Abdul Ghani

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Independent investigation into
the death of Mr Abdul Ghani,
on 25 February 2024,
following his release from
HMP The Mount
A report by the Prisons and Probation Ombudsman
Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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© Crown copyright, 2025
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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Summary
1. The Prisons and Probation Ombudsman aims to make a significant contribution to
safer, fairer custody and community supervision. One of the most important ways in
which we work towards that aim is by carrying out independent investigations into
deaths, due to any cause, of prisoners, young people in detention, residents of
approved premises and detainees in immigration centres.
2. If my office is to best assist His Majesty’s Prison and Probation Service (HMPPS) in
ensuring the standard of care received by those within service remit is appropriate,
our recommendations should be focused, evidenced and viable. This is especially
the case if there is evidence of systemic failure.
3. Since 6 September 2021, the PPO has investigated post-release deaths that occur
within 14 days of the person’s release from prison.
4. Mr Abdul Ghani died from metastatic pancreatic cancer on 25 February 2024,
following his release from HMP The Mount on 17 February 2024. He was 60 years
old. We offer our condolences to those who knew him.
5. We did not find any significant issues for learning in the pre or post-release
planning. We make no recommendations.
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The Investigation Process
6. HMPPS notified us of Mr Ghani’s death on 11 September 2024.
7. The PPO investigator obtained copies of relevant extracts from Mr Ghani’s prison
and probation records.
8. We informed HM Coroner for Hertfordshire of the investigation. He gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. The Ombudsman’s office contacted Mr Ghani’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. Mr Ghani’s brother did
not have any specific questions but asked for a copy of our report.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Ghani’s family received a copy of the initial report. They did not make any
comments.
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Background Information
HMP The Mount
12. HMP The Mount is a category C prison which holds convicted adult male prisoners.
It is managed by HMPPS. Practice Plus Group provides physical and mental health
care.
Probation Service
13. The Probation Service works with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, prepare reports to advise the Parole Board and have links
with local partnerships to which they refer people for resettlement services, where
appropriates. Post-release, the Probation Service supervises people throughout
their licence period and post-sentence supervision.
HM Inspectorate of Prisons
14. The most recent inspection of HMP The Mount was in March 2022. Inspectors
reported that patients who had long-term conditions and/or complex health needs
benefited from a nurse-led service. A multi-disciplinary initiative helped patients to
manage and overcome the challenge of suffering with long-term pain and receive
the most appropriate pain relief.
HM Inspectorate of Probation
15. The most recent inspection of National Probation Service (NPS) West Midlands
region was in August 2022. Inspectors reported that the Probation Delivery Unit
(PDU) was rated inadequate overall. The necessary quality assurance processes
and management oversight to ensure effective sentence planning was evidently not
in place.
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Key Events
16. On 19 March 2009, Mr Abdul Ghani was remanded to HMP Birmingham charged
with murder. On 6 October 2010, he was sentenced to life imprisonment and
received a minimum term of 999 months. On 31 August 2023, Mr Ghani was
transferred to The Mount.
17. Mr Ghani had some pre-existing medical conditions including asthma, ischemic
heart disease (IHD) and chronic obstructive pulmonary disease (COPD). These
conditions were managed well.
18. In August, Mr Ghani was diagnosed with pancreatitis (inflamed pancreas) and
hepatic portal vein thrombosis (the formation of blood clots in the veins of the liver).
He received appropriate medication to manage these conditions.
19. On 10 September, healthcare staff saw Mr Ghani after he complained of abdominal
pain. He said that he had been in pain for the last two or three days and had not
opened his bowels in that time. Healthcare staff referred him to hospital specialists.
Mr Ghani was admitted to hospital for treatment.
20. On 13 September, a hospital specialist phoned a GP at the prison and said that
they were investigating masses found on Mr Ghani’s pancreas.
21. On 25 September, Mr Ghani was discharged from hospital and returned to The
Mount. On 30 September, Mr Ghani complained of pain in his chest, kidneys,
abdomen, legs and head. Mr Ghani was taken to hospital and admitted as an
inpatient.
22. On 9 October, a nurse at The Mount attended a virtual meeting with consultants
from the hospital. They said that Mr Ghani had stage four pancreatic cancer with
lung metastases and that he was not suitable for chemotherapy. The consultants
gave his life expectancy as between three and 12 months. Due to Mr Ghani’s
prognosis, the prison started end of life planning and applied for early release on
compassionate grounds (ERCG - a prisoner can be released early in exceptional
circumstances such as terminal illness). The application was refused because Mr
Ghani’s life expectancy at that time was more than three months.
23. On 2 November, Mr Ghani was discharged from hospital and returned to The
Mount, but he returned to hospital the following day because of a urinary tract
infection.
24. On 9 November, Mr Ghani was discharged from hospital and returned to The Mount
with a walking frame. He was fully trained in self-catheterising. That day, the
hospital palliative care team referred Mr Ghani to a community hospice.
25. On 10 November, a Cancer Nurse Specialist from the community palliative care
team visited Mr Ghani in prison and completed an initial assessment. She assessed
The Mount as not being a suitable location to meet his care needs and advised that
when Mr Ghani deteriorated, he would need to be transferred to a prison with 24-
hour healthcare or a hospice.
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26. In January 2024, Mr Ghani was admitted to hospital due to increased pain and his
inability to mobilise. The hospital did not feel this was a warranted admission and he
was discharged with increased pain relief and a wheelchair. Healthcare staff
reviewed Mr Ghani on his return from the hospital and they agreed to assess and
review him every day and the GP would review him every Friday. He was returned
to hospital on 26 January after experiencing increased pain in his abdomen and for
fluid retention.
27. On 16 January, Mr Ghani’s ERCG application was approved as his life expectancy
was now weeks rather than months. Mr Ghani was suitable for palliative care only
and on 7 February, he was placed on end-of-life care. Mr Ghani remained in
hospital as his health drastically deteriorated and he was too unwell to return to The
Mount.
28. On 17 February, Mr Ghani was released on compassionate grounds to a hospice in
London.
29. On 19 February, Mr Ghani’s Community Offender Manager (COM) phoned the
hospice twice to check on Mr Ghani. The nurse at the hospice said that he was
weak and only had days to live. He was not responsive, so his COM was not able to
talk to him.
30. On 25 February, Mr Ghani died in the hospice with his family by his side.
Cause of death
31. A post-mortem examination was not carried out as the coroner accepted the cause
of death provided by the doctor. The doctor gave Mr Ghani’s cause of death as
metastatic pancreatic cancer (when cancer spreads to other parts of the body).
32. The coroner chose to not hold an inquest given the natural cause of Mr Ghani’s
death.
Findings
33. We did not find any issues of concern and make no recommendations. We are
satisfied that prison and probation staff supported Mr Ghani with the deterioration of
his health. The healthcare team at The Mount regularly contacted the hospital for
updates on Mr Ghani’s condition and when he returned from the hospital, staff
monitored him appropriately.
34. Mr Ghani was promptly referred for the necessary scans and support he required,
and there is evidence of good multi-disciplinary care within healthcare at The Mount
and the community hospital and his COM ensuring Mr Ghani was supported
appropriately.
Good practice
35. The application for ECRG was made promptly and re-submitted when his condition
deteriorated.
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36. Although Mr Ghani had been released under ERCG, the prison still appointed a
Family Liaison Officer, who kept in contact with Mr Ghani’s family after he was
released to the hospice, and prison staff continued to visit Mr Ghani in the hospice.
Adrian Usher
Prisons and Probation Ombudsman March 2025
6 Prisons and Probation Ombudsman
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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