Sex offender died in his cell at HMP Wymott - probe reveals concern over care and 'significant' delay
A probe into the death of a sex offender at Wymott Prison has revealed failings in care.
The Prison and Probation Ombudsman (PPO) investigated the death of William Jolly, 64, in his cell on March 26, 2024, and a report has been released this week.
It points out that the care Jolly received at Wymott was not of a satisfactory standard and was not equivalent to what he could have expected to receive in the community. It also highlights a “significant delay” in healthcare staff responding to the medical emergency code.
What happened?
On September 21, 2018, William Jolly was sentenced to 20 years in prison for sexual offences. He was initially at HMP Manchester, but in February 2021 was transferred to HMP Wymott.
Jolly had a medical history including high blood pressure, stroke, and Chronic Obstructive Pulmonary Disease (COPD). Healthcare staff created a COPD care plan which was reviewed in 2022, but had not been reviewed again prior to his death. On February 5, 2022, healthcare staff created an older persons care plan for Jolly, which was regularly reviewed. On November 6, he was moved to the Haven Unit - a unit for older prisoners and those with a disability, social and palliative care needs.
He experienced some breathing difficulties in 2023 and on February 8, 2024, a GP at the prison saw Jolly after he reported chest pain and gave antibiotics and steroids to treat a chest infection.
At 5am on March 26, an officer began conducting the routine check of all prisoners on the Haven Unit. When he could not see Jolly in his cell, he opened the cell door and found him lying on the floor, unresponsive. The officer raised the alarm and other officers arrived and began CPR. It took the emergency response nurse six minutes to reach Jolly’s cell. At 5.05am, the control room staff called an ambulance. At 5.21am, paramedics arrived at the prison and took over Jolly’s care. At 5.30am, the paramedics confirmed that Jolly had died.
The coroner gave Mr Jolly’s cause of death as coronary artery disease.
The report
A PPO report by Adrian Usher states: “The clinical reviewer concluded that the care Mr Jolly received at Wymott was not of a satisfactory standard and was not equivalent to what he could have expected to receive in the community.” It adds: “ He was concerned that Mr Jolly’s COPD care plan was not reviewed annually as it should have been, however he noted that Mr Jolly’s condition was adequately monitored. He also identified that there were inaccuracies in data recording.”
Mr Usher also asked why it took six minutes for a nurse to respond to the code blue. In response, the nurse said that although he was already on the wing, he went to collect the emergency equipment from the wing treatment room. He said the distance between Jolly’s cell and the treatment room was not far and that the delay may have been because he was checking that all the emergency equipment was in the bag.
The report states: “We spoke to the primary care manager, who told us that all emergency bags were checked weekly, and the tags on the bags were checked daily. She said she would not expect a nurse to check the bag during a medical emergency. She spoke to the emergency healthcare response following the interview to address the issue. We make no recommendation.”
Mr Usher has also urged the prison governor to consider reports from staff that they were unaware of a debrief after the death and claims of not being signposted to or offered support following Mr Jolly’s death.
Deaths at Wymott
William Jolly was the 30th prisoner to die at Wymott since March 2021. Of the previous deaths, 26 were from natural causes and three were self-inflicted. In a previous death at Wymott, the PPO made a recommendation about care plans being initiated and reviewed on a regular basis. The Head of Healthcare agreed to review care plan audits regularly which aimed to highlight any areas of concern, and agreed to remind all staff of the initiation and review of care plans.
In another previous death, the PPO made a recommendation to the Governor about ensuring that an ambulance is requested immediately when a medical emergency code is called. The Governor agreed that the Safety Custodial Manager would carry out awareness sessions with all control room staff, and once completed staff would be required to sign a compact to confirm they had undertaken the session and understood what actions were required.