Steven Lee

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Independent investigation into
the death of Mr Steven Lee,
a prisoner at HMP Preston, on
19 October 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
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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.
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.
Mr Steven Lee died in hospital of acute subdural haemorrhage (bleeding on the surface of
the brain) on 19 October 2023, while a prisoner at HMP Preston. He also had chronic
kidney disease, ischemic heart disease (caused by narrow arteries), a stroke, and Type 2
diabetes which contributed to but did not cause his death. He was 60 years old. We offer
our condolences to his family and friends.
The clinical reviewer concluded that the clinical care that Mr Lee received at Preston for
his long-term conditions was equivalent to that which he would have received in the
community.
However, when Mr Lee was found unresponsive, staff did not radio an emergency medical
code for 21 minutes. This represented an unacceptable delay in assessing the severity of
the situation, causing delays going into the cell, treating Mr Lee and requesting an
ambulance.
It was also completely unacceptable that Mr Lee was restrained when he went to hospital,
despite being in a coma.
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 July 2024
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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. In December 2022, Mr Steven Lee was remanded to custody and taken to HMP
Forest Bank, charged with fraud. On 1 September 2023, he transferred to HMP
Preston.
2. At his initial health screen, Mr Lee told a nurse that he had chest pains. The nurse
sent him to hospital, and it was later confirmed that Mr Lee had had a heart attack.
On 15 September, Mr Lee returned to Preston and lived in the healthcare wing for a
period of enhanced observations.
3. At 3.37pm on 19 October, a Healthcare Support Worker (HSW) went to Mr Lee’s
cell to give him his medication. The HSW was unable to rouse him. A nearby nurse
telephoned for an officer to open the cell door. The nurse and HSW thought that Mr
Lee was in a deep sleep. At 3.48pm, an officer opened the cell door. They tried to
rouse Mr Lee but were unable to do so. Seven minutes later, the nurse asked a GP
and another nurse to attend.
4. At 3.57pm, a GP arrived, examined Mr Lee, and asked the nurse to call an
ambulance. Another nurse arrived and recorded Mr Lee had a Glasgow Coma
Scale score of 4, which indicated that Mr Lee was in a coma. She inserted an
airway.
5. At 4.14pm, ambulance paramedics arrived and took over Mr Lee’s treatment. At
4.59pm, they took him to hospital. Two officers escorted Mr Lee, who was
restrained with an escort chain. At 5.55pm, hospital staff told the officers with Mr
Lee that he would be placed on end-of-life care. At 6.05pm, the officers removed
the restraint. Mr Lee died later that evening.
Findings
Emergency response
6. There was a delay of eleven minutes opening Mr Lee’s cell door after staff found
him unresponsive. There was a further nine-minute delay before staff requested an
ambulance and a minute after that they radioed an emergency medical code.
Restraints, security and escorts
7. Mr Lee was inappropriately restrained when he was taken to hospital in a coma.
Recommendations
• The Head of Healthcare should ensure that where there are serious concerns about
the health of a prisoner, staff use an emergency code to summon assistance and
alert control room staff to call an ambulance immediately, in line with Prison Service
Instruction (PSI) 03/2013.
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• The Governor and Head of Healthcare should ensure that staff accurately reflect
their professional opinion on restraint risk assessment forms, that there are clear
and considered conversations between healthcare and prison staff about a
prisoner’s risk where necessary and that these conversations are routinely
documented.
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The Investigation Process
8. On 19 October 2023, the PPO was informed of Mr Lee’s death.
9. The investigator issued notices to staff and prisoners at HMP Preston informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Lee’s prison and
medical records.
11. The investigator interviewed two members of staff by video call on 15 November
and 22 November 2023.
12. NHS England commissioned a clinical reviewer to review Mr Lee’s clinical care at
the prison.
13. We informed HM Coroner for Lancashire of the investigation. He gave us Mr Lee’s
cause of death. We have sent the Coroner a copy of this report.
14. The Ombudsman’s family liaison officer wrote to Mr Lee’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
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Background Information
HMP Preston
16. HMP Preston is a Category B local prison serving the courts in Lancashire and
Cumbria. It holds up to 680 adult male prisoners. Spectrum Community Health CIC
provides community healthcare services 24 hours a day, seven days a week, as
well as substance misuse services. Tees Esk and Wyre Valleys NHS Foundation
Trust provides mental health services at Preston.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Preston was in June 2023. Inspectors reported
that health care was very well led, and the Governor understood the importance of
these services for such a complex and vulnerable population, appointing extra staff
to support the work.
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 March 2023, the IMB reported
that the prison had a well-staffed regional enhanced care unit with services in place
to oversee long-term conditions and chronic disease.
