Prisoner found dead in cell after missing appointment

A prisoner was found dead in his cell after he missed an appointment for medication. Paul Horrocks was jailed on September 5, 2018, for two years and eight months for burglary.

He had a long history of substance misuse in the community and when he was sent to prison he was prescribed methadone, used to treat heroin addiction. Initially, Horrocks was sent to HMP Forest Bank before being moved to HMP Thorn Cross in Appleton Thorn, Warrington, in April 2019.

When he arrived at the Cheshire prison, he continued his methadone detoxification programme that he had started in the previous prison and engaged with the prison's substance misuse team and mental health team. As well as methadone, Horrocks was prescribed antipsychotic and antidepressant medications.

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In a Prison and Probation Ombudsman report published on November 8, 2024, an investigation found that prisoners described Horrocks as being under the influence of illicit drugs on the evening of Saturday, June 29, 2019, but failed to inform staff at the prison. At around 7.30am on Sunday, June 30 that year Horrocks failed to go to the healthcare unit for his methadone medication, leading to staff checking his cell.

He was found unresponsive on his bed and the officer called for a nurse. The report said the nurse attended and "considered that Mr Horrocks has clearly been dead for some time and that any attempts at resuscitation would be futile" and decided to not to attempt CPR. Paramedics arrived at the cell at around 8.15am where they confirmed the 43-year-old had died.

A post-mortem failed to determine the cause of death and it remains unexplained. An investigation by the ombudsman found that the substance misuse and mental health care Horrocks had received had been of a good standard and he had daily contact with healthcare staff.

It also found that the clinical care Horrocks received at Thorn Cross was of a good standard and equivalent to what he would have received in the community. However, there were concerns that during the initial health screening it was found that Horrocks had high blood pressure but staff did not complete any further tests or follow up action. There was also concerns over healthcare staff not arranging a secondary health screen.

In the review for emergency care, it was found that prison staff did not use a medical emergency code as they should have done when Horrocks was found unresponsive in his cell on June 30. This meant staff were not aware of the nature of the medical emergency and there was a delay in calling an ambulance as a result. However, the ombudsman said this did not affect the outcome for Horrocks.

The ombudsman also raised concerns that none of the prison staff who responded to the emergency in Horrocks' cell on June 30 were first aid trained. It was also found that prison staff failed to update control room staff about the nature of the medical emergency meaning they were "unable to relay accurate information to the ambulance emergency services".

However, Prison and Probation Ombudsman report said it was satisfied that this did not affect the outcome for Horrocks. In the list of recommendations sent to the HM Prison and Probation Service, the report said:

• The Head of Healthcare should ensure that any prisoners with elevated blood pressure readings are monitored in accordance with NICE guidelines.

• The Head of Healthcare should ensure that all new prisoners receive secondary health screens within seven days, in line with NICE guidelines and PSO 3050, Continuity of Healthcare for Prisoners.

• The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies including that staff: use an emergency code immediately where there are serious concerns about the health of a prisoner to alert control room staff to call an ambulance automatically; and efficiently communicate the nature of a medical emergency so that there is no delay in directing or discharging ambulances.

• The Governor should ensure there are a sufficient number of radios available to officers on each Unit.

• The Governor should ensure that this report is shared with Officer A and that a senior manager discusses the Ombudsman’s findings with him.

• The Governor and the Head of Healthcare should liaise with the local Ambulance Service to ensure that an effective protocol is in place so that the Ambulance Service understands the nature of medical emergencies in a prison context and that staff who request ambulances might not be able to provide detailed information about a prisoner’s medical condition immediately.

• The Governor should ensure there are sufficient numbers of first aid trained staff on duty at all times, in line with PSI 29/2015.

Since the report, HMP Thorn Cross has ensured staff in every residential area of the prison have sufficient radios at all times and it has also introduced a first aid training programme as well as completing a review to ensure there are enough first aid trained staff available.

A Prison Service spokesperson said: “Our thoughts remain with the friends and family of Paul David Horrocks. We have since implemented all of the Prison and Probation Ombudsman’s recommendations including introducing a new first aid training programme and improving 24/7 radio access for frontline staff.”