Andrew Bullough

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Independent investigation
into the death of
Mr Andrew Bullough, a prisoner
at HMP/YOI Thorn Cross,
on 21 August 2025
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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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. On 15 March 2024, Mr Andrew Bullough was sentenced to six years in prison for
drug offences. He died in hospital of congestive cardiac failure caused by acute
myocardial infarction with rupture and severe coronary artery atheroma on 21
August 2025, while a prisoner at HMP/YOI Thorn Cross. He was 59 years old. We
offer our condolences to Mr Bullough’s family and friends.
4. The Ombudsman’s office wrote to Mr Bullough’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They asked
questions about the emergency response and asked for a copy of our report. We
have answered the family’s questions in the clinical review and in separate
correspondence.
5. NHS England commissioned an independent clinical reviewer to review Mr
Bullough’s clinical care at HMP Thorn Cross. The clinical reviewer’s report is
attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Bullough received at HMP
Thorn Cross was of a good standard and equivalent to what he could have
expected to receive in the community. He found that Mr Bullough had limited
contact with healthcare staff at Thorn Cross, however when appropriate, he was
reviewed in a timely manner and his healthcare needs were met and supported.
The clinical reviewer made no recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Bullough’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS) and
Practice Plus Group. They did not find any factual inaccuracies.
10. Mr Bullough’s family received a copy of the draft report. They did not make any
comments.
11. At the inquest held on 28 April 2026, the coroner concluded that Mr Bullough died of
natural causes.
Adrian Usher
Prisons and Probation Ombudsman April 2026
Prisons and Probation Ombudsman 1
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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
OFFICIAL - FOR PUBLIC RELEASE