Previous deaths at HMP Preston
19. In the three years before Mr Lee’s death, there were seven deaths from natural
causes and two self-inflicted deaths at Preston. Up until the end of January 2024
there has been one self-inflicted death since Mr Lee’s death. There are no
similarities between our findings in the investigation into Mr Lee’s death and
previous investigations.
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Key Events
20. On 24 December 2022, Mr Steven Lee was remanded to HMP Forest Bank for
fraud. In January 2023, Mr Lee transferred to HMP Liverpool. He had a number of
health conditions notably Type 2 diabetes, chronic kidney disease stage 3 (a long-
term disease where the kidneys do not work as well as they should), unstable
angina (a condition where the heart does not get enough blood flow and oxygen)
and high blood pressure and was sent to hospital on a number of occasions with
chest pains.
21. On 1 September, Mr Lee was transferred to HMP Preston. That day during his initial
health screen, he told an Associate Nurse Practitioner (ANP) that he had chest
pains. The ANP thought that he was having a heart attack and sent him to hospital.
The hospital later confirmed that Mr Lee had had a heart attack.
22. On 15 September, Mr Lee returned to Preston and went to the healthcare wing for a
period of enhanced observations. He was scheduled to have a cardiology follow up
appointment in three months, but he died before the appointment.
23. At 10.13am on 22 September, a nurse found Mr Lee on the floor in his cell. He told
her that he had lost his footing on the way back from the toilet. Mr Lee was not
injured. She completed a falls risk assessment and offered him a walking frame
which he refused, preferring his stick.
Events of 19 October 2023
24. On 19 October at 11.17am, as part of the daily routine observations, a HSW saw Mr
Lee in his cell. She completed his physical observations and noted that his National
Early Warning Score (NEWS, a tool to detect and respond to clinical deterioration)
was zero, which indicated no clinical risk. At 2.30pm, she saw Mr Lee in his cell. He
was resting on his bed, and she had no concerns about him.
25. At 3.37pm, the HSW went to Mr Lee’s cell to give him his medication (due to Mr Lee
being unstable on his feet he received his medication through the cell door hatch).
She called to him through the observation panel and thought he was snoring and
appeared to be in a deep sleep.
26. A nurse told the HSW to bang harder on the door and shout to Mr Lee, as she said
he was a deep sleeper. The HSW was unable to rouse Mr Lee. Believing him to be
in a deep sleep, the nurse telephoned for an officer to attend the healthcare wing to
open the cell door (nurses to do not carry cell keys). She spoke to a member of staff
and told them that they could not wake up Mr Lee and needed to go into his cell to
give him his medication. Five minutes later, after no one came, she telephoned
again for an officer.
27. At 3.48pm, an officer got to Mr Lee’s cell and opened the door. He and the HSW
tried to rouse him. (For medical reasons, the nurse was not having face to face
contact with prisoners at the time, so she did not go into the cell.) At 3.55pm, the
nurse telephoned a GP and another nurse to come and assess Mr Lee. The GP
said that the nurse told him that Mr Lee was “unconscious and unresponsive”. He
went straight to Mr Lee’s cell and got there at 3.57pm. He told the nurse to call an
ambulance.
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28. The nurse radioed a code blue (an emergency code when a prisoner is having
difficulty or not breathing) which triggers staff in the control room to call an
ambulance. Another nurse got to Mr Lee’s cell at 4.00pm. She recorded a Glasgow
Coma Scale (a clinical assessment scale to measure a patient’s level of
consciousness) of 4 (the highest score is 15, and the lowest is 3. A score of 15
indicates fully awake and a score of 8 or fewer indicates a coma). The nurse
inserted an airway. At 4.14pm, paramedics arrived and took over Mr Lee’s care. At
4.59pm, they took him to hospital.
29. Before Mr Lee went to hospital, prison staff completed an escort risk assessment. A
nurse told the investigator that she spoke to a Custodial Manager (CM) and said
that Mr Lee did not need to be restrained as he was unresponsive. The CM then
telephoned the Head of Security and told him that the nurse did not think Mr Lee
needed to be restrained. The Head asked if Mr Lee would need to be shocked
through the use of a defibrillator. The nurse said that there was only a slight
possibility of a defibrillator being used. Therefore, the Head said that Mr Lee
needed to be restrained due to concerns about previous hospital visits. The
paramedics present shared the nurse’s concerns about Mr Lee being restrained.
However, the nurse completed the medical section of the escort risk assessment
noting that she did not object to the use of restraints. In the section where she
recorded the prisoner’s current medical condition, she wrote, “unstable
comorbidities”. She said that she did not feel empowered to object to the use of
restraints on the form.
30. The Head of Security authorised that Mr Lee be accompanied by two officers and
be restrained with 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). He said normally
unsentenced prisoners were accompanied by two officers and double cuffed
(double cuffing is when the prisoner’s hands are handcuffed in front of them, and
one wrist is attached to a prison officer by an additional set of handcuffs). He said
that on previous hospital visits, Mr Lee’s family had attended in large numbers, and
it had been difficult to manage. He told the investigator that he was not aware that
Mr Lee’s condition was life-threatening. He considered his prior knowledge of Mr
Lee, that he was unwell and being taken to hospital by ambulance and decided that
the use of the escort chain was appropriate.
