Prisoner found dead after inadequate welfare check

Curtis Cadman, 50, was found dead in his cell after a prison officer had earlier assumed he was sleeping

A welfare check on the morning of a prisoner's death "fell short" of the required standards, a report by the prison ombudsman has said.

Curtis Cadman, 50, was found dead in his cell at HMP Lincoln on 21 November 2022 after a prison officer had earlier assumed he was sleeping.

The investigation also found control room staff did not adhere to the mandatory requirement to request an ambulance for a medical emergency.

The Prison Service said action had been taken to address the issues raised in the report.

'Staff awareness'

Mr Cadman was remanded to HMP Lincoln on 10 November 2022.

He had a history of substance misuse and was placed under the supervision of health professionals at the jail, according to the report by the Prison and Probation Ombudsman.

A post-mortem examination found he died of heart disease, with the use of cocaine and methadone contributory factors.

The report said at about 07:50 GMT on 21 November 2022, a prison officer conducted a welfare check and thought Mr Cadman was asleep but spoke to his cellmate.

The officer told the investigation Mr Cadman was "always asleep during the morning checks", but, using the light from the television, had concluded the prisoner was breathing.

Later, at about 08:10, Mr Cadman’s cellmate tried to wake him, but found he was cold.

He alerted an officer, who called a code blue medical emergency, and healthcare and operational staff were called to the cell. Rigor mortis in Mr Cadman's face and arms indicated he was dead so they did not try to resuscitate him.

A paramedic employed at the prison confirmed his death.

Ombudsman Adrian Usher said: "The investigation found that Mr Cadman’s clinical care was equivalent to that which he could have expected to receive in the community."

However, he said: "The welfare check on the morning of Mr Cadman’s death fell short of the required standards, but I am satisfied that the governor has since taken steps to increase staff awareness of their responsibilities when conducting such checks."

Welfare check 'deficiencies'

Lincoln’s policy on managing medical emergencies "should be strengthened" and control room staff "should not wait" for authorisation to request an ambulance when a medical emergency code is called, he added.

Mr Usher said he was also concerned that a review of Mr Cadman’s death did not explore the fundamental issues highlighted in his report, relating to staff actions before and immediately after he was found dead.

The report said Mr Cadman was the eleventh prisoner at Lincoln to die since November 2019. Six were from natural causes and four were self-inflicted.

"We have highlighted deficiencies in welfare checks at Lincoln in previous investigations, as well as the need to comply with the medical emergency response procedures," the ombudsman added.

A Prison Service spokesperson said: “Our thoughts remain with Curtis Cadman’s friends and family.

"Since his death, staff at HMP Lincoln have been reminded of the correct actions to take in a medical emergency to reduce the chances of this happening again.”

Follow BBC Lincolnshire on Facebook, X (formerly Twitter), and Instagram. Send your story ideas to [e-mail]