Prisons ombudsman concludes investigation after Higham Ferrers sex offender's death

An investigation has concluded after a Higham Ferrers sex offender died while a prisoner earlier this year.

Dennis Damon, formerly of Nene Road, was jailed for 16 years in 2018 after he was convicted of historic child sex offences, including eight counts of rape.

He had been a prisoner at HMP Stafford when he died on January 16.

A recently-published report by the Prisons and Probation Ombudsman said the 81-year-old, who had vascular dementia, was transferred to the prison in April 2019 and had a catheter fitted the following month.

He died from a urinary tract infection in hospital and NHS England commissioned a review into his clinical care at HMP Stafford.

The report from the Prisons and Probation Ombudsman found: “The clinical reviewer concluded that the clinical care that Mr Damon received at Stafford was good and equivalent to that which he could have expected to receive in the community.

“However, the clinical reviewer found that when Mr Damon had his catheter changed on December 22, 2021, it was not fitted properly and he was admitted to hospital the next day with a low urine output, blood in his urine, abdominal pain, and a raised temperature.

“The clinical reviewer has made two recommendations which are not directly related to Mr Damon’s death but which the head of healthcare will need to address.”

The report found that in October a dementia nurse specialist thought relocating him to a care home setting should be considered but felt that his needs were being met at Stafford. Later that month a urine sample showed that he had a urinary infection.

Two months later, on December 23, a nurse saw the sex offender who had abdominal pain and a raised temperature. She found that he had only passed a small amount of urine and had blood in his catheter bag. She noted that his National Early Warning Score (a tool to detect and respond to clinical deterioration) indicated a high clinical risk and radioed a medical emergency code blue. Ambulance paramedics took him to hospital and hospital staff told an officer that his catheter was not properly fitted. They replaced his catheter and sent him back to Stafford.

The investigation found that five days later, on December 28, a nurse went to his cell because of a medical emergency code blue. He saw that there was blood in the catheter bag and ambulance paramedics took Damon to hospital, where hospital staff found that he had a chest and urine infection and treated him with intravenous antibiotics. On January 4 the prisoner returned to HMP Stafford with antibiotic tablets.

On January 7 a nurse noted that Damon had prolonged periods of delirium and that he could be moved to the special care unit (SCU) for safe 24-hour care. Later that day, the dementia nurse specialist spoke to a consultant psychiatrist, who said that Damon’s delirium could mean that he still had an infection and that he should go back to hospital. The nurse sent him to hospital, where he died on January 16.

The investigation report added: “He was also frail and had posterior reversible encephalopathy syndrome. These factors contributed to but did not cause his death.”