PPO publish independent investigation into the death of Mr David Morgan on 30 August 2018

The Prisons and Probation Ombudsman (PPO) has published an independent investigation into the death of Mr David Morgan on 30 August 2018, who was a resident at HMP/YOI Chelmsford.

Our investigation found there was a comprehensive failure by prison and healthcare staff to discharge their duty of care to Mr Morgan. Kimberley Bingham, who was Acting Prisons and Probation Ombudsman at the time the final report was drafted, stated that she is disturbed by the uncaring and disrespectful culture that surrounded Mr Morgan.

Mr Morgan was placed in a holding cell after he had taken an overdose of medication and showed signs of being unwell. Without any evidence, staff concluded he was drunk on hooch. He became distressed and even more unwell; his cognition became sufficiently impaired for him to be incapable of coherent speech, and he was unable to prevent himself from repeatedly falling on the floor. Despite the presence of several staff and a nurse, our investigation showed that he sustained a broken nose, eye socket and fractures to both of his legs during these falls. Over two and a half hours after entering the holding cell, he lapsed into unconsciousness and an ambulance was called. He was taken to hospital and died eight days later.

This is an extremely disturbing case where staff involved showed a shocking lack of compassion, empathy and concern for Mr Morgan’s well-being and decency. The treatment he received was nothing short of inhumane and degrading. We offer our condolences to Mr Morgan’s family and friends.

The prison needs to demonstrate that it now has the strong leadership and positive partnerships needed to ensure that the awful treatment Mr Morgan received is never repeated.

Click here to view the report

We would like to acknowledge the delay in publishing the final report after Mr Morgan’s inquest concluded. There are a number of factors that may delay a report’s publication, from inquests, the impact of COVID-19, to considering the feelings of families involved, and we are conscious that the report’s publication should not be delayed any further.

Please note, readers may find the report distressing to read.