William Dawson

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Independent investigation into
the death of Mr William Dawson,
a prisoner at HMP Holme House,
on 11 March 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, 2025
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Summary
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. Mr William Dawson died of metastatic cancer of the pancreas on 11 March 2024,
while a prisoner at HMP Holme House. He was 73 years old. We offer our
condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Dawson received at Holme
House was of a good standard and at least equivalent to that which he could have
expected to receive in the community. The clinical reviewer made recommendations
which were not related to Mr Dawson’s death but which the Head of Healthcare will
want to address.
5. It was particularly shocking that although Mr Dawson had had both legs amputated
and posed a low risk, HMP Durham, Mr Dawson’s previous prison, considered it
appropriate to restrain him using an escort cable when he went to hospital two
months before he died. Healthcare staff had not completed an escort risk
assessment and were not always asked to contribute to the risk assessment
process.
Recommendation
• The Governor and Head of Healthcare at HMP Durham should ensure that all
staff undertaking escort risk assessments understand the legal position on
the use of restraints, that assessments fully take into account the current
health, mobility and risk of a prisoner and that healthcare staff complete the
medical sections accurately.
• The Governor of HMP Durham should ensure that a quality assurance
process is implemented to satisfy himself that restraints decisions are
credible, and all necessary parties are consulted.
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The Investigation Process
6. HMPPS notified us of Mr Dawson’s death on 11 March 2024.
7. NHS England commissioned an independent clinical reviewer to review Mr
Dawson’s clinical care at HMP Holme House.
8. The PPO investigator investigated the non-clinical issues relating to Mr Dawson’s
care.
9. Mr Dawson had no recorded next of kin.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Holme House and HMP Durham
11. Mr Dawson was the twelfth prisoner to die at Holme House since March 2022. Of
the previous deaths, 10 were from natural causes, and one was non-natural. There
are no similarities between the findings in our investigation into Mr Dawson’s death
and the findings from our investigations into the previous deaths.
12. However, we have previously made recommendations to HMP Durham in two
cases in early 2023 about the need for healthcare staff to contribute to the escort
risk assessment process and for this to be properly documented when deciding
whether or not to use restraints. Durham agreed to implement our
recommendations.
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Key Events
HMP Durham
13. On 9 January 2023, Mr William Dawson was sentenced to 27 years in prison for sex
offences and sent to HMP Durham. He had a significant medical history, including
chronic obstructive pulmonary disease. He had had both legs amputated above the
knee and used a wheelchair.
14. On 5 January 2024, a doctor operating at Durham saw Mr Dawson for suspected
jaundice. They advised that he needed to be admitted to hospital, but this could not
be done until the following day due to prison staffing pressures.
15. Prison staff completed an escort risk assessment on 5 January and decided that,
when he went to hospital, he should be restrained with a D-cuff escort cable (where
a prisoner is restrained by a long metal cable with a cuff at either end, one of which
is attached to the prisoner and the other to an officer). The escort risk assessment
noted that there were no medical objections to restraining Mr Dawson but also that
he was a double leg amputee, used a wheelchair, had ‘reduced mobility’, and was
assessed as low risk for escape and harm to others.
16. The officer who completed the escort risk assessment told the investigator that
healthcare staff had not been asked to complete the medical section of the risk
assessment and he could not recall if he had spoken to healthcare staff about Mr
Dawson. Instead, he had completed some details using the alerts from Mr
Dawson’s prison records but could not recall whether he completed the section to
say there were no medical objections to the use of restraints.
17. The Head of Business Assurance at the time, and the authorising manager, told us
that she authorised the use of an escort cable because Mr Dawson was a sex
offender and consideration had to be given to his risk to others. She said that an
escort cable was used as opposed to other forms of restraints because he was a
double leg amputee.
18. On 6 January, Mr Dawson was admitted to hospital for suspected obstructive
jaundice (which is caused by a blocked bile or pancreatic duct), restrained with an
escort cable.
19. On 9 January, Mr Dawson’s restraints were removed in hospital. The bed watch log
stated that this was because Mr Dawson was a double leg amputee and there was
no security intelligence about him.
20. On 11 January, a hospital doctor told Mr Dawson that he had inoperable pancreatic
cancer. He was discharged to Durham on 16 January, unrestrained for the journey
back to the prison.
HMP Holme House
21. On 21 January, Mr Dawson was transferred to the healthcare unit at HMP Holme
House as he needed palliative care. He was not restrained for any visits to hospital
for cancer treatment.
