Satish Kumar

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Independent investigation into
the death of Mr Satish Kumar,
a prisoner at HMP Oakwood,
on 15 May 2023
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
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
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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 Satish Kumar died in hospital of lung cancer on 15 May 2023, while a prisoner at
HMP Oakwood. He was 47 years old. We offer our condolences to Mr Kumar’s
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Kumar received at
Oakwood was of a good standard and equivalent to that which he could have
expected to receive in the community. However, she made a recommendation
about ensuring requests for clinical investigations, such as requests for chest X-
rays, are actioned promptly, which the Head of Healthcare will wish to address.
5. We found that there was a delay in removing Mr Kumar’s restraints when his
condition deteriorated in hospital. We do not make a recommendation but bring this
issue to the Director’s attention.
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The Investigation Process
6. HMPPS notified us of Mr Kumar’s death on 15 May 2023.
7. NHS England commissioned an independent clinical reviewer to review Mr Kumar’s
clinical care at HMP Oakwood.
8. The PPO investigator investigated the non-clinical issues relating to Mr Kumar’s
care.
9. The PPO family liaison officer wrote to Mr Kumar’s partner to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked about the quality of healthcare Mr Kumar received at Oakwood. This has
been addressed in this report and in the clinical review.
10. We shared our initial report with HMPPS. They found no factual inaccuracies.
11. We sent a copy of our initial report to Mr Kumar’s partner. She did not notify us of
any factual inaccuracies.
Previous deaths at HMP Oakwood
12. Mr Kumar was the twelfth prisoner to die at HMP Oakwood since May 2020. Nine of
the previous deaths were from natural causes and two were drug related.
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Key Events
13. On 9 March 2020, Mr Satish Kumar was remanded in custody at HMP Birmingham.
14. On 20 October 2021, Mr Kumar was sentenced to nine years imprisonment for
robbery. He was moved to HMP Oakwood on 29 October.
15. On 12 April 2022, Mr Kumar went to see a GP at Oakwood as he was experiencing
a persistent cough with haemoptysis (blood-streaked phlegm) and night sweats.
The GP requested a chest X-ray, blood test, and sputum (phlegm) test to screen for
tuberculosis. On 27 June, the sputum and blood test results were returned and
showed that Mr Kumar did not have tuberculosis.
16. On 11 July, a different GP saw Mr Kumar because his cough was getting worse.
She discovered that the chest X-ray requested in April had never been completed.
She then requested an urgent chest X-ray.
17. On 20 July, Mr Kumar had ‘crushing pain’ in his chest and was taken to hospital to
attend the emergency department. A chest X-ray was done, and Mr Kumar was
discharged back to Oakwood after brief treatment in hospital. On 27 July, a GP told
Mr Kumar that she had referred him for further tests under the cancer pathway
following his X-ray results. A CT scan was scheduled for 9 August, however Mr
Kumar declined to attend this appointment and it was rescheduled to a later date.
On 26 August, Mr Kumar had a CT scan of his chest and abdomen.
18. On 30 August, Mr Kumar attended the Lung Cancer Clinic where he was told by a
respiratory doctor that his CT scan results indicated he may have a tumour in his
lung, and that further tests would be needed to confirm this. Mr Kumar returned to
hospital on 2 September for an endo-bronchial ultrasound scan (EBUS - used to
diagnose various types of lung disorder including cancer).
19. On 6 September, Mr Kumar had a telephone consultation with a respiratory doctor
from New Cross Hospital. The doctor told him that his EBUS results showed a
tumour on his lung and that the location of the tumour meant it could not be
surgically removed.
20. On 15 September, a consultant oncologist (cancer specialist) reviewed Mr Kumar.
The consultant told Mr Kumar that his cancer was incurable due to its advanced
stage, but that it could be treated with chemotherapy to extend his life expectancy.
Mr Kumar began chemotherapy on 20 September and underwent five rounds of
chemotherapy over the following months.
21. On 9 November, prison staff started an application for Mr Kumar’s early release on
compassionate grounds, however the application was not completed as there was
no clear prognosis of life expectancy at that stage. Mr Kumar was still undergoing
chemotherapy and responding well.
22. After finishing his planned rounds of chemotherapy, Mr Kumar was offered
‘consolidative radiotherapy’ to his chest, which would kill any remaining cancer cells
left in the body. From 27 February 2023 onwards, Mr Kumar began attending
radiotherapy appointments at the Deanesly Radiation Oncology Centre.
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23. On 10 May, Mr Kumar began to experience shortness of breath and a rapid heart
rate. A GP prescribed antibiotics for a possible infection and staff kept him under
observation for the following days.
24. On 12 May at approximately 5.00pm, Mr Kumar had a telephone consultation with
an oncologist who told Mr Kumar that he might be experiencing ‘radiotherapy
pneumonitis’ (inflammation of the lung caused by radiotherapy). The doctor asked
Mr Kumar to attend the emergency department in hospital, however Mr Kumar
refused due to it being late in the day. He agreed to go first thing in the morning
instead.
25. On the morning of 13 May, Mr Kumar was taken to New Cross Hospital. Two
officers accompanied him and applied 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).
26. When he arrived at the hospital, Mr Kumar was admitted onto an acute medical
unit, where he continued to be restrained.
27. The next day, Mr Kumar’s condition deteriorated, and he was struggling to breathe.
At approximately 10.00pm, Mr Kumar’s heart rate became very rapid. A doctor
attended and assessed that Mr Kumar might require emergency resuscitation using
defibrillation (electric shock). The doctor asked the escort staff to remove Mr
Kumar’s restraints as they would interfere with emergency resuscitation. An
escorting officer contacted a manager by phone who authorised the removal of Mr
Kumar’s restraints due to his deteriorating condition. The prison’s duty manager
contacted Mr Kumar’s family and they went to the hospital.
28. Mr Kumar’s condition continued to deteriorate and he died in hospital at 2.36pm on
15 May.
Cause of death
29. The coroner accepted the cause of death provided by a hospital doctor and no post-
mortem examination was carried out. The doctor gave Mr Kumar’s cause of death
as lung cancer.
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Non-Clinical Findings
Restraints, security and escorts
30. 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.
31. The investigator reviewed the escort risk assessment completed on 13 May, when
Mr Kumar was taken to hospital for the final time. The assessment was completed
thoroughly and we consider that the decision to restrain Mr Kumar with an escort
chain was reasonable given his condition at the time. However, the next day, Mr
Kumar’s condition deteriorated. The prison bed watch records show that from
4.35pm, Mr Kumar was struggling to breathe. Over the next five and a half hours,
he remained on the escort chain.
32. The escort chain was not removed until around 10.00pm that night, at the request of
a doctor. We consider that prison staff should have reassessed Mr Kumar’s risk
earlier, given his deteriorating health. Mr Kumar had been assessed as posing a
low risk of escape and medium risk to the public at the time of the escort risk
assessment, and his progressive illness would have reduced this risk even further,
calling into question the need for restraints. We consider that the escorting officers
should have alerted a prison manager that Mr Kumar’s condition had deteriorated in
hospital, rather than waiting to be prompted by medical staff, which delayed the
removal of Mr Kumar’s restraints. We bring this issue to the Director’s attention.
Adrian Usher
Prisons and Probation Ombudsman February 2024
Inquest
The inquest, held on 1 July 2025, concluded that Mr Kumar died from natural causes.
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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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