HMP Chelmsford prisoner showed ‘no indication’ of underlying heart disease before death

A Chelmsford prisoner showed ‘no indication’ of underlying heart disease before his death and had received a good standard of healthcare, a report has concluded.

Duncan Ford, 56, died of dilated cardiomyopathy, a disease of the heart muscle, on March 2, 2023 at HMP Chelmsford.

A report by the Prisons and Probation Ombudsman into his death said the clinical care provided to Mr Ford was equivalent to that which he could have expected to receive in the community. Mr Ford did not report any symptoms of physical illness and his death was “unexpected.”

Mr Ford had been remanded to Chelmsford Prison for various public order offences. He had a history of substance misuse issues and diagnoses of schizophrenia and bipolar disorder.

On the day before his death, Mr Ford had flooded his cell and refused to explain why. He had to move cells due to the flooding and became agitated during the process, so handcuffs were applied.

Mr Ford said he would go if the cuffs were removed, which staff did. He was successfully transferred to another wing.

When being locked into his cell for the night, Mr Ford swore at a prison officer and threw a plastic cup. During the evening, the prisoner in the neighbouring cell complained about Mr Ford being disruptive.

The night officer tried to speak to him, but Mr Ford was abusive and would not engage. At around midnight, Mr Ford stopped making noise, and his neighbour heard him snoring.

Just after 5am during the morning routine check, Mr Ford was observed lying on the cell floor where he appeared to be sleeping. The night officer had seen him do it before and noted movement so did not raise an alarm.

He returned at 5.36am to double-check if Mr Ford was okay and again thought he saw movement.

At 6am, the night officer tried to gain a response from Mr Ford but could not get one. When prison officers arrived on the wing at 6.15am, he asked them to check on Mr Ford.

They went into his cell and saw blood around his head so called for medical assistance. Mr Ford was not breathing and showed no signs of life. Nurses arrived, followed by paramedics, and it was agreed that Mr Ford had died.

A statement concluded: “The clinical reviewer concluded that Mr Ford received a good standard of healthcare in Chelmsford, which was equivalent to that which he could have expected to receive in the community.

“Mr Ford did not report any physical health concerns so there was no indication of underlying disease. Mr Ford’s main area of need was his mental health. Staff identified his mental health diagnoses and completed regular reviews. When Mr Ford did not collect his medication, staff encouraged him to comply with his prescription.

“When a member of staff asked a mental health nurse to see Mr Ford on 1 March, the nurse said that she would but did not do so. We were unable to establish why as the nurse has since left employment, but the omission did not impact on the outcome for Mr Ford who died of natural causes.”


Piers Meyler

Local Democracy Reporter