Terrence Clover

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Terrence Clover,
a prisoner at HMP Swaleside,
on 27 February 2024
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, 2024
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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. In September 2019, Mr Terrence Clover received an extended determinate
sentence of nine years for sexual offences. He died of lymphoma (a type of blood
cancer that affects the lymphatic system) on 27 February 2024, while a prisoner at
HMP Swaleside. He was 82 years old.
4. The prison told us that Mr Clover had no identified next of kin. We nonetheless offer
our condolences to those who knew him.
5. NHS England commissioned an independent clinical reviewer to review Mr Clover’s
clinical care at HMP Swaleside.
6. The clinical reviewer concluded that the clinical care Mr Clover received at HMP
Swaleside was of a good standard and equivalent to that which he could have
expected to receive in the community. She found good practice in the patient-
centred prescribing of end-of-life medications and the good documentation of Mr
Clover’s care plans. She also found that healthcare staff maintained good
communication and professional relationships with the hospital. In recognition of the
good practice identified, we make the following recommendation:
The Head of Healthcare should provide timely feedback to healthcare staff
about the good practice identified in the clinical review and consider how this
can continue to be role modelled to staff to ensure ongoing good quality care
and patient experience for patients receiving end-of-life care.
7. The PPO investigator investigated the non-clinical issues relating to Mr Clover’s
care. We did not find any significant learning related to his death.
Governor to note
8. While Mr Clover was appropriately not restrained when he attended hospital in the
months before his death, the prison was unable to find the escort risk assessments
and bed watch logs for his hospital admissions between December 2023 and
February 2024 and for his transfer to a hospice on 7 February 2024.
9. Cell bell records were also unavailable as the cell bell system’s memory was full
and prison staff did not know how to clear it.
Prisons and Probation Ombudsman 1
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10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. At an inquest held on 13 August 2024, the Coroner concluded that Mr Clover died
of natural causes.
Adrian Usher July 2024
Prisons and Probation Ombudsman
2 Prisons and Probation Ombudsman
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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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