Anthony Aldoescu

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation
into the death of
Mr Anthony Aldoescu,
a prisoner at HMP Gartree,
on 6 March 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
OFFICIAL - FOR PUBLIC RELEASE
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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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.
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.
Mr Anthony Aldoescu died of the effects of a synthetic cannabinoid in combination with left
ventricular hypertrophy (thickening of the heart muscles of the left ventricle) on 6 March
2025, while a prisoner at HMP Gartree. He was 52 years old. I offer my condolences to Mr
Aldoescu’s family and friends.
Mr Aldoescu had a history of substance use. While prison staff acted appropriately by
submitting intelligence reports, conducting a cell search and requesting a suspicion-based
drug test, I am concerned they did not make a referral to the substance misuse team so
that they could offer him support.
The clinical reviewer concluded that the healthcare Mr Aldoescu received at Gartree was
at least equivalent to what he could have expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2026
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. On 14 April 2005, Mr Anthony Aldoescu was sentenced to life in prison with a
minimum term of five years and three months for possession of a firearm with intent
to cause fear of violence.
2. Over the next 20 years, Mr Aldoescu progressed through his sentence, got a job
and generally worked well and without any issues. He moved to HMP Gartree in
2023. He had a history of illicit substance use and was suspected of being involved
in the supply of drugs at Gartree. Prison staff submitted several intelligence reports
about his suspected drug use and involvement in drug supply and took actions
including conducting a cell search and requesting a mandatory drug test, but they
did not refer him to the substance misuse team.
3. At around 6.00pm on 6 March 2025, an officer went to lock Mr Aldoescu’s cell and
saw him sat on his bed, leant against the wall, with his head facing away from the
cell door. The officer thought he saw Mr Aldoescu move and carried on locking up
the remaining prisoners. He returned to the cell a few minutes later to check on him
and found Mr Aldoescu unresponsive. He shouted for assistance and an officer
radioed a medical emergency code, but they did not start cardiopulmonary
resuscitation (CPR) immediately. At 6.10pm, nurses arrived and continued
resuscitation efforts.
4. At 6.23pm, paramedics arrived at the prison. They reached Mr Aldoescu’s cell three
minutes later and took over treatment. At 6.43pm, an ambulance paramedic
pronounced life extinct.
5. The post-mortem concluded that Mr Aldoescu died from the toxic effect of a
psychoactive substance (PS) and thickening of the heart muscle of the left ventricle.
Findings
6. Mr Aldoescu had a history of substance use and was able to obtain PS in prison. In
response to previous incidents, prison staff submitted intelligence reports and took
appropriate action, such as conducting a cell search and requesting a mandatory
drug test. However, Mr Aldoescu did not receive any substance misuse support at
Gartree. He was offered intervention when he first arrived, but declined. Prison staff
observed him under the influence of illicit substances several times and suspected
him of being involved in the distribution of drugs but did not notify the substance
misuse team. This meant they were unable to offer him further opportunities to
engage.
7. Gartree’s drug strategy sets out various measures to target illicit drug trafficking and
reduce the demand for drugs. The substance misuse team provide interventions
that include educating prisoner of the risk associated with illicit drug use and the
prison also has an incentivised substance free living unit.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Recommendations
• The Governor should ensure, through a robust quality assurance process,
that operational staff are aware of what action to take when they observe a
prisoner under the influence, including making a referral to the substance
misuse team.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
8. HMPPS notified us of Mr Aldoescu’s death on 6 March 2024.
9. The investigator issued notices to staff and prisoners at HMP Gartree informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
10. The investigator visited Gartree on 14 March. He obtained copies of relevant
extracts from Mr Aldoescu’s prison record and interviewed one prisoner.
11. The investigator interviewed three members of staff at Gartree on 24 April. He also
interviewed one member of staff by video conference on 2 May.
12. NHS England commissioned a clinical reviewer to review Mr Aldoescu’s clinical
care at the prison.
13. We informed HM Coroner for Leicester of the investigation. The Coroner gave us
the results of the post-mortem examination. We have sent the Coroner a copy of
this report.
14. The Ombudsman’s office contacted Mr Aldoescu’s mother to explain the
investigation and to ask if she had any matters she wanted us to consider. She
asked what happened before he died. We have addressed this in the report.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies but identified that one of the
attachments was not a transcript (as listed). HMPPS action plan is annexed to this
report.
16. Mr Aldoescu’s mother received a copy of the draft report. They did not make any
comments.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Gartree
17. HMP Gartree holds prisoners mainly sentenced to life imprisonment and other
indeterminate sentences. Practice Plus Group provides integrated healthcare.
Nursing staff are available 24 hours a day.
HM Inspectorate of Prisons
18. The most recent inspection of HMP Gartree was in January 2023. Inspectors
reported that too many illicit items, including drugs, were entering the prison, and
further action was required to reduce supply. Inspectors found that although prison
leaders had taken some appropriate steps to disrupt the supply of drugs into the
prison, prisoners told them that they could easily access illicit substances, and this
had caused some prisoners to build large debts and be at risk of violence.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year to November 2024, the IMB
reported that it remained concerned that drugs and other illicit items continued to
infiltrate the prison by a variety of means. They reported that despite stringent
procedures for preventing illicit items entering the prison, they were still reaching
prisoners and drone activity continued to be a problem, particularly at night.
Previous deaths at HMP Gartree
20. Mr Aldoescu was the twelfth prisoner to die at Gartree since March 2022. Of the
previous deaