Steven Haldane

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Independent investigation into
the death of Mr Steven Haldane,
a prisoner at HMP Stafford,
on 29 August 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
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© Crown copyright, 2025
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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 Steven Haldane died in the reception area of HMP Stafford on 29 August 2022, while
waiting for a prison van to take him to hospital. His cause of death was toxic megacolon
(extreme inflammation of the colon) caused by chronic constipation. He was 55 years old. I
offer my condolences to Mr Haldane’s family and friends.
The clinical reviewer found that the care Mr Haldane received up to 29 August was
equivalent to that which he could have expected to receive in the community. However,
she was concerned about the care Mr Haldane received on 29 August, after he told staff
he felt unwell and had been unable to defecate for a month. In particular, the nurse who
went to see Mr Haldane on the morning of 29 August failed to record his clinical
observations in his medical record and failed to use the NEWS2 tool (used to assess
clinical deterioration). Inconsistent use of NEWS2 has been a repeated failure at Stafford
and is a matter that the Head of Healthcare should address without delay.
I am also concerned that there was a delay in staff starting CPR when Mr Haldane
became unresponsive in reception on 29 August. CPR was not started until nurses arrived
around three minutes later.
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 May 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 9 April 2020, Mr Steven Haldane was recalled to prison custody after breaching
his licence conditions. On 25 March 2021, he was moved to HMP Stafford.
2. On the morning of 29 August 2022, Mr Haldane’s cellmate rang his emergency cell
bell as Mr Haldane felt unwell and had been trying unsuccessfully to defecate
throughout the night. An officer radioed for a nurse, who noted that Mr Haldane’s
stomach was distended, though his clinical observations were normal. The nurse
gave Mr Haldane a laxative and arranged to review him later that day.
3. The nurse went back to see Mr Haldane in the early afternoon and he told her that
he had vomited black vomit that morning. The nurse found that Mr Haldane was
breathless and his abdomen was more taut than earlier. She asked officers to
arrange his transfer to hospital, though she did not consider that it was an
emergency.
4. Mr Haldane was taken by wheelchair to reception at around 3.10pm. At 3.15pm,
staff noticed that he had slumped forward in his wheelchair and they struggled to
find a pulse. They radioed a medical emergency code. They said they were about to
move Mr Haldane from his wheelchair and start CPR when nurses arrived. Nurses
arrived at 3.18pm and realised that Mr Haldane was not breathing. Staff then
moved Mr Haldane to the floor and began CPR.
5. Ambulance paramedics arrived at 3.25pm and took over Mr Haldane’s care. At
3.49pm, the paramedics pronounced that Mr Haldane had died.
6. A post-mortem examination found that Mr Haldane died from toxic megacolon
(extreme inflammation of the colon) caused by chronic constipation.
Findings
7. The clinical reviewer concluded that the care Mr Haldane received at Stafford up to
29 August was equivalent to that which he could have expected to receive in the
community.
8. However, the clinical reviewer was concerned about the care he received on 29
August. She was concerned that after the nurse checked Mr Haldane at 9.30am,
she failed to note his clinical observations in his medical record. She was also
concerned that the nurse did not use NEWS2 (National Early Warning Score - a tool
used to assess clinical deterioration).
9. There was a delay in staff starting CPR when Mr Haldane became unresponsive in
reception. We consider that staff should have started CPR as soon as the medical
emergency code was called. Instead, there was a three minute delay before nurses
arrived and started CPR.
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Recommendations
• The Head of Healthcare should ensure that when staff take clinical
observations, they:
• record the readings in the prisoner’s medical record; and
• calculate and record the NEWS2 score and know when to escalate care
as a result.
• The Governor should ensure that staff start CPR without delay when a
prisoner has no pulse and stops breathing.
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The Investigation Process
10. The investigator issued notices to staff and prisoners at HMP Stafford informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Haldane’s prison and
medical records.
12. The investigator interviewed six members of staff and two prisoners from HMP
Stafford. All interviews were conducted by telephone.
13. NHS England commissioned a clinical reviewer to review Mr Haldane’s clinical care
at the prison. The investigator and clinical reviewer conducted joint interviews with
the clinical staff and with a custodial manager.
14. We informed HM Coroner for Staffordshire South of the investigation. The Coroner
gave us the results of the post-mortem examination. We have sent the Coroner a
copy of this report.
15. Mr Haldane had no identified next of kin so there was no family involvement in this
investigation.
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Background Information
HMP Stafford
16. HMP Stafford is a medium security prison in Staffordshire for adult male sex
offenders. It holds around 750 prisoners across seven wings. Care UK provides
healthcare services. Nurses are on duty daily between 7.30am and 5.30pm.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Stafford was in January 2020. Inspectors noted
that nearly half of the prisoner population at Stafford was over 50 years old.
Inspectors found that an up-to-date health needs analysis informed service delivery
although there was an insufficiently sharp focus on certain important patient
outcomes. Inspectors found that there was a positive relationship between prison
staff and local health partners. Inspectors noted that the clinical records they
reviewed were professional and that arrangements to provide a rapid response to
medical emergencies were sound.
Independent Monitoring Board
18. 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
that in the last year they had received very few complaints about staff/prisoner
relationships. The IMB noted that in the main, the healthcare provision at Stafford
often received praise from prisoners and the care was equal to what could be
expected in the community. However, the IMB was critical of medicines
management which was not sufficiently focused on whether the patient had
received the right medication at the right time and in the right dose.
Previous deaths at HMP Stafford
19. Mr Haldane was the 16th prisoner to die at Stafford since August 2020. Of these, 14
deaths were from natural causes and one was self-inflicted. We have made
recommendations in three of these cases about the failure to use the NEWS2
assessment tool, most recently in February 2023 (for a death that occurred in June
2022). In response to earlier recommendations, the healthcare provider said that
refresher training on NEWS2 would be delivered in early 2021.
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Key Events
20. In April 2015, Mr Steven Haldane was sentenced to nine years in prison for sex
offences.
21. Mr Haldane was released from prison on 17 December 2019, but on 9 April 2020 he
was recalled for breaching his licence conditions.
22. On 25 March 2021, Mr Haldane was moved to HMP Stafford.
23. In July 2022, Mr Haldane asked for a meeting with his former cellmate who had
moved to a different wing. It appears that Mr Haldane wanted to pursue a
relationship with him. On 8 July, Mr Haldane was told that the prison would not
arrange a meeting.
24. On 12 July, Mr Haldane said that he had started a hunger strike and would continue
until a meeting was arranged between him and his former cellmate. Stafford began
plans to start Prison Service suicide and self-harm monitoring (known as ACCT) if
Mr Haldane continued with his hunger strike after 72 hours.
25. On 15 July, Mr Haldane collected his afternoon meal. Staff noted that he was in a
good mood and chatted with peers and staff.
26. On 27 August, Mr Haldane’s key worker met with him. Mr Haldane said that he was
okay, that he was eating his meals, that he had no issues on the wing and that
there was nothing that he wanted to discuss.
27. The investigator spoke to Mr Haldane’s cellmate. He said that after Mr Haldane
threatened a hunger strike, he then went through a period of around two weeks in
August when he would collect his meals but would then dispose of them by flushing
them down the toilet. However, around a week before his death, Mr Haldane began
eating again, which caused him indigestion.
Events of 29 August
28. On the morning of 29 August, Mr Haldane’s cellmate rang the emergency cell bell
as he was concerned about Mr Haldane who was not feeling well and who had tried
without success to defecate throughout the night. An officer responded to the cell
bell and then radioed for a nurse.
29. A nurse saw Mr Haldane at 9.30am. Mr Haldane said that he had not been able to
defecate properly for around a month and that he had vomited the previous night.
The nurse noted that Mr Haldane’s stomach was distended. The nurse told the
investigator that she took Mr Haldane’s clinical observations, which were all within
the normal range. She said that she noted his observations on a piece of paper but
acknowledged that she failed to enter these in his medical record. The nurse gave
Mr Haldane a laxative and told him that she would review him later in the day. She
told him to ask to see healthcare staff if he began to feel worse in the interim.
30. The nurse went back to see Mr Haldane between 1.30pm and 2.00pm. Mr Haldane
said that he had vomited that morning and the vomit was black. She noted that Mr
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Haldane had still not defecated, that his abdomen was very taut and he was also
breathless. The nurse decided that Mr Haldane needed to be sent to hospital for an
assessment and she arranged for him to go that afternoon by prison van or taxi,
which she thought at the time was appropriate. She said that if she had been very
concerned, she would have called an emergency ambulance, although she also
said that transfer by prison van or taxi was often quicker than transfer by
ambulance.
31. At just after 3.00pm, an officer and a prisoner, who worked as a career, went to
collect Mr Haldane from his cell. His cell was one floor above reception and was
close to the stairs.
32. The prisoner carer told the investigator that Mr Haldane was able to walk down the
stairs without assistance and was able to talk as they went. When they reached the
bottom of the stairs, Mr Haldane got into a wheelchair and the prisoner carer
pushed him to reception.
33. The Orderly Officer arranged to send Mr Haldane to hospital in a prison van. After
identifying officers to accompany Mr Haldane to hospital, the Orderly Officer went to
reception. The Orderly Officer said that Mr Haldane did not look well when he
arrived, but he was conscious, was breathing, was sitting upright in the wheelchair
and was looking around.
34. A custodial manager (the CM) was also in reception. He told the investigator that Mr
Haldane was grey in colour and it was clear he was not well. The Orderly Officer
noticed that Mr Haldane’s head had slumped forwards and when the CM asked him
if he was okay, he did not respond. Neither the Orderly Officer or the CM could find
a pulse so at 3.15pm, the Orderly Officer called a medical emergency code blue (to
indicate that a prisoner is unconscious or having breathing difficulties). Control room
staff called for an ambulance.
35. The Orderly Officer said that they were on the point of deciding to move Mr Haldane
onto the floor and start CPR when nurses arrived.
36. A nurse arrived in reception at 3.18pm. She said that Mr Haldane was still in the
wheelchair when she arrived. She shook his shoulder and called his name, but got
no response. She asked the officers to move Mr Haldane onto the floor and as they
were doing that she realised that CPR needed to be started straight away. Other
nurses had arrived with the nurse and they took turns giving CPR and gave Mr
Haldane oxygen. They applied a defibrillator, which advised that no shock should
be given and CPR should continue.
37. Paramedics arrived at 3.25pm and took over efforts to resuscitate Mr Haldane. A
second ambulance crew arrived at 3.30pm. At 3.49pm, the paramedics stopped
CPR and pronounced that Mr Haldane had died.
Contact with Mr Haldane’s family
38. Stafford were unable to establish whether Mr Haldane had any next of kin.
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Support for prisoners and staff
39. The Stafford’s Head of Reducing Reoffending debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
40. The prison posted notices informing other prisoners of Mr Haldane’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 Haldane’s death.
Post-mortem report
41. The pathologist noted that Mr Haldane’s colon was markedly distended and
contained abundant faeces and that there was a large amount of impacted faeces
within his rectum. The pathologist gave his cause of death as toxic megacolon
(extreme inflammation of the colon) caused by chronic constipation.
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Findings
Clinical care
42. The clinical reviewer noted that Mr Haldane had not reported being constipated
prior to 29 August and told his key worker on 27 August that he was fine and was
taking his meals. The clinical reviewer concluded that the care Mr Haldane received
up to 29 August was equivalent to that he could have expected to receive in the
community.
43. However, the clinical reviewer found that the care Mr Haldane received on 29
August was not equivalent. She noted that the nurse failed to record Mr Haldane’s
clinical observations in his medical record after she examined him at 9.30am. The
clinical reviewer also considered that constipation for one month with abdominal
distension should have given the nurse more concern, especially the risk of sepsis,
and she should have calculated a NEWS2 score. (National Early Warning Score
(NEWS2) is a clinical tool used to assess clinical deterioration.)
44. The clinical reviewer noted that the nurse did not take a complete set of
observations (she did not take respiratory rate) so she would have been unable to
calculate a NEWS2 score. The nurse said her watch was not working properly so
she could not take Mr Haldane’s respiratory rate, but the Head of Healthcare said a
stopwatch was always available in the healthcare visiting bag. Although the nurse
said that Mr Haldane did not appear breathless, his respiratory rate should have
been measured. The clinical reviewer noted that if his respiratory rate had been
higher than normal, then the NEWS2 score could have indicated a medium to high
risk of sepsis.
45. We have previously made recommendations to Stafford about the failure to use
NEWS2 consistently and so the Head of Healthcare should address this issue
urgently. We recommend:
The Head of Healthcare should ensure that when staff take clinical
observations, they:
• record the readings in the prisoner’s medical record; and
• calculate and record the NEWS2 score and know when to escalate care
as a result.
Emergency response
46. The Orderly Officer radioed a code blue emergency at 3.15pm and nurses arrived
at 3.18pm. We are concerned that reception staff had not started CPR by the time
nurses arrived.
47. In his statement, the Orderly Officer said that it was clear something was seriously
wrong with Mr Haldane as his head had slumped forwards. He said he checked for
a pulse but could not find one and then called the code blue. At interview, he said
that nurses arrived very quickly which is why staff had not started CPR. However, it
was around three minutes before nurses arrived so we consider that reception staff
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should have started CPR in the interim and as soon as possible after the code blue
was called. We recommend:
The Governor should ensure that staff start CPR without delay when a
prisoner has no pulse and stops breathing.
Inquest
48. An inquest into Mr Haldane’s death held on 12 June 2025 concluded that his cause
of his death was toxic megacolon secondary to chronic constipation.
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