Wayne Franks

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Independent investigation into
the death of Mr Wayne Franks,
a prisoner at HMP Wakefield,
on 5 December 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 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 Wayne Franks died on 5 December 2022, at HMP Wakefield. He was 47 years old. The
cause of his death was heart disease and an enlarged heart, as well as a high level of
dihydrocodeine that had not been prescribed to him. I offer my condolences to Mr Franks’
family and friends.
The clinical reviewer concluded that Mr Franks’ clinical care was reasonable and
equivalent to that which he could have expected to receive in the community. However,
there was no care plan in place to guide the management of his long-term hypertension
and ensure the appropriate level of care.
The investigation could not establish how Mr Franks obtained illicit medication. However, I
am satisfied that Wakefield is actively addressing the unsafe medication practices
identified by HM Chief Inspector of Prisons and the Independent Monitoring Board, as well
as the issues highlighted in this report.
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 ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
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Summary
Events
1. Mr Wayne Franks had been in prison since March 2003. On 5 May 2004, he was
sentenced to life imprisonment for murder and served most of his sentence at HMP
Wakefield.
2. Mr Franks was diagnosed with high blood pressure in 2014. His blood pressure and
cholesterol levels were regularly monitored, and his medication adjusted.
3. Between 2004 and 2016, Mr Franks was thought to be involved in dealing and
using illicit prescription medication, but there was no recent evidence of this.
4. On 21 January 2021, Mr Franks reported recurrent chest pains. Heart tracing tests
were conducted that day as well as several times over the following months and the
results were all normal.
5. In December 2021, Mr Franks’ prescription for dihydrocodeine (an opioid painkiller)
was changed from in-possession to supervised. From March 2022, it was gradually
reduced and stopped, with ibuprofen and paracetamol prescribed as alternatives.
6. Just after 4.35pm on 5 December, a prisoner told a prison officer he was concerned
about Mr Franks. The officer went into Mr Franks’ cell and found him unresponsive.
Staff were unable to revive him, and paramedics confirmed his death at 4.57pm.
7. The pathologist found a high level of dihydrocodeine in Mr Franks’ blood, which
contributed to his death. There were also traces of carbamazepine and
galantamine, which had not been prescribed to him.
Findings
8. The clinical reviewer concluded that Mr Franks’ clinical care was of a reasonable
standard and equivalent to that which he could have expected to receive in the
community. However, although his blood pressure was monitored regularly, there
was no care plan in place to underpin the management of his long-term condition.
9. We do not know how Mr Franks obtained illicit medication, but we note that the
prison has taken active steps to address weaknesses in safe prescribing systems,
identified by HM Chief Inspector of Prisons and the Independent Monitoring Board.
Recommendations
• The Head of Healthcare should ensure that personalised care plans with aims,
planned interventions and monitoring, are in place for all patients with long-term
health conditions.
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The Investigation Process
10. HMPPS notified us of Mr Franks’ death on 5 December 2022.
11. The investigator issued notices to staff and prisoners at HMP Wakefield informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
12. The investigator obtained copies of relevant extracts from Mr Franks’ prison and
medical records. After notification of the cause of death, she spoke to the Head of
Drug Strategy and Healthcare Provision.
13. NHS England commissioned a clinical reviewer to review Mr Franks’ clinical care at
the prison. The investigator and clinical reviewer jointly interviewed three healthcare
staff on 2 February 2023.
14. We informed HM Coroner for West Yorkshire (Eastern) of the investigation. He
gave us the results of the post-mortem examination. We have sent the coroner a
copy of this report.
15. The Ombudsman’s family liaison officer contacted Mr Franks’ daughter to explain
the investigation. She had no specific matters that she wanted us to consider.
16. We suspended our investigation in March 2023, pending the outcome of toxicology
tests and receipt of the post-mortem report. We resumed the investigation in
December 2023.
17. We sent a copy of our report to Mr Franks’ daughter. She did not report any factual
inaccuracies.
