Thomas Cole

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Independent investigation into
the death of Mr Thomas Cole,
a prisoner at HMP Northumberland,
on 13 May 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.
If my office is to best assist HM Prisons 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 Thomas Cole died at HMP Northumberland, on 13 May 2022. He was 73 years old.
The cause of his death was a blood clot in a coronary artery. I offer my condolences to Mr
Cole’s family and friends.
The clinical reviewer concluded that Mr Cole’s clinical management before he went into
hospital was equivalent to that which he could have expected to receive in the community.
However, his care when he returned to the prison after surgery, in May 2022, did not meet
the expected standards, as an important post-operative action was not completed by
healthcare staff at the prison.
I consider that insufficient account was taken of Mr Cole’s age, mobility and the debility
caused by his medical condition when the prison completed his security risk assessment
and that the use of restraints, particularly for an extended period, was grossly
disproportionate to his risk and morally indefensible.
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 February 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 7
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Summary
Events
1. Mr Thomas Cole had been in prison since 2009 and transferred to HMP
Northumberland on 24 August 2021. A health screen was conducted when he
arrived and it was noted he had a history of coronary heart disease and angina, as
well as impaired mobility.
2. On 26 March 2022, Mr Cole complained of recurrent chest pain, which continued for
several days. He was examined by healthcare staff and paramedics, who thought it
was a gastric problem. On 30 March, Mr Cole’s clinical observations were
abnormal. He was taken to hospital by emergency ambulance, escorted by two
prison officers using restraints.
3. Mr Cole remained in hospital as an inpatient. On 20 April, he had heart bypass
surgery, and he was discharged on 7 May. A discharge summary listed several
follow-up clinical actions for healthcare staff, including that the GP should check
that Mr Cole’s blood had stabilised, two to three days after his discharge.
4. At 4.25pm on 13 May, Mr Cole was found unresponsive. Resuscitation attempts by
staff and paramedics were unsuccessful and his death was confirmed at 5.11pm.
Findings
5. The clinical reviewer concluded that Mr Cole’s clinical care before he went into
hospital was satisfactory and equivalent to that which he could have expected to
receive in the community. However, his care after his discharge from hospital was
not equivalent to the expected standards.
6. There is no evidence that the blood test and GP check specified in the hospital
discharge summary was carried out.
7. In spite of Mr Cole’s age, reduced mobility, serious medical condition and low
security risk, restraints were used for his first 20 days in hospital. They were
removed on the day he had surgery and re-applied on his journey back to the
prison.
Recommendations
• The Head of Healthcare should ensure that healthcare staff complete all post-
operative actions requested in hospital discharge summaries.
• The Director and Head of Healthcare should ensure that all staff undertaking risk
assessments for prisoners taken to hospital understand the legal position on the
use of restraints and that, in all cases:
• healthcare staff complete the medical information section of the escort risk
assessment, accurately reflecting how the prisoner’s current health and
medical condition affects their risk of escape;
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• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk; and
• prison managers regularly review the level of restraints used on prisoners in
hospital.
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The Investigation Process
8. HMPPS notified us of Mr Cole’s death on 13 May 2022.
9. The initial investigator issued notices to staff and prisoners at HMP Northumberland
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 Cole’s prison and
medical records. Another investigator completed the latter stages of the
investigation.
11. NHS England and NHS Improvement (NHSE&I) commissioned a clinical reviewer to
review Mr Cole’s clinical care at the prison.
12. We informed HM Coroner for Northumberland of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
13. The prison was unable to trace Mr Cole’s next of kin.
14. The initial report was shared with HM Prison and Probation Service (HMPPS). They
reported a factual inaccuracy, which has been amended. The recommendations
were accepted.
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Background Information
HMP Northumberland
15. HMP Northumberland is a Category C prison, located near Morpeth, with the
capacity to hold approximately 1,300 adult men. Sodexo Justice Services manages
the prison under contract from the Ministry of Justice.
16. Spectrum Community Health provides healthcare services. Nurses are on duty
during the day and early evening. In addition to the NHS 111 service, prison staff
can speak to a GP or Advanced Nurse Practitioner provided by Spectrum, for
advice out-of-hours.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Northumberland was in August and September
2022. Inspectors considered that the commissioned healthcare staffing profiles
were insufficient to meet demand, but staff worked flexibly and were committed to
providing good care. There was limited capacity for the GPs service to meet
additional demand and there were extended waiting times for services, such as
reviews of long-term conditions.
