Paul Horrocks was found unresponsive while serving a sentence for theft

A prisoner who missed his medication appointment was found dead in his cell. Paul Horrocks was sentenced to two years and eight months in prison for theft on 5 September 2018.

He had a long history of substance abuse in the community, and when he was sent to prison he was given a prescription for methadone, which is used to treat heroin addiction. Initially Horrocks was posted to HMP Forest Bank before being moved to HMP Thorn Cross in Appleton Thorn. warringtonIn April 2019.

when you get there Cheshire In prison, he continued the methadone detoxification program he had started in his previous prison and worked with the prison’s substance abuse team and mental health team. Horrocks was prescribed antipsychotic and antidepressant medications, as well as methadone.

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In the Prison and Probation Ombudsman report published on 8 November 2024, an investigation found that prisoners described Horrocks as being under the influence of illegal drugs on the evening of Saturday 29 June 2019 but did not inform prison staff. At around 7.30am on Sunday 30 June the same year, Horrocks was unable to go to the medical unit for methadone medication, prompting staff to check his cell.

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

The autopsy was unable to determine the cause of death and remained unexplained. An investigation by the Ombudsman found that the substance abuse and mental health care Horrocks received was of a good standard and that he had daily contact with medical staff.

It also found that the clinical care Horrocks received at Thorn Cross was of a good standard and equivalent to the care he would receive in the community. However, there were concerns that staff did not carry out any further testing or follow-up, despite Horrocks being found to have high blood pressure during an initial health screening. There were also concerns about medical staff not organizing a second health screening.

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

The Ombudsman also raised concerns that none of the prison staff who responded to the emergency in Horrocks’ cell on June 30 had received first aid training. It was also revealed that prison staff did not inform control room staff about the nature of the medical emergency, meaning they “were unable to convey accurate information to ambulance emergency services”.

But the Prison and Probation Ombudsman report said it was satisfied this did not affect Horrocks’ outcome. In a list of recommendations sent to HM Prison and Probation Service, the report stated:

• The Head of Health Services must ensure that all prisoners with elevated blood pressure readings are monitored in accordance with NICE guidelines.
• The Director of Health Services must ensure that all new prisoners undergo second health screenings within seven days in accordance with NICE guidelines and PSO 3050, Continuity of Health Services for Prisoners.
• The governor must ensure that all prison staff, including himself, are aware of and understand their responsibilities during medical emergencies: where there are serious concerns about the health of a prisoner, immediately use an emergency code to automatically alert control room staff to call an ambulance; and effectively communicate the nature of the medical emergency so that there is no delay in routing or evacuating ambulances.
• The Governor must ensure that sufficient radios are available to officers in 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 Health Services should liaise with the local Ambulance Service to ensure that the Ambulance Service understands the nature of medical emergencies in the prison context and that an effective protocol is in place to understand that staff requesting an ambulance may not be able to provide it. Immediate detailed information about an inmate’s medical condition.
• The governor must ensure that a sufficient number of first aid trained personnel are on duty at all times in accordance with PSI 29/2015.

Since the report, HMP Thorn Cross has ensured that staff in every residential area of ​​the prison have adequate radios at all times and has also completed a review to ensure sufficient first aid trained staff are available, as well as launching a first aid training programme.

A Prison Service spokesman said: “Our thoughts are with the friends and family of Paul David Horrocks. The Prison and Probation Ombudsman has since carried out a number of interventions, including the launch of a new first aid training program and improving 24/7 radio access for frontline staff.” We followed all of his recommendations.”