18. The initial report was shared with HMPPS. They found no factual inaccuracies.
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Background Information
HMP Wakefield
19. HMP Wakefield is a high security prison, with an operational capacity of 750. Most
of the men are serving either life or indeterminate sentences, or determinate
sentences of over ten years. Practice Plus Group provides healthcare services.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Wakefield was in November 2022. Inspectors
reported that there was an appropriate range of primary care services, but there
were not enough clinical leads, so there were gaps in cardiology and respiratory
diseases. Patients with long-term conditions received adequate care and were
regularly invited for review, but inadequate staffing levels had affected outcomes in
most areas of health provision and the majority of care plans were poor.
21. Inspectors noted that the pharmacy team monitored the prescription of medicines
liable to be misused. However, medicines management was poor, oversight
inadequate, and the transport and storage of some medication was not in line with
safe standards.
Independent Monitoring Board
22. 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 April 2022, the IMB reported that
primary care services had been accessible, with increased capacity to treat
complex patients, but there had been periods of understaffing.
23. The Board found that the prison monitored and reviewed substance misuse and
had implemented processes such as routine random prisoner testing. However,
illicit drug use had remained constant, including the inappropriate use of prescribed
medication. The healthcare provider was trying to implement safer prescribing.
Previous deaths at HMP Wakefield
24. Mr Franks was the 27th prisoner to die at Wakefield since December 2019. Twenty-
three of the previous deaths were due to natural causes and three were self-
inflicted. There have since been seven deaths, six due to natural causes and one
self-inflicted. We have raised the issue of care plans for prisoners at Wakefield
several times.
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Key Events
25. Mr Wayne Franks was remanded to HMP Hull in March 2003. He was later
convicted of murder and, on 5 May 2004, sentenced to life imprisonment, with a
minimum period to serve of 20 years. Mr Franks served most of his sentence at
HMP Wakefield, with a short transfer to Rampton Hospital in 2003/2004, and
periods at other prisons between 24 April 2013 to 28 March 2014.
26. While at HMP Frankland in 2013/14, Mr Franks was diagnosed with high blood
pressure. He also had longstanding mental health problems but did not fully engage
with the mental health team.
27. Between 2004 and 2016, several security intelligence reports suggested that Mr
Franks was involved in trading diverted prescribed medication, mostly supplying but
occasionally as a user. He admitted to healthcare staff that he had often bought
illicit medication.
2021/2022
28. On 11 January 2021, Mr Franks reported chest pains. Healthcare staff took an
electrocardiogram (ECG – a test to record the electrical activity of the heart). The
results of this, (and repeated ECGs in January, November and December) were
normal.
29. On 21 January, a prison GP reviewed Mr Franks’ medical records and noted a
raised cholesterol level. She calculated a QRISK score which indicated that Mr
Franks had a 10.76% risk of a heart attack, or stroke within ten years. (QRISK
assesses the risk of developing cardiovascular disease. A score of less than 10%
signifies low risk.) She requested an urgent review of Mr Franks’ chest pain and
blood tests, but there is no evidence that the latter was followed up.
30. Healthcare staff monitored Mr Franks’ blood pressure regularly. He did not always
comply with medical advice, such as requests for monitoring, attending
appointments and taking medication.
31. On 10 December, an Advanced Nurse Practitioner (ANP) changed Mr Franks’
dihydrocodeine prescription from ‘in-possession’ in his cell, to supervised
dispensing, as it was a high-risk drug and often illicitly traded. He also noted that it
should not be used long term and there was no reason for prolonged use in Mr
Franks’ case.
32. On 22 March 2022, the ANP started a gradual reduction of Mr Franks’
dihydrocodeine, substituting ibuprofen and paracetamol.
33. On 7 November, the ANP held a general review with Mr Franks and prescribed
alternative medications for high blood pressure and high cholesterol. Checks in late
November and early December indicated that his blood pressure was within the
acceptable range and his cholesterol level had reduced.
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Events of 5 December
34. At midday on 5 December, an officer conducted the lunchtime roll checks on Mr
Franks’ landing, before prisoners’ cells were locked. Mr Franks appeared to be
asleep. The officer, who knew him well, said this was not unusual as Mr Franks
slept for long periods during the day, especially around lunchtime.
35. Just after 4.35pm, a prisoner told an officer that he was concerned as he could not
get a response from Mr Franks through his cell door. The officer went into the cell.
There was no response when he called out to Mr Franks, so he touched his
shoulder. It was cold and his lips were blue. The officer asked a colleague to radio a
code blue (a medical emergency code which indicates a prisoner has difficulty
breathing or is unresponsive) and an ambulance was requested at 4.39pm. Several
other operational staff responded and began cardiopulmonary resuscitation.
36. Two nurses arrived and took over the resuscitation attempts, including use of a
defibrillator, while waiting for the ambulance crew. An attempt to insert an airway
failed, as Mr Franks’ jaw was clenched.
37. Paramedics arrived at the cell at 4.57pm and confirmed Mr Franks’ death.
Contact with Mr Franks’ family
38. The prison’s family liaison officer and a colleague went to the home of Mr Franks’
daughter. They informed her of Mr Franks’ death and offered support. The family
liaison officer kept in touch over the following weeks.
39. The prison arranged and paid for Mr Franks’ funeral.
Support for prisoners and staff
40. A prison manager and a custodial manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support.
41. The prison posted notices informing other staff and prisoners of Mr Franks’ death
and offering support.
Post-mortem report
42. The report of the post-mortem examination concluded that the cause of Mr Franks’
death was ischaemic heart disease (blockage of the blood vessels supplying the
heart), arising from coronary artery atheroma (fatty deposits) and cardiomegaly
(enlarged heart) in the context of a high blood dihydrocodeine level.
43. Toxicology tests revealed the presence of dihydrocodeine, carbamazepine and
galantamine. None of these drugs had not been prescribed to Mr Franks.
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Findings
Clinical findings
44. The clinical reviewer concluded that Mr Franks’ clinical care was of a reasonable
standard and equivalent to that which he could have expected to receive in the
community.
Management of Mr Franks’ hypertension
45. Although Mr Franks’ blood pressure was monitored (with increased frequency in
2021/22), there was no hypertension care plan. The clinical reviewer noted that a
care plan is the primary source of information to ensure that individual needs and
goals are met. We agree that they are essential for effective management of long-
term conditions. We recommend:
The Head of Healthcare should ensure that personalised care plans with aims,
planned interventions and monitoring, are in place for all patients with long-
term health conditions.
Substance misuse and diversion of medication
46. Dihydrocodeine, found in Mr Franks’ blood during toxicology tests, contributed to his
death. Healthcare staff had stopped prescribing this to him in March 2022. We were
unable to establish how Mr Franks obtained the drugs. He had previously traded
and used illicit medication over a long period, but in recent years there was no
evidence that he had been involved in such activity.
47. The Inspectorate and the IMB were critical of the safe management and
inappropriate use of prescribed medication, respectively. There has since been a
review of transporting medicines and issuing in-possession medications and more
secure processes have been implemented.
48. The Head of Drug Strategy and Healthcare Provision told the investigator that in
January 2023, the prison had formed a dedicated healthcare staffing group, to
ensure consistency in healthcare-related operational tasks such as supervision of
the inpatient unit, medication queues, clinics and hospital escorts. Medication
dispensing is strictly supervised by the same group of experienced prison officers.
Prisoners are not allowed to leave until the nurse is satisfied that the medication
has been swallowed and, in the event of concerns, the officer is alerted and escorts
the prisoner away to be searched. As a result, there had been a significant
reduction in the trading of medication, which was no longer a widespread problem.
Currently, the drugs of concern are mainly psychoactive substances. The drug
strategy document is currently being updated.
49. Additionally, a dedicated nurse has reviewed all high-risk and tradeable medication
prescribed to individual prisoners and made adjustments, where necessary. An
example of this is that no prisoners at Wakefield are currently prescribed tramadol.
50. In view of the considerable steps taken to address concerns about the misuse of
medication, we make no further comment.
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Inquest
51. At an inquest held on 20 May 2024, the Coroner concluded that the Mr Franks’
death was misadventure – a chronic heart condition in the context of high levels of
dihydrocodeine which was illicitly obtained in the prison.
Prisons and Probation Ombudsman 7
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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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