18. Inspectors reported that healthcare facilities were clean and patient records were
reasonable. However, secondary health screens were not always completed within
the required timescale. Arrangements for medical emergencies were effective, but
most prison officers had not received first aid or basic life support updates. PPO
recommendations were addressed and shared at a monthly forum. The Care
Quality Commission issued ‘requirement to improve’ notices after the inspection.
Independent Monitoring Board
19. 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 December 2022, the IMB
reported that the healthcare provider had experienced staffing and leadership
difficulties, which had led to unreliability in provision. Recruitment of additional staff
and a locum GP had led to some improvement.
Previous deaths at HMP Northumberland
20. Mr Cole was the thirteenth prisoner at Northumberland to die, since May 2019. Of
the previous deaths, seven were due to natural causes, four were self-inflicted and
one was related to substance misuse. There have been nine deaths since, six were
from natural causes and three were self-inflicted. We have previously raised the
issue of adhering to care plans. HMPPS implemented action plans to introduce a
quality assurance forum and to ensure regular auditing of the existence and quality
of care plans.
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Key Events
21. Mr Thomas Cole was remanded to HMP Durham on 24 June 2009. He was later
convicted of sexual offences and given an indeterminate sentence, with a minimum
period to serve of four years.
22. Mr Cole transferred from HMP Full Sutton to HMP Northumberland on 24 August
2021. A health screen was completed, but it was unclear if this was the initial or
secondary health assessment. It was noted that Mr Cole had coronary heart
disease and angina, but there were no other health concerns at that time. He used
a walking stick for long distances due to back and knee pain, and balance issues.
Mr Cole’s medications were noted and re-prescribed.
23. On 30 November, healthcare staff created nursing care plans to manage Mr Cole’s
coronary heart disease and high blood pressure. They were reviewed and updated
on 8 February 2022.
24. On 26 March, Mr Cole reported that he had felt chest pain for two weeks. After
examining him, a nurse thought his symptoms suggested a gastric problem. She
prescribed medication for heartburn and reflux and asked the GP at the prison to
review Mr Cole’s other medication.
25. At 11.52pm on 29 March, Mr Cole again reported chest pain, which had not been
relieved by his glyceryl trinitrate (GTN) spray (prescribed for angina). Wing officers
contacted the on-call clinician. As there were no healthcare staff overnight to take
blood tests and an ECG (to check the heart’s rhythm and electrical activity), the
clinician instructed the wing staff to request an emergency ambulance and send Mr
Cole to hospital. The paramedics who attended diagnosed gastritis and advised that
he did not need to go to hospital.
26. On 30 March, a GP at the prison reviewed Mr Cole and requested an urgent ECG,
which was carried out that morning.
27. At 2.45pm the same day, Mr Cole had further chest pains and wing staff called a
code blue medical emergency.
28. Two nurses responded. They took clinical observations and calculated a National
Early Warning Score 2 (NEWS2) of 7. (NEWS2 is a clinical scoring system to
assess acute illness. A score of 7 indicates the need for urgent assessment by a
critical care team.) Mr Cole was taken to Northumbria Specialist Emergency Care
Hospital, escorted by two prison officers and handcuffed with an escort chain.
29. Hospital doctors found that Mr Cole had had a heart attack, caused by blockage of
an artery. He was transferred to the coronary care unit at Freeman Hospital for a
coronary artery bypass graft (also known as a triple heart bypass) but tested
positive for COVID-19, so surgery was delayed until 20 April. Healthcare staff
obtained updates on his recovery and discharge plans.
30. Mr Cole was discharged from hospital to Northumberland during the evening of 7
May (healthcare staff incorrectly recorded the date as 8 May). A cardiology
discharge summary listed actions for the GP, including reviewing and adjusting Mr
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Cole’s medication; and requesting a routine blood test two to three days after
discharge to ensure his blood had stabilised.
31. A nurse reviewed Mr Cole at around 5.00pm on 8 May. She changed his dressings
on his chest and armpit, gave him his medication and booked an appointment for
his stitches to be removed on 14 May.
32. On 11 May, a nurse noted that Mr Cole’s wounds had not been reviewed for three
days. She cleaned the wounds, applied new dressings and arranged for them to be
dressed every two days.
Events of 13 May
33. A prison chaplain visited Mr Cole between 2.15pm and 3.00pm on 13 May. Mr Cole
expressed some negative thoughts about his health, so the deacon responsible for
pastoral care telephoned him at 3.45pm to check his welfare.
