John Leadbitter, 62, died from lung cancer on January 31 last year at HMP Hull, according to the findings by the Prisons and Probation Ombudsman (PPO).
Leadbitter, of no fixed address, had been charged with causing arson with intent to endanger life, carrying a knife in public, unlawful violence and causing actual bodily harm.
All the offences were alleged to have happened on August 29, 2023, at Ampleforth Surgery, near Helmsley.
Ampleforth Surgery said the incident had been a “distressing event” that “deeply affected every member of our team”.
Photographs shared after the fire showed the surgery badly damaged with the interior walls black from the blaze.
Leadbitter was to have been tried last year, but lawyers raised concerns about his mental state and the case was delayed. He had been remanded in custody since his arrest.
At previous hearings, York Crown Court heard that Leadbitter had been refusing to come out of his cell and was not co-operating with his legal team or a psychiatrist instructed to prepare a report on his fitness to plea.
The interior of Ampleforth surgery after the fire in August 2023 (Image: Supplied) The PPO’s report found that Leadbitter had poor health, limited mobility and there was “no indication he posed a risk” before his death.
Leadbitter had previously served a lengthy jail sentence for raping a woman and almost severing her head with an axe before pouring petrol over her.
Then 36 and living in Stockton, Leadbitter had initially denied all charges but was convicted of rape, wounding with intent to cause grievous bodily harm, and false imprisonment at the end of a six-day trial at Teesside Crown Court in 1997.
Jailing him for 15 years, Judge Peter Fox said it was the most serious wounding case he had come across in 30 years, reported the Herald.
Leadbitter had been using wheelchair before death – report
The report into Leadbitter’s death said he had been using a wheelchair during his final months due to mobility issues.
A coroner concluded at an inquest held on June 6 that Leadbitter died of natural causes.
The PPO’s report said the care Leadbitter received at HMP Hull had been “partially equivalent to that which he could have expected to receive in the community”.
But the watchdog found that the prison’s health department was “not appropriately equipped to care for prisoners receiving palliative care”.
Its report said Leadbitter had been restrained with “an escort chain or a double cuff” while being taken to hospital for treatment, which the ombudsman said should not have been the case.
The watchdog noted there was “no intelligence to suggest [Leadbitter] posed a security risk in terms of escape or risk to staff or the public”, and said: “Despite this, Hull restrained Mr Leadbitter.”
In its report, the ombudsman told HMP Hull’s governor and head of healthcare to “ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints”.
A Prison Service spokesperson said: “We have accepted all of the PPO’s recommendations in this report including training all staff to deliver palliative care and ensuring appropriate equipment is available at HMP Hull to support this.
“We are also currently reviewing the arrangements around restraints during hospital visits.”
