Barry Horrocks · Prevention of Future Deaths report

On 9th April 2013, I commenced an investigation into the death of Barry Horrocks (aged 65). The investigation concluded at the end of the Inquest on 15th October 2014. The conclusion of the Inquest was death from natural causes. The cause of death being:-

1(a) Intraventricular haemorrhage (stroke)
2 Systemic atheroma and hypertension

I concluded that “Barry Horrocks was aged 65 and was serving a 9 year sentence of imprisonment at Her Majesty’s Prison, Wakefield. Mr Horrocks suffered with heart related problems, cerebral vascular problem and he had previous strokes. He was on a substantial amount of medication. As a consequence of his medical condition, he had a poor memory, failing eye sight and mobility problems. He had got to the stage where he was struggling to deal with the activities of daily living such as personal hygiene and other aspects of intimate self-care. Although the Inquest has established that there was no comparable provision for Social Services’ input as a person within prison would enjoy in the community, none of these apparent shortcomings or issues have in anyway caused or contributed to Mr Horrocks’ death. It is believed that he suffered some sort of cerebral event whilst in his cell on 29th March 2013 which caused him to be admitted to Pinderfields General Hospital where his condition deteriorated and where his death was confirmed at 16.35 hours on 5th April 2013.

1. Barry Horrocks was aged 65 and was sentenced to nine years imprisonment in January 2011. He suffered from a number of physical and mental health problems and he had been diagnosed with Vascular Dementia.

2. Whilst at HMP Wakefield, he was on normal location and received help from a number of prisoner volunteer carers. He became increasingly unable to carry out routine activities of daily living or attend to his more intimate needs such as toileting, dressing and undressing. His personal hygiene was deteriorating. He was struggling to deal with his copious amounts of medication and keeping his cell in an acceptably clean and tidy condition.

3. His deteriorating mental health was attributed to factors such as high blood pressure and previous strokes. This coupled with poor eye sight made him extremely vulnerable whilst in prison.

4. The main concern raised by this investigation was the lack of co-ordinated care for Mr Horrocks. His personal hygiene was allowed to deteriorate in a way that was neither decent nor dignified. For example, there were occasions when through no fault of his own he was incontinent of faeces whilst taking a shower.

(1) When Mr Horrocks lived in the community he was supported by local Social Services who provided him with considerable assistance with activities of daily living. He lived in a specially adapted bungalow which was adapted to his individual needs.

(2) It was when in Prison that his immediate environment, that is his Prison cell was not in any way adapted to assist with activities of daily living. The ‘Social Services’ input’ which was a vital element of his care obviously could not be replicated whilst he was in prison. Such an input though was needed and necessary for his well-being.

(3) Mr Horrocks, by virtue of his condition “fell through the net” in that none of the providers of care including health care had responsibility for a man in his condition. I was informed that assistance with intimate aspects of the activities of daily living were outside the remit of prisoner volunteers; the uniform prison officers; and those who provide primary care such as GPs and nursing staff nor, I was told, was it appropriate for him to be cared for in the Prison Healthcare Centre whether as an in-patient or out-patient. Those who provide mental health care and out of hours care did not accept any responsibility for his well-being.