Record and this shows that Mr Sakaria was restrained by an escort chain.
Incomplete bedwatch records show that restraints were removed on 29 November
when Mr Sakaria was on a ventilator.
56. We are concerned that the prison was unable to provide risk assessment
documentation, raising the question of whether an assessment was done at all.
57. In the absence of a risk assessment, it is difficult to say whether restraints were
justified at any point. Mr Sakaria was located in a disability cell and was a
wheelchair user at the time of his admission to hospital and this would normally
suggest that his risk to others and risk of escape were significantly reduced by his
poor health. He was also a Category C prisoner.
58. However, Mr Sakaria was the subject of a Proceeds of Crime Act confiscation order
requiring him to pay over £2.3m or serve a lengthy additional prison sentence, and
it appears that this was still outstanding at the time of his death. This suggests that
he had the financial means to organise an escape. In these circumstances we do
not consider that the use of restraints was unreasonable before the deterioration in
his condition.
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59. We make the following recommendation:
The Governor should ensure that escort risk assessments are completed for
every hospital transfer and the documentation retained.
Allegation of racism
60. We are concerned that the prison does not have a contemporary record of the
incident that took place with Mr Sakaria’s brother on 28 November 2018. This
should have been recorded in the bedwatch records and the bedwatch records
should have been retained.
61. We are satisfied that the prison’s Equalities Manager conducted a thorough
investigation into the complaint of racism. This is a case of one person’s word
against another’s and we cannot reach a conclusion about what happened.
62. We recognise that the family of a seriously ill or dying prisoner may prefer to speak
to him in his first language (if that is not English) for reasons of comfort or privacy,
and that some family members may have no choice because they do not speak
English. We do not consider that this should be a problem unless there is a genuine
risk of escape. If there is such a risk, it should be reflected in the escort risk
assessment and escort officers should be briefed accordingly. We recommend:
The Governor should ensure that:
• bedwatch staff understand the need to treat prisoners’ visitors
sensitively; and
• escort risk assessments cover the use of language other than English
where this is relevant to the individual’s risk.
Inquest
63. The inquest, heard on 26 April 2024, gave a narrative conclusion that Mr Sakaria
died of complications of necessary surgery, chemotherapy to treat lymphoma, heart
failure, severe aortic stenosis and heart disease.
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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