Thomas Simmons

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Independent investigation
into the death of Mr Thomas
Simmons, a prisoner at HMP
Humber on 20 April 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, 2024
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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 Thomas Simmons died in hospital on 20 April 2022, after he suffered a seizure in his
cell at HMP Humber the previous day. He was 45 years old. I offer my condolences to Mr
Simmons’ family and friends.
Mr Simmons suffered a serious head injury in April 2021 while in the community and a
post-mortem concluded that this injury likely contributed to his death a year later.
We had concerns about the way in which the emergency response was managed. The
clinical reviewer concluded that this aspect of Mr Simmons’ care was not equivalent to that
which he could have expected to receive in the community.
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 August 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 7
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Summary
Events
1. On 19 July 2021, Mr Thomas Simmons was sentenced to 11 months in prison for
possession of a bladed article.
2. Mr Simmons was released on licence on 3 December but was recalled ten days
later. He was moved to HMP Humber on 5 January 2022.
3. On 19 April, at around 3.30pm, staff found Mr Simmons collapsed on the floor of his
cell. Staff called a medical emergency code. Shortly after healthcare staff arrived at
the cell, Mr Simmons appeared to be recovering and staff thought he had been
under the influence of an illicit substance. A nurse said that the ambulance was no
longer required, and healthcare staff continued to care for Mr Simmons in his cell.
4. However, at around 4.15pm, Mr Simmons’ condition began to deteriorate. Staff
requested an ambulance again and continued to treat him, carrying out
cardiopulmonary resuscitation (CPR) when he became unresponsive, until
ambulance staff arrived and took over his care. Mr Simmons was transported to
hospital but did not regain consciousness and died the following day.
5. The post-mortem examination found that Mr Simmons died from a presumed
seizure arising from an old head injury.
Findings
6. Staff stood down the ambulance too early before they were satisfied that Mr
Simmons had fully recovered.
7. An unqualified member of healthcare staff was left to manage the emergency
situation, with a suction machine that did not work. This situation continued for
around 15 minutes before another nurse arrived with a working suction machine
and took charge of the situation. The clinical reviewer established that while the
contents of the emergency bags are audited daily, the audit does not include a
check that the equipment is in good working order.
8. We found some failings in the ongoing family liaison from the prison.
Recommendations
• The Head of Healthcare should ensure that, once an emergency code blue has
been called and an ambulance is on the way, staff should only stand it down if they
are confident that the patient has fully recovered.
• The Head of Healthcare should ensure that the daily audit of the emergency bags
includes checking that the equipment is in good working order.
• The Governor should ensure that there are sufficient trained family liaison officers to
contact and provide effective and consistent support for bereaved families.
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The Investigation Process
9. HMPPS notified us of Mr Simmons’ death on 20 April 2022.
10. The investigator issued notices to staff and prisoners at HMP Humber informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Simmons’ prison and
medical records.
12. NHS England commissioned an independent clinical reviewer to review Mr
Simmons’ clinical care at the prison. The investigator and clinical reviewer jointly
interviewed four members of staff.
13. We informed HM Coroner for Hull and the East Riding of Yorkshire of the
investigation. The coroner shared Mr Simmons’ post-mortem report with us. We
have sent the coroner a copy of this report.
14. The Ombudsman’s family liaison officer contacted Mr Simmons’ father to explain
the investigation and to ask if he had any matters he wanted us to consider. Mr
Simmons’ father had no questions but asked for a copy of our report.
15. We shared our initial report with Mr Simmons’ father. He did not raise any factual
inaccuracies.
16. We shared our initial report with the Prison Service. The Prison service identified a
factual inaccuracy which has been amended within our report.
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Background Information
HMP Humber
17. HMP Humber is a category C prison that holds up to 1,062 men. Spectrum
Community Health CIC provides primary healthcare services between the hours of
07:30 to 20:30. Tees Esk and Wear Valleys NHS Foundation Trust provides mental
health services but during core hours only.
HM Inspectorate of Prisons
18. The last full inspection of HMP Humber was in November and December 2017.
Inspectors found that access to healthcare services was adequate, with appropriate
treatment provided for most prisoners and the care of prisoners with long-term
health problems being reasonably good. They found some aspects of operational
management to be weak, including that emergency equipment was not routinely
checked and there was a significant backlog of unanswered health care complaints.
19. Inspectors carried out a Scrutiny Visit in October and November 2020 and found
that healthcare provision had progressed since their last inspection. They noted that
healthcare staff had maintained core functions during the COVID-19 restrictions, but
some clinics still had not restarted. Inspectors found some errors with medicines
management which compromised prisoner safety.
Independent Monitoring Board
20. 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 2021, the IMB
reported that the health and wellbeing of prisoners had been extremely well-
managed during challenges and constraints of the COVID-19 pandemic.
Previous deaths at HMP Humber
21. Mr Simmons was the ninth prisoner to die at Humber since April 2019. Six of the
previous deaths were from natural causes and two were self-inflicted. There are no
similarities between the findings from our investigation into Mr Simmons’ death and
our findings from previous investigations.
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Key Events
Background
22. On 19 July 2021, Mr Thomas Simmons was sentenced to 11 months in prison for
possession of a bladed article. He was sent to HMP Hull and later transferred to
HMP Humber.
23. Mr Simmons was released on licence on 3 December but was recalled ten days
later. He initially returned to Hull before being transferred back to Humber on 5
January 2022.
24. Mr Simmons had been in prison many times before and had a history of substance
misuse and mental health issues. Staff appropriately referred him to the relevant
services to offer him treatment and support. In April 2021, a few months prior to
starting his last prison sentence, he had suffered a major head injury after being
assaulted in the community. Mr Simmons was not receiving any active treatment for
the head injury by the time he was sent to Hull.
25. On arrival at Humber on 5 January, staff noted no significant concerns. Mr
Simmons requested an increase in his antidepressant medication, and this was
appropriately actioned by the mental health team.
26. Mr Simmons had unwarranted concerns about his physical health and told staff on
numerous occasions that he was worried that he might have cancer. He did not at
any time raise concerns about his previous head injury and there was no cause for
staff to see him or assist him in attending any appointments about his head injury.
27. On 18 April, Mr Simmons made cuts to his arms with a razor blade and staff started
suicide and self-harm monitoring (known as ACCT). He said he had done this
because he was feeling unwell, and he continued to tell staff that he thought he had
cancer and a sexually transmitted infection.
Events of 19 April 2022
28. At around 2.15pm on 19 April, staff tried to conduct an ACCT assessment with Mr
Simmons, but he did not want to come out of his cell. Staff went to his cell and
found that he and the cell appeared dirty and unkempt. He became angry when a
mental health nurse pointed this out to him. He continued to say that staff were
ignoring his health issues. Staff agreed to arrange appointments for him to see the
sexual health nurse, the mental health nurse, and also his offender manager to
discuss his concerns about his forthcoming release. Staff left the cell at 2.40pm and
agreed to continue monitoring him on hourly observations.
29. At around 3.30pm, Officer A was returning another prisoner to his cell when he
looked into Mr Simmons’ cell and saw him lying on the floor. He said he was not
entirely sure what was wrong with Mr Simmons, but he was aware he was subject
to ACCT monitoring. Therefore, after returning the other prisoner to his cell, he went
back to Mr Simmons’ cell, opened the door and tried unsuccessfully to get a
response from him. When he could not get a response, he radioed a code blue (a
medical emergency code which tells the control room that a prisoner is
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unresponsive or not breathing and an ambulance is required immediately). He said
that the call did not immediately go through as there was a communications network
test going on, so he had to call the code again. He thought this did not take more
than 30 seconds to one minute.
30. Two other members of staff arrived and continued to try to rouse Mr Simmons while
waiting for healthcare staff to arrive. Staff suspected that Mr Simmons was under
the influence of an illicit substance and put him into the recovery position on the
floor.
31. Nurse A, a senior nurse, arrived at the cell with the emergency bag, accompanied
by assistant practitioner and a healthcare assistant. Healthcare staff took
observations and found that Mr Simmons appeared to be recovering so they moved
him onto the bed. Within eight minutes of the code blue being called, the nurse said
the ambulance was no longer required.
32. At around 4.00pm, Nurse A administered naloxone (a drug that can reverse the
effects of opioids) as staff suspected Mr Simmons may have taken illicit drugs.
However, Mr Simmons’ condition began to deteriorate and, shortly afterwards, he
began to have a seizure and started to vomit. She requested an ambulance again
at around 4.10pm, but left the cell as she was feeling unwell, leaving unqualified
staff to take control of the situation. The assistant practitioner tried to remove vomit
from Mr Simmons’ mouth, but the suction machine in the emergency bag was not
working properly, so she had to use her hands and a sheet. She requested support
from Nurse B, who was working elsewhere in the prison. She asked him to attend
and to bring a working suction machine.
33. Nurse B attended at approximately 4.30pm and took control of the emergency. By
this time, Mr Simmons had been having a seizure for around 20 minutes. Nurse B
used the suction machine to clear Mr Simmons’ airway. He also instructed the
assistant practitioner to administer rectal diazepam to help control the seizures and
a further dose of naloxone. Staff moved Mr Simmons onto the floor in case
emergency cardiopulmonary resuscitation (CPR) became necessary.
34. At around 4.49pm, Mr Simmons suffered a cardiac arrest and staff started CPR
while waiting for the ambulance to arrive. The ambulance arrived shortly before
5.00pm and paramedics took over Mr Simmons’ care. They were able to resuscitate
Mr Simmons and transfer him to hospital. However, Mr Simmons did not regain
consciousness, and died around 1.40am the following morning.
Contact with Mr Simmons’ family
35. When Mr Simmons was taken to hospital, records show that the prison tried to
contact his stepfather, who was listed as his next of kin. However, they were unable
to get in touch with him by telephone. Staff located a number for Mr Simmons’ sister
and told her that he had been taken to hospital. After Mr Simmons’ death, hospital
staff informed his sister by telephone that he had died. Mr Simmons’ brother was a
prisoner at another prison and prison staff also informed him.
36. At around midday on 20 April, the prison’s family liaison officer (FLO) and a prison
manager visited the home of Mr Simmons’ stepfather to let him know that his
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stepson had died. Mr Simmons’ stepfather said that he had already heard about his
stepson’s death.
37. The FLO resigned from the role on 29 April, and we found that no-one else from the
prison contacted Mr Simmons’ stepfather until the start of August, when he was
trying to make arrangements for the funeral.
38. The prison paid a contribution to Mr Simmons’ funeral expenses in line with national
policy.
Support for prisoners and staff
39. After Mr Simmons’ death, a prison manager debriefed the staff involved in the
emergency response to ensure that 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 Simmons’ death and
offering support. Staff reviewed all prisoners assessed as at risk of suicide or self-
harm in case they had been adversely affected by Mr Simmons’ death.
Post-mortem report
41. The post-mortem report found that Mr Simmons died due to complications of an out
of hospital cardiac arrest and presumed seizure arising in the context of an old head
injury. Post-mortem toxicology results did not identify any illicit substances in Mr
Simmons’ system.
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Findings
Clinical care
42. The clinical reviewer concluded that Mr Simmons’ mental health and substance
misuse care was of a good standard and equivalent to that which he could have
received in the community. However, the clinical reviewer considered that the level
of care given during the emergency response was inadequate.
Emergency response
43. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
requires prisons to have a two-code medical emergency response system.
Humber’s local policy instructs staff to use a code blue where a prisoner is
unconscious or otherwise shows signs of breathing difficulties. Calling an
emergency medical code should automatically trigger the control room to call an
ambulance and for healthcare staff to attend with the appropriate medical
equipment.
44. When Officer A called the code blue, an ambulance was called immediately, and
healthcare staff arrived at Mr Simmons’ cell within a few minutes. However, Nurse A
made the decision that an ambulance was no longer required before Mr Simmons’
condition had been fully assessed.
45. Due to feeling unwell, Nurse A left the cell after Mr Simmons’ health deteriorated,
meaning that there was no fully qualified member of healthcare staff managing the
situation for around 15 minutes.
46. The suction machine in the emergency bag was not working and the assistant
practitioner had to remove vomit from Mr Simmons’ mouth using her hand and a
sheet until Nurse B arrived with a working suction machine. We agree with the
clinical reviewer’s opinion that the assistant practitioner coped well in what was a
challenging situation until Nurse B arrived and took charge. While we understand
that the situation was unavoidable due to Nurse A’s sudden illness, we consider
that the pressure on the assistant practitioner during that time would have been
eased if she had access to proper working equipment.
47. At their last inspection of Humber, HM Inspectorate of Prisons noted that
emergency equipment was not always checked. The clinical reviewer established
that the contents of the emergency bags are audited daily. However, the audit does
not include a check that the equipment is in good working order. We make the
following recommendations:
The Head of Healthcare should ensure that, once an emergency code blue
has been called and an ambulance is on the way, staff should only stand it
down if they are confident that the patient has fully recovered.
The Head of Healthcare should ensure that the daily audit of the emergency
bags includes checking that the equipment is in good working order.
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Family liaison
48. No FLO support was made available from the prison to Mr Simmons’ family
between the end of April and the start of August 2022. During this time, Mr
Simmons’ stepfather was trying to get information about arrangements for his
stepson’s funeral. There was also a delay of some five months before Mr Simmons’
property was returned to his stepfather. However, we acknowledge that when a new
FLO was appointed on 1 August, she worked well with the family, offering support
and resolving their outstanding queries. We make the following recommendation:
The Governor should ensure that there are sufficient trained family liaison
officers to contact and provide effective and consistent support for bereaved
families.
Inquest
49. The inquest, held on 19 November 2024, concluded that Mr Simmons died from
hypoxic brain injury caused by a seizure. The delay in administering the medication
during his seizure contributed to his death.
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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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