A prisoner should not have been cuffed during the final months of his life, an independent investigation has found.

Raymon Coburn, aged 77, from Redditch, died in hospital of metastatic rectal cancer on November 25, 2022, whilst he was an inmate at HMP Rye Hill.

Coburn was jailed for 25 years in 2015 after being found guilty of 17 historical child sexual offences between 1974 and 1994.

Most of the offending took place in Redditch where he groomed vulnerable victims and made them perform various sex acts upon him.

At an inquest held on February 14, 2024, the coroner concluded that he died from natural causes but the findings of an independent investigation have now been released by the Prisons and Probation Ombudsman.

The report concludes that although the clinical care received at HMP Rye Hill was of a good standard, the prison had used unnecessary restraints on Coburn during the final months of his life.

In particular, during hospital visits between March and June 2022 and again in October before his death, the investigators saw "no justification" for him being restrained due to his declining health and mobility issues.

In a statement from the report, the investigators said: "We found that Mr Coburn was inappropriately restrained when he went to hospital for outpatient appointments on four occasions between March and June 2022, and again in October, when he was admitted to hospital a month before he died.

"The Director and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that assessments fully take into account the health of a prisoner and are based on the actual risk he presents at the time."

On his final visit to the hospital, Coburn was restrained using an escort chain before it was decided to remove the restraint. The report said it was only at this point that healthcare staff considered his physical deterioration.

The next day it was noted that Mr Coburn was "medically unwell and frail, was a wheelchair user and found transferring to the bed difficult". 

It was also noted that the likelihood of escape was very low with the report raising further concerns over HMP Rye Hill's "continuing failure to comply with case law on the use of restraints", particularly following investigations into two earlier deaths.

It said: "We are particularly concerned that following our investigations into two earlier deaths, Rye Hill agreed to implement training on the completion of escort risk assessment, including training to ensure staff take into account the requirements of the Graham judgment.

"Although we were told that all risk assessments would include the principles of the judgment to help ensure that decision-making was appropriate, we cannot see that this happened in Mr Coburn’s case."

In response to the findings of the report, a spokesperson for HMP Rye Hill said: "When using restraints on escorts, we act with decency while protecting the public. "In line with the recommendations in this report, our staff perform risk assessments for prisoner escorts and take into account the health of a prisoner and the risk presented at the time of the escort."