Lancaster prison criticised after inmate is kept chained to officers as he dies of Covid-19

Andrew Mason, a prisoner at HMP Lancaster Farms, died as a result of Covid-19 18 days after being admitted to the Royal Lancaster Infirmary.

He only had his handcuffs removed when he was put into a medically induced coma.

Officers had originally kept the 62-year-old 'double cuffed' as doctors attempted to ventilate him.

An investigation into Mr Mason's death by the Prisons and Probation Ombudsman has now criticised the continued use of handcuffs, the lack of planning for such a situation, and the manner in which officers were placed at risk of catching the virus from him.

The Prisons & Probations Ombudsman investigation, which looks into the circumstances of the death of any prisoner, raised concerns at the lack of a Covid-19 care plan or escalation plan for Mr Mason while he was in Lancaster Farms.

Mr Mason was first imprisoned in 2006 when he was given an indeterminate sentence for a violent offence with a minimum tariff of three years.

He was briefly released for around a month in 2018 and then again let out in November 2019, only to be recalled the following April.

He was moved to Lancaster Farms on April 28 2020.

On October 22 2020, Mr Mason told a healthcare support worker that he was feeling unwell and had a high temperature and no sense of smell.

It was observed he looked pale but did not have shortness of breath and he was advised to report any worsening symptoms.

He was also swabbed to test for Covid and was one of three prisoners sent to isolate.

Three days later, a nurse saw Mr Mason, who said that he felt very short of breath. The nurse found that Mr Mason’s oxygen saturation rate was very low, so she called a 'code blue’ emergency (which indicates that a prisoner is unconscious or having difficulty breathing).

Between 11.18am and 12.20pm, the prison’s control room made four calls to the ambulance service to request an ambulance and to chase it up as the nurses were concerned about Mr Mason’s condition. An ambulance arrived at 12.27pm.

At 1.01pm, paramedics took Mr Mason to the Royal Lancaster Infirmary.

A witness statement from a prison manager noted that Mr Mason needed to use a wheelchair when he moved from his cell to the ambulance.

Despite Mr Mason’s poor condition and limited mobility, the medical information section of the escort risk assessment made no reference to these issues.

Two prison officers accompanied Mr Mason and restrained him by ‘double cuffing’ him using an escort chain (a long chain with a handcuff at each end, one of which is attached to the prisoner and the other to an officer) rather than an additional set of handcuffs.

At the RLI, doctors decided to ventilate Mr Mason. One of the escorting officers contacted the prison for permission to remove the restraints, but a senior prison manager refused this.

At 5.45pm, doctors moved Mr Mason to the intensive care unit and placed him in a medically induced coma.

The senior prison manager this time authorised the escorting officers to remove the restraints, which were not reapplied.

Mr Mason’s condition continued to deteriorate, and he died at 5.56pm on November 12.

A hospital doctor recorded that Mr Mason’s death was caused by Covid-19 pneumonitis.

An inquest held in January 2022 concluded that Mr Mason’s death was from natural causes.

Sue McAllister, the Prisons and Probation Ombudsman, reported: "We are concerned that Mr Mason’s escort risk assessment was authorised without access to his Mercury (intelligence) file and that this resulted in an overestimation of the risks that he presented.

"Furthermore, we do not consider that it was appropriate to use double handcuffs on Mr Mason when he was taken to hospital.

"Double cuffing is usually required for moving category A or category B prisoners in good health.

"Mr Mason was a seriously ill, category C prisoner, with very poor mobility, and it is difficult to see how the escort risk assessment could conclude that he had the ability to escape unaided from two escort officers."

A further concern related to the decision to keep an officer in the room when Mr Mason was ventilated, which breached the expected procedure where a Category B, C or D prisoner should instead be viewed from an observation window outside the room.

As a result of the decision, two officers were placed at risk of catching Covid and were required to isolate.

Concluding her investigation, the Ombudsman recommended that the prison governor and head of healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases, the following takes place:

• healthcare staff complete the medical information section of the escort risk assessment to say whether the prisoner’s current medical condition affects their mobility and risk of escape;

• prison staff complete the security assessment section of the escort risk assessment by assessing the prisoner’s intelligence file;

• authorising managers show that they have taken this information into account when assessing a prisoner’s current level of risk.

The Governor should also ensure that managers authorise the removal of restraints for Covid-19 positive, non-category A prisoners needing ventilation or intensive care unit treatment, in line with the Standard Operating Procedure, Escorts & Bedwatches – Covid-19, unless abnormal circumstances apply.