Inadequate Welfare Checks Highlight Risks in Prison System Following Inmate's Death

In a tragic incident at HMP Lincoln, a prisoner, identified as Mr. Cadman, was found dead in his cell following what has been described as an inadequate welfare check by prison staff. Mr. Cadman, who had been remanded to the facility on November 10, 2022, had a documented history of substance misuse and was under the supervision of health professionals during his time in custody. The details surrounding Mr. Cadman's death, which occurred on November 21, 2022, have been highlighted in a recent report by the Prison and Probation Ombudsman. The post-mortem examination revealed that Mr. Cadman died from heart disease, with cocaine and methadone use cited as contributory factors. On the morning of his death, a prison officer conducted a routine welfare check around 7:50 a.m. The officer, believing Mr. Cadman was asleep, communicated with his cellmate instead. According to the officer’s statement, it was common for Mr. Cadman to be asleep during morning checks, leading to a lack of thorough investigation into his condition. The officer utilized the light from the television to observe Mr. Cadman's breathing, concluding that he was simply in slumber. However, the situation took a grim turn when Mr. Cadman's cellmate attempted to wake him around 8:10 a.m. and discovered that he was cold to the touch. This alarming discovery prompted the cellmate to alert a nearby officer, who immediately called for a medical emergency. When healthcare and operational staff arrived, they found that Mr. Cadman had already succumbed to death, as indicated by the presence of rigor mortis. The Ombudsman's findings noted that while Mr. Cadman's clinical care in prison was on par with what he might have received in the community, the welfare check that morning failed to meet necessary standards. Ombudsman Adrian Usher emphasized the importance of adequate protocols during such critical checks and expressed satisfaction with the steps the prison governor has since taken to enhance staff awareness and adherence to their responsibilities in this regard. The death of Mr. Cadman not only raises serious questions about the adequacy of welfare checks in prisons but also underscores the ongoing challenges surrounding the care of inmates struggling with substance misuse. As the Prison Service implements changes to address these issues, it remains vital for oversight bodies to continue monitoring the situation to ensure that the health and safety of all prisoners are prioritized. The loss of Mr. Cadman serves as a stark reminder of the potential consequences of oversight in correctional facilities.