34. At 4.25pm, a Prison Custody Officer (PCO) unlocked Mr Cole’s cell for his evening
meal. As he did not respond when she called out to him, she went into the cell and
found him sitting on his cell chair, unresponsive. She radioed a code blue medical
emergency (which indicates a prisoner is unresponsive or has breathing difficulties)
and an ambulance was requested. With the help of a prisoner, she placed Mr Cole
on the floor.
35. A Senior Prison Custody Officer (SPCO) and a PCO then arrived and began
cardiopulmonary resuscitation (CPR), while the first PCO fetched a defibrillator. A
nurse arrived at the cell, followed by additional prison officers and nurses. They
continued CPR until paramedics arrived at 4.48pm and took over.
36. The resuscitation attempts were unsuccessful, and the paramedics confirmed Mr
Cole’s death at 5.11pm.
37. Mr Cole was estranged from his family and prison staff were unable to trace his
next of kin. The prison arranged and paid for his funeral, which was held on 11 July.
Support for prisoners and staff
38. The Deputy Director and another prison manager jointly debriefed the staff involved
in the emergency response, to offer support and ensure they had the opportunity to
discuss any issues arising. The staff care team also offered support.
39. The prison posted notices informing other prisoners and other staff of Mr Cole’s
death and offering support.
Post-mortem report
40. The post-mortem report concluded that the cause of Mr Cole’s death was coronary
artery graft thrombosis (a blood clot in a coronary artery, a complication of heart
bypass surgery).
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Findings
Clinical care
41. The clinical reviewer concluded that the management of Mr Cole’s coronary heart
disease and angina was satisfactory and equivalent to that which he could have
expected to receive in the community. However, she was not satisfied that his
clinical care after his discharge from hospital met the expected standards. She also
noted deficiencies in Mr Cole’s reception health screens.
42. The clinical reviewer made recommendations about reception health screens, which
we do not repeat in this report, but the Head of Healthcare will need to consider.
Clinical actions requested in Mr Cole’s hospital discharge letter
43. After Mr Cole’s surgery, a cardiology discharge summary listed several actions to
be taken, including a GP review within two to three days of his discharge, to ensure
that his blood had stabilised. There is no evidence that this was carried out. We
recommend:
The Head of Healthcare should ensure that healthcare staff complete all post-
operative actions requested in hospital discharge summaries.
Security risk assessments and the use of restraints
44. 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.
45. 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 he has a serious medical
condition. The judgment indicated that a 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.
46. These requirements are reflected in the HMPPS’ Prevention of Escape – External
Escorts Policy Framework, on the use of restraints. The policy encourages sensitive
handling to ensure that the needs of security are balanced against the clinical
needs of a seriously ill prisoner and makes clear that restraints should not be used,
“… if the prisoner’s medical condition or advanced age or physical impairment
renders restraints inappropriate … unless there is intelligence to suggest that an
escape attempt might be made.
47. The medical section of the security risk assessment for Mr Cole’s journey to
hospital was not completed. Mr Cole was assessed by security staff as ‘low’ on the
risk of escape and the likelihood of outside assistance. The head of security
authorised the use of restraints, annotating the form to indicate that an escort chain
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should be used in the ambulance. Three subsequent reviews of Mr Cole’s risk did
not specify the level of restraints. The restraints were removed three weeks after his
admission to hospital, on the day of his heart bypass surgery. Staff were instructed
to re-apply them for the journey back to the prison.
48. Mr Cole was a category C prisoner on the enhanced level of the prison’s privileges
scheme, with no recent disciplinary problems and was escorted by two prison
officers. That a 73-year-old man with a history of heart disease and angina, who
required a walking stick to move any distance, suffered from balance problems, had
recently suffered a heart attack and was on a hospital ward guarded by prison
officers as he awaited triple heart bypass surgery was restrained with handcuffs for
over three weeks is inexplicable and morally indefensible. We recommend:
The Director and Head of Healthcare should ensure that all staff undertaking
risk assessments for prisoners taken to hospital understand the legal
position on the use of restraints and that, in all cases:
• healthcare staff complete the medical information section of the escort
risk assessment, accurately reflecting how the prisoner’s current
health and medical condition affects their risk of escape;
• authorising managers show that they have taken this information into
account when assessing a prisoner’s current level of risk; and
• prison managers regularly review the level of restraints used on
prisoners in hospital.
Inquest
49. An inquest held on 6 December 2024, concluded Mr Cole died as a result of the
recognised complication of a necessary medical procedure – coronary artery graft
thrombosis.
8 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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