William Evans

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr William Evans,
a prisoner at HMP Ashfield,
on 13 March 2023
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 William Evans died in hospital from a heart attack on 13 March 2023, while a prisoner
at HMP Ashfield. He was 72 years old. I offer my condolences to his family and friends.
The clinical reviewer found that the clinical care that Mr Evans received at Ashfield was
partially equivalent to that which he could have expected to receive in the community. She
found that the care he received prior to 11 March 2023 was good, but that on that day, it
fell below the standard reasonably expected as there was a delay in escalating treatment.
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 September 2023
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 23 March 2018, Mr William Evans was sentenced to 15 years in prison. On 27
November 2019, he was moved to HMP Ashfield.
2. When Mr Evans arrived at Ashfield, it had already been identified that he was at
high risk of a heart attack or stroke. Staff offered him statins (cholesterol-lowering
medication) to reduce his risk, but he repeatedly refused them as he said they gave
him side effects.
3. Mr Evans experienced some chest pains in early 2022. He was referred to hospital
for tests, but they found nothing of concern.
4. Shortly before 5.00am on 11 March, Mr Evans pressed his emergency cell bell as
he was feeling unwell and finding it difficult to breathe. Officers attended and found
the cell was very hot. They turned off the heater and increased the ventilation in the
cell. They asked healthcare staff to see Mr Evans when they arrived at the prison
(no healthcare staff are on duty overnight).
5. At around 11.30am, healthcare staff saw Mr Evans in his cell. Mr Evans complained
of nausea and dizziness in the night, and ongoing issues of pins and needles in his
arm, constipation and a frequent need to urinate. He did not mention chest pains.
Healthcare staff took his clinical observations which were all within normal ranges.
They told Mr Evans to call for help if he felt worse.
6. Officers checked on Mr Evans throughout the day. He remained unwell and did not
eat, but as he did not feel worse during the day and evening, staff did not call for
healthcare staff.
7. When Mr Evans was unlocked at around 8.30am on 12 March, he was still feeling
unwell, so officers called for a nurse to see him. She found that some of Mr Evans’
clinical observations were abnormal, and she asked an officer to call a medical
emergency code. An ambulance arrived at 9.30am. Paramedics assessed that Mr
Evans might be having a heart attack and that he needed to go to hospital.
8. On the way to hospital, Mr Evans suffered a heart attack in the ambulance. He was
admitted to hospital but died there the next day.
Findings
9. The clinical reviewer found that the care Mr Evans received up to 11 March 2023
was of a good standard. Staff had tried to persuade Mr Evans to take statins and
explained the risks of not doing so. Despite this, there were long periods when Mr
Evans did not take his medication.
10. The clinical reviewer found that the care Mr Evans received on 11 March, fell below
the standard reasonably expected and was not equivalent to that which he could
have expected to receive in the community. She found no evidence that the
healthcare staff who saw Mr Evans on 11 March had checked his medical history
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before seeing him, or that they had asked him about it. She considered that the
assessment did not take into account Mr Evans’ high risk of heart attack and there
were missed opportunities to escalate his care.
Recommendations
• The Head of Healthcare should ensure that when healthcare staff undertake clinical
assessments of acutely unwell patients, they complete a comprehensive
assessment that includes obtaining a patient’s past medical history to inform a safe
and comprehensive ongoing clinical treatment plan.
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The Investigation Process
11. HMPPS notified us of Mr Evans’ death on 13 March 2022.
12. The investigator issued notices to staff and prisoners at HMP Ashfield informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
13. The investigator obtained copies of relevant extracts from Mr Evans’ prison and
medical records.
14. NHS England commissioned an independent clinical reviewer to review Mr Evans’
clinical care at the prison.
15. The investigator and clinical reviewer interviewed two Ashfield healthcare staff on 1
June, and the investigator interviewed two Ashfield prison officers on 5 June. All
interviews were carried out by video call.