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22. On 31 January, Mr Dawson’s palliative care treatment began, and healthcare staff
discussed his end-of-life care with him. He signed an order not to be resuscitated if
his heart or breathing stopped.
23. On 5 February, Mr Dawson became confused and was admitted to hospital, where
he was diagnosed with biliary sepsis and acute kidney injury. He was treated with
intravenous antibiotics.
24. On 9 February, Mr Dawson was discharged from hospital to Holme House and told
that he may need palliative chemotherapy.
25. On 3 March, nursing staff found Mr Dawson drowsy and slumped in his chair. He
was admitted to hospital again for biliary sepsis and acute kidney injury. Although
he was given antibiotics, his health continued to deteriorate.
26. He was discharged on 9 March to Holme House and moved to the palliative care
suite for end-of-life care. A hospital consultant told prison staff that Mr Dawson had
a prognosis of a few days.
27. At approximately 6:40pm on 11 March, Mr Dawson died.
Post-mortem report
28. A hospital doctor established that Mr Dawson had died from metastatic cancer of
the pancreas. He also had peripheral vascular disease (a disease where circulation
to a body part is reduced due to a blocked or narrowed vessel), hypertension and
chronic obstructive pulmonary disease which contributed to but did not cause his
death. The Coroner accepted the cause of death, and no post-mortem examination
was carried out.
Inquest
29. At an inquest held on 9 October 2024, the Coroner concluded that Mr Dawson died
of natural causes.
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Non-Clinical Findings
Restraints, security and escorts
30. 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.
31. A judgment in the High Court in 2007, known as the Graham judgment, 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. 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. The Prevention of Escape: External
Escorts policy framework states that restraints should not routinely be used where
mobility is severely limited such as in the case of advanced age and disability.
32. On 6 January, while at HMP Durham, Mr Dawson was taken to hospital for
suspected jaundice, restrained with an escort cable. Mr Dawson was 73 years old.
He used a wheelchair, as he was a double leg amputee, and he was a Category C
prisoner. His risk level was assessed as low in all areas, with no intelligence to
suggest there was a risk of escape or harm to staff. He was an enhanced prisoner
who had had no previous disciplinary hearings. Mr Dawson had no family contact
which might have further reduced his risk of escape.
33. An officer told the investigator that he completed the medical section of the risk
assessment using information from Mr Dawson’s prison records. This section did
not note that Mr Dawson was a double leg amputee. He could not recall if he had
spoken to healthcare staff or if they had contributed to the risk assessment, but the
risk assessment noted no medical objections to restraints.
34. The Head of Business Assurance told the investigator that the decision to use an
escort cable was in the interests of decency, as well as the health and safety of
staff. The Head of Healthcare told us that the prison often did not ask healthcare
staff to complete escort paperwork at the time and she did not want staff to sign
such paperwork when a prisoner’s clinical condition could subsequently change,
and they could be liable for the decision. She also told the investigator that
healthcare staff were not always consulted on the use of restraints if the prison did
not consider it necessary.
35. As a result, Mr Dawson’s severely limited mobility as a double amputee was not
taken into account when deciding to restrain him. This decision was unjustified and
not in line with the policy framework, particularly as he was identified as posing a
low risk of escape and harm to others and he was escorted by two officers.
36. We have previously made recommendations to the Governor of HMP Durham in
January and February 2023 about the inappropriate use of restraints and about the
need for healthcare staff to complete the escort risk assessment appropriately.
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Durham accepted our recommendations and agreed to ensure clinical staff
complete the escort risk assessment properly and review and amend the risk
assessment form on a trial basis. However, this case demonstrates that significant
issues with the inappropriate use of restraints remain that must be addressed, and it
is clear that greater oversight and closer monitoring of decisions is needed. We
make the following recommendations:
The Governor and Head of Healthcare at HMP Durham should ensure that all
staff undertaking escort risk assessments understand the legal position on
the use of restraints, that assessments fully take into account the current
health, mobility and risk of a prisoner and that healthcare staff complete the
medical sections accurately.
The Governor of HMP Durham should ensure that a quality assurance
process is implemented to satisfy himself that restraints decisions are
credible, and all necessary parties are consulted.
Governor to note
37. HMP Durham continue to use their own template for the escort risk assessment.
This is contrary to the Prevention of Escape: External Escorts Policy Framework
which requires prisons to use the risk assessment template which is annexed to the
policy. The Governor of HMP Durham will wish to review this practice.
Adrian Usher
Prisons and Probation Ombudsman October 2024
6 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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