August 2019

Sex offender died naked on his prison cell floor soaked in his own urine

An elderly sex offender serving a 15-year sentence died naked and soaked in his own urine on his cell floor.

The Prisons & Probation Ombudsman investigated the death of James Baldwin, 81, who died of a blood clot after falling from his bed in HMP Littlehey, near Huntingdon.

Baldwin, who was serving a 15-year-sentence, had an incurable form of blood cancer and had received treatment at the nearby Hinchingbrooke Hospital for his health issues.

At 5.30am on August 6, 2018, an officer found that he had fallen out of bed and was lying naked on the floor and in his own urine.

He was conscious and kept repeating ‘hello’ over and over again.

The officer went to the office to phone for assistance, but she stayed outside his door and only spoke to him through the observation panel whilst she waited for others to arrive.

After 15 minutes, four members of staff entered his cell, but the officer who initially found him said she stood outside for ‘decency reasons’.

Baldwin was conscious but struggled to communicate verbally and instead responded to questions by putting his thumbs up or down. He confirmed that he was not in any pain and was told someone would check on him later.

At 6.15am, the same officer found he had fallen out of bed yet again. He was lying on the floor, breathing and with his eyes open but not looking at her.

She again went to phone for assistance then stood outside his cell and kept talking to him.

After about 10 minutes, Baldwin stopped breathing and an ambulance was called, though the officer continued to stay outside the cell.

He died at 7.15am that same morning.

The officer later said that as a lone female working in a male sex offender wing, she did not feel safe going into cells on her own.

She also said that she was not medically trained and could not, therefore, have done anything to help Mr Baldwin had she entered the cell.

Under normal circumstances, a cell should only be opened with at least two or three staff present, according to the prison’s rules.

But it has been ruled that the preservation of life must take precedence over this as long as there is no danger to themselves or others.

In the report on Baldwin’s death, published on Wednesday (July 31), Prisons & Probations Ombudsman Elizabeth Moody said: “It is particularly difficult to understand why she did not enter the cell when she thought that Mr Baldwin had stopped breathing.

“We appreciate that the officer was not first aid trained and that Mr Baldwin had a DNACPR [Do Not Resuscitate] order in place, but she might have been able to make Mr Baldwin more comfortable and allow him to die with more dignity.”

A first-aid trained member of staff checked for signs of life when he arrived but found none. He did not start CPR because of the Do Not Resuscitate order.

Ms Moody said the officer on duty should have been briefed at the start of her shift that Baldwin was ‘terminally ill, very frail, and nearing the end of his life’.

There were also concerns that after his initial cancer diagnosis, Baldwin was restrained whilst being escorted to hospital on three instances, despite being a wheelchair user as he was too frail to walk.

Ms Moody said this was not proportionate to the risks he posed, given that ‘his health was clearly deteriorating and he had poor mobility’.

The report recommended prison staff have clearer guidance on the management of seriously ill prisoners, especially out-of-hours when healthcare staff are not on hand.

It also said the escort risk assessment form should require healthcare staff to say whether the prisoner’s current state of health has an impact on mobility.