Leon Cadman had been serving seven year sentence for drug offences

An ombudsman has raised concerns following the death of a man at HMP Peterborough.

Leon Cadman had been serving seven year sentence for drug offences when he died in hospital in July 2022 of cirrhosis of the liver.

The Prisons and Probation Ombudsman report into his death raised a number of concerns about the case.

The report said Mr Cadman had been sentenced in July 2021, and On 3 August, Mr Cadman was sent to hospital, where he was treated for liver disease.

He was discharged from hospital on November 2, and placed on the healthcare wing of HMP Peterborough.

On 4 November, a nurse noted that he had turned down a liver transplant and was on a palliative care pathway. Appropriate palliative care plans were put in place.

Over the next few months, Mr Cadman requested a ‘do not resuscitate’ order – then asked for that to be rescinded, before asking for it to be put in place again.

On 22 December, Mr Cadman was released on temporary licence to continue medical treatment in hospital without escorting prison officers by his side.

On the morning of July 12 2022, a Healthcare Assistant (HCA) attended Mr Cadman’s cell to carry out physical observations. She recorded that his blood pressure was low and that his heart rate was high. His temperature and oxygen saturation levels were within normal range. She did not complete a NEWS2 score. (A clinical tool to identify and address clinical deterioration. A score above

seven indicates the need for an emergency response.) The report said that if she had calculated a NEWS2 score using the recorded observations, it would have been at least nine.

At 10.34am, two nurses saw Mr Cadman because an officer reported to them that Mr Cadman was uncomfortable. They attended to his legs as they were leaking fluid and made him comfortable.

At 1.19pm, the officer telephoned to request an emergency ambulance and ambulance paramedics arrived at 1.42pm. The ambulance left at 2.27pm.

At 4.51pm, Mr Cadman died with his family by his side.

The ombudsman report said: “The clinical reviewer concluded that the clinical care Mr Cadman received at Peterborough was mostly of the required standard and partially equivalent to that which he could have expected to receive in the community. She said there was evidence of appropriate care planning, timely transfers to hospital when required and ongoing monitoring of his health needs. However, she was concerned that there was no timely escalation when Mr Cadman’s health deteriorated on 12 July 2022, NEWS2 scores were not calculated correctly, and healthcare staff were not offered appropriate support after his death.”

The report added: “Following a death in April 2022, our investigation found that although clinical observations were taken, NEWS2 scores were not always assessed at Peterborough. We await HM Prison and Probation Service’s action plan at the time of issuing this report.”

The ombudsman also said: “A hot debrief took place the day after Mr Cadman’s death. It was attended by two officers who had escorted Mr Cadman to hospital, however there is no record that any of the other staff involved in the incident, including healthcare staff were invited to attend. During interview, a nurse, who was involved in the emergency response, reported that she did not receive any support and that she was not invited to the hot debrief.

"We are concerned that healthcare staff involved were given no opportunity to discuss any concerns that arose and were not offered support services. We make the following recommendation: The Governor at HMP Peterborough should ensure that a manager holds a hot debrief promptly after a death in custody and that all those involved in the incident, including healthcare staff, are invited to attend.”

An HMP Peterborough spokesperson said: “Our thoughts continue to be with Mr. Cadman’s family and friends. A full Coroner’s Inquest has been held which examined all relevant matters. While many changes and improvements have been made in the prison in the two years since Mr. Cadman’s death, we have considered the Coroner’s findings and conclusions with great care and continue to build on progress made.”

To read the report in full, visit https://ppo.gov.uk/fatal_incident/leon-cadman/