16. We informed HM Coroner for Avon of the investigation. She gave us the cause of
death. We have sent the Coroner a copy of this report.
17. The Ombudsman’s family liaison officer wrote to Mr Evans’ son to explain the
investigation and to ask if he had any matters he wanted us to consider. He did not
respond.
18. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found no factual inaccuracies.
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Background Information
HMP Ashfield
19. HMP Ashfield is a Category C prison, operated by Serco and holding approximately
400 men who have been convicted of sexual offences. Oxleas NHS Foundation
Trust provide physical healthcare services during the day from 7.30am to 5.30pm.
An out of hours service is available for other times.
HM Inspectorate of Prisons
20. The most recent inspection of HMP Ashfield was in March 2019. Inspectors
reported the health and social care provisions were of a good standard and most
prisoners were satisfied with the quality of healthcare received. However, inspectors
found that not all prisoners with long-term health conditions had care plans in place.
Independent Monitoring Board
21. 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 30 June 2022, the IMB found that
although access to routine healthcare services was generally assessed as equal to
that provided in the community, they were concerned that healthcare staff
shortages could present a risk to the long-term health and wellbeing of prisoners.
Previous deaths at HMP Ashfield
22. Mr Evans was the seventh prisoner to die at Ashfield since March 2020. All the
deaths were from natural causes. In one of these recent deaths, we were also
concerned about a delay in escalating treatment. The healthcare provider has not
yet responded to our recommendation.
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Key Events
23. On 23 October 2017, a court ordered that Mr William Evans should be remanded to
prison, pending the outcome of his charges of sexual offences. However, because
of chest pains, Mr Evans was taken to hospital. Doctors found no issues of concern.
They discharged him from hospital the next day and he was taken to prison.
24. On 23 March 2018, Mr Evans was sentenced to 15 years in prison. On 27
November 2019, he was moved to HMP Ashfield.
25. Mr Evans had been diagnosed with high cholesterol in the blood (which increases
the risk of heart attack and stroke) before he arrived at Ashfield and had been
prescribed statins (cholesterol-lowering medication). In May 2020, he said that he
no longer wanted to take statins due to the side effects. Healthcare staff at Ashfield
advised him of the risks of not taking the medication but he still refused.
26. In February 2021, a QRISK assessment (which calculates the likelihood of a stroke
or heart attack in the next ten years) showed that Mr Evans was at high risk. He
continued to refuse statins.
27. On 25 January 2022, Mr Evans complained of chest pains. Healthcare staff took his
clinical observations which were normal. However, blood test results showed a
potential heart problem. A GP at Ashfield told Mr Evans that he needed to go to
hospital, but Mr Evans said he felt fine and did not want to go to hospital. He again
refused statins. He said that he had tried them before and felt better without them.
28. The GP referred Mr Evans to a hospital rapid access chest clinic, and a cardiac
nurse specialist saw Mr Evans on 15 March. Mr Evans said that he had
experienced chest pain three times in the last three months. He said this occurred
at rest and lasted for about 10-20 seconds and felt like someone poking him inside
his chest. However, there were no significant abnormalities detected and the nurse
discussed Mr Evans with the consultant cardiologist who considered that Mr Evans’
symptoms were not heart related. They suggested that Mr Evans should take statin
medication.
29. In June, a GP at Ashfield persuaded Mr Evans to try statins but once again he
complained of side effects and stopped taking them in July.
30. In September, a GP at Ashfield persuaded Mr Evans to try a different statin. Once
again, he complained of side effects but remained on the medication and was still
taking it in March 2023. Besides collecting his statin medication, in the weeks prior
to 11 March, Mr Evans had no physical complaints and had very little contact with
healthcare staff.
