Paul Horrocks is serving a sentence for theft when he was found unresponsive

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

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

When he arrived at Cheshire prison, he continued the methadone detoxification program he had started in his previous prison and engaged with the prison’s substance abuse team and mental health team. In addition to methadone, Horrocks was prescribed antipsychotic and antidepressant medication.

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In a report by the Prisons and Probation Ombudsman published on 8 November 2024, an investigation found that inmates described Horrocks as being under the influence of illicit drugs on the evening of Saturday 29 June 2019 but failed to inform prison staff. At around 7.30am on Sunday 30 June that year, Horrocks failed to attend the health facility for methadone medication, leading to staff checking the 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 had clearly been dead for some time and that any attempt at resuscitation would be futile” and decided not to attempt CPR. Paramedics arrived at the cell at around 8.15am, where they confirmed that the 43-year-old man had died.

An autopsy failed to determine the cause of death and it remains unexplained. An investigation by the ombudsman found that the substance abuse and mental health care Horrocks received was of a good standard and 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 what he would have received in the community. However, there were concerns that during the initial health check Horrocks was found to have high blood pressure, but no further tests or follow-up were carried out by staff. There were also concerns that medical staff had not arranged a secondary health screen.

The assessment for emergency care found prison staff did not use an emergency medical code as they should have done 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. 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 had been trained in first aid. It also found that prison staff failed to update control room staff as to the nature of the medical emergency, meaning they were “unable to relay accurate information to the emergency ambulance services”.

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

• The Head of the Health Service should ensure that all prisoners with high blood pressure are monitored in accordance with NICE guidelines.
• The Head of Nursing should ensure that all new prisoners receive secondary medical reviews within seven days in accordance with NICE guidelines and PSO 3050, Continuity of care for prisoners.
• The governor should ensure that all prison staff are informed and understand their responsibilities during medical emergencies, including that staff: immediately use an emergency code when there are serious concerns about an inmate’s health to alert control room staff to automatically call an ambulance; and effectively communicate the nature of a medical emergency so that there are no delays in directing or unloading ambulances.
• The governor should ensure that there are a sufficient number of radios 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 Chief Medical Officer 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 calling for ambulances are able to cannot provide detailed information about a detainee’s medical condition immediately.
• The Governor should ensure that there are sufficient first aid trained staff 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 enough radios at all times and has also introduced a first aid training program as well as completing a review to ensure that there are sufficient first aid trained personnel available.

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