31. In hospital, Mr Lee had a CT scan, which showed that he had suffered a large brain
haemorrhage. Hospital staff said that he should be placed on end-of-life care. At
6.05pm, an officer contacted the Head of Security, who authorised that the restraint
could be removed. Mr Lee died at 9.50pm.
Contact with Mr Lee’s family
32. On 19 October, a prison chaplain was appointed as the family liaison officer. At
6.17pm, she telephoned Mr Lee’s wife and told her that Mr Lee was seriously ill in
hospital. The chaplain went to the hospital, where she met Mr Lee’s family, who
were with him when he died. The prison contributed to the cost of Mr Lee’s funeral
in line with national instructions.
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Support for prisoners and staff
33. After Mr Lee’s death, the Head of Security debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. He arranged for the staff care team to offer ongoing
support.
34. The prison posted notices informing other prisoners of Mr Lee’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 Lee’s death.
Post-mortem report
35. A hospital doctor established that Mr Lee died from acute subdural haemorrhage
(spontaneous bleeding on the surface of the brain). He also had chronic kidney
disease, ischemic heart disease, a stroke and Type 2 diabetes which contributed to
but did not cause his death.
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Findings
Clinical care
36. The clinical reviewer found that the clinical care that Mr Lee received at Preston
was of a mixed standard. She was satisfied that the care of Mr Lee’s long-term
conditions was equivalent to that which he would have received in the community.
He was appropriately located in the healthcare wing to allow him to be monitored.
37. However, she was concerned about the emergency response and delay in radioing
a code blue. This is discussed further below.
38. The clinical reviewer also made a recommendation about the transfer of medication
between prisons which was not relevant to Mr Lee’s death, but which the Heads of
Healthcare at Liverpool and Preston will want to address.
Emergency response
39. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes and
Preston’s local protocol, Medical Emergency Response Codes sets out the actions
staff should take in a medical emergency. Both instructions state that if a person is
found unresponsive then staff should radio an emergency code which means staff
will respond and an ambulance will immediately be requested. The PSI says that
local procedures must ensure that staff understand they should not delay
summoning emergency assistance. It is essential that an ambulance is called in all
cases where there are serious concerns about the health of a prisoner and that
access to both the prison and the individual prisoner is not delayed.
40. At 3.37pm, a HSW found Mr Lee unresponsive in his cell and thought he was in a
deep sleep. A nurse was also present. Healthcare staff made a non-urgent request
for an officer to open the cell door. An officer opened the cell door 11 minutes later.
Seven minutes later, the nurse asked a nurse and GP to attend as Mr Lee was still
unresponsive. At 3.57pm, after a GP went to the cell, he asked the nurse to request
an ambulance. She did so immediately. This was 21 minutes after staff first found
Mr Lee unresponsive. This was an unacceptable delay. It is extremely concerning
that two members of healthcare staff did not recognise the severity of the situation
or radio a code blue when they first discovered Mr Lee unresponsive. It delayed
staff going into the cell, his treatment and an ambulance being requested. We make
the following recommendation:
The Head of Healthcare should ensure that where there are serious concerns
about the health of a prisoner, staff should use an emergency code to
summon staff and alert control room staff to call an ambulance immediately,
in line with Prison Service Instruction (PSI) 03/2013.
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Restraints, security and escorts
41. 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.
42. 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. We have identified a number of significant concerns about
the use of restraints on Mr Lee.
43. On 19 October, staff found Mr Lee unresponsive in his cell and subsequently
assessed him as being in a coma. The nurse did not include this information in the
medical section of the escort risk assessment form and noted that she did not
object to the use of restraints. She said that she objected verbally to the use of
restraints but did not feel able to write this on the form once the Head of Security
told another member of staff that Mr Lee would be restrained. She told the
investigator that she would not feel pressured into changing her opinion again and if
she objected to the use of restraints, she would note this on the form regardless of
what the final decision was.
44. The Head of Security said he was unaware that Mr Lee’s condition was life-
threatening and authorised restraint with an escort chain. We accept that in
hospital, when officers updated him on Mr Lee’s condition, he authorised the
restraint to be removed. However, Mr Lee was in a coma and should never have
been restrained.
45. We make the following recommendation:
The Governor and Head of Healthcare should ensure that staff accurately
reflect their professional opinion on restraint risk assessment forms, that
there are clear and considered conversations between healthcare and prison
staff about a prisoner’s risk where necessary and that these conversations
are routinely documented.
Inquest
46. The inquest into Mr Lee’s death concluded in May 2025 and found that he died of
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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