Events of 11-13 March
31. Shortly before 5.00am on 11 March, Mr Evans pressed his emergency cell bell. He
said that something was happening to him, but he did not know what, and that he
was sweating and finding it difficult to breathe. The Duty Custodial Operational
Manager (COM) and two officers went to Mr Evans’ cell which was very hot (staff
told the investigator that it usually was). An officer said they opened up vents, which
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Mr Evans had blocked, and turned off a heater, and that after a while Mr Evans said
that he felt better. The officers left Mr Evans in his cell and checked on him again
after around 15 minutes. Mr Evans said he felt much better. The officers told Mr
Evans that they would let healthcare staff know when they arrived that morning, so
that they could visit him.
32. At about 10.00am, Mr Evans made a phone call to a friend. He said that he felt very
unwell and was phoning in case anything happened to him. He said he had also
notified his solicitor. He said that he had a chest pain that felt like he had a weight
on his chest, and that he felt very disorientated and weak.
33. At around 11.30am, the Head of Healthcare (who was carrying out a nurse shift that
day) and a nurse saw Mr Evans in his cell. The Head of Healthcare said that
officers had told her about the events earlier that morning, but that when she saw
Mr Evans, he did not mention any chest pain. He complained of dizziness and
nausea in the night, and recent constipation and a frequent need to urinate. Mr
Evans said he had pins and needles in his arm, but he thought this related to a
long-term issue with a trapped nerve. He thought some of his other symptoms were
side effects of his statin medication. The Head of Healthcare took Mr Evans’ clinical
observations which were all normal.
34. At interview, the Head of Healthcare said that as all Mr Evans’ clinical observations
were normal, she would have advised him to contact an officer if he had any further
problems. She arranged for a GP to review Mr Evans and his medication in a
routine appointment. The wing logbook records that the healthcare staff told the
officers that Mr Evans would need to go over to the pharmacy to pick up some
paracetamol.
35. At interview, an officer who was on the wing during the day told us that they
checked on Mr Evans every now and then to see how he was. Mr Evans did not
want to come out of his cell and refused all offers of food that day. The officer said
that Mr Evans thought that he had food poisoning. They also said that the advice
from healthcare was to contact them again if Mr Evans got any worse, and although
Mr Evans did not get better, he did not get any worse during the officer’s shift. The
officer said that Mr Evans did not mention chest pains at all.
36. The night officer who had responded to Mr Evans’ call at around 5.00am, was back
on duty that night. He said that at the beginning of his shift he went to see Mr
Evans, who told him that he felt better. The officer advised him to press his cell bell
in the night if he needed to.
37. At around 8.30am the next morning, when an officer unlocked Mr Evans’ cell, Mr
Evans said that he felt very unwell. He again told the officer that he thought he had
food poisoning. The officer consulted with his colleague who had seen Mr Evans
the day before. He then reported this to a nurse, who had also seen Mr Evans the
day before, and she advised that Mr Evans should get some fresh air. The officers
were concerned about Mr Evans and suggested that he should be seen as soon as
possible.
38. Shortly after the call from the officer, the nurse went to Mr Evans’ cell to check on
him. She said at interview that his physical presentation was not immediately
concerning as he was alert and appeared to be breathing without too much
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difficulty, but when she carried out clinical observations on him, his blood pressure,
heart rate and blood oxygen levels were all below normal limits and generated a
National Early Warning Score (NEWS2) of 7. (NEWS2 is a tool for assessing
clinical deterioration. It allocates a score of 0-3 for each vital sign: respiratory rate;
blood oxygen level; pulse; blood pressure; temperature and level of consciousness.
The scores are added together, and the higher the score, the greater the risk and
need for escalation of care. A NEWS2 rating of 7 is high and indicates an urgent
clinical assessment is required.)
39. At around 9.00am, the nurse asked one of the officers to call a code blue (a medical
emergency code used when a prisoner is unconscious or having breathing
difficulties that alerts healthcare staff and prompts the control room to call an
ambulance). At 9.06am, the control room called for an ambulance, which arrived at
the prison at around 9.30am.
40. Paramedics took Mr Evans to the hospital, and on the way, one of the prison escort
staff reported that paramedics suspected that Mr Evans had a heart attack in the
back of the ambulance. Doctors at the hospital discovered that Mr Evans had
severe damage to his heart and also had kidney failure.
41. Doctors were unable to treat Mr Evans and he died in hospital the next day, on 13
March.
Contact with Mr Evans’ family
42. The prison appointed a family liaison officer (FLO) very soon after Mr Evans was
taken to hospital on 12 March. The FLO contacted Mr Evans’ son soon after that,
and he was able to visit his father in hospital the same day. Following Mr Evans’
death, the FLO maintained contact with his son and coordinated funeral
arrangements with him and the return of his father’s property. The prison
contributed to the funeral costs in line with national policy.
Support for prisoners and staff
43. After Mr Evans’ death, staff were offered support, and the prisoners on the wing
were called together and managers explained that Mr Evans had died.
Subsequently both the prison chaplaincy and Safer Custody staff were on hand for
prisoners if they wanted support.
Cause of death
44. The Coroner told us that Mr Evans died from a myocardial infarction (heart attack).
There was no post-mortem examination.
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Findings
Clinical care
45. Mr Evans was identified as being at high risk of heart attack and stroke. The clinical
reviewer found plenty of evidence that healthcare staff at Ashfield had tried to
encourage Mr Evans to take statins to lower his risk of heart attack and stroke, but
he repeatedly refused. There were no concerns about Mr Evans’ understanding of
the risks of not taking his medication, so this was his personal decision, which staff
had to respect. The clinical reviewer found that the care Mr Evans received up to 11
March 2023 was of a good standard.
46. The clinical reviewer found that the care Mr Evans received at Ashfield on 11 March
was not of the expected standard. She noted that when the Head of Healthcare and
a nurse saw Mr Evans in his cell on 11 March, neither of them were familiar with
him and neither had looked at his medical records. There is also no evidence that
they asked him about his medical history, though the Head of Healthcare told the
clinical reviewer that she would have checked this when she made the entry in Mr
Evans’ medical record following the visit. The clinical reviewer noted that had this
visit occurred on a weekday rather than a Saturday, Mr Evans would have attended
the healthcare unit, where his medical record would have been more easily
accessible.
47. The clinical reviewer was concerned that Mr Evans’ symptoms of chest pain, pins
and needles and urinary frequency, were not seen in the context of his high risk of
heart attack (though she noted that Mr Evans did not complain of chest pain by the
time the Head of Healthcare saw him). She noted that the clinical observations were
normal but pointed out that early symptoms of a heart attack are not identified
through abnormal clinical observations. She also noted that both the Head of
Healthcare and nurse who saw Mr Evans on 11 March did not consider that he
presented as though he was having a heart attack as he was not short of breath.
However, she considered, on balance, that the assessment of Mr Evans could have
been more thorough, with reference to his medical history.
48. We recommend:
The Head of Healthcare should ensure that when healthcare staff undertake
clinical assessments of acutely unwell patients, they complete a
comprehensive assessment that includes obtaining a patient’s past medical
history to inform a safe and comprehensive ongoing clinical treatment plan.
Note to Governor
Emergency response
49. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
says that when a medical emergency code is called, staff in the
control/communications room should call an ambulance immediately. It says, ‘...the
member of staff using the medical emergency code must also provide relevant
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information about the condition of the prisoner to the control room staff, so that they
can pass it on to the ambulance service for use in the triage process’.
50. On 12 March, the code blue was called at 9.00am but the call to the ambulance
service was not made until 9.06am. It became apparent during interviews that there
was a little confusion about whether the code blue was called initially so that the
nurse could get a second opinion from another member of healthcare staff (after
healthcare staff had not responded to an initial call for healthcare staff to attend).
However, whenever a code blue is called, the control room should call for an
ambulance immediately. The call should not be delayed in order to get relevant
information from staff at the scene, and certainly not for six minutes.
51. We make no recommendation, but the Director may wish to consider the learning
from this case.
Inquest
52. The inquest, held on 21 October 2024, concluded that Mr Evans died from natural
causes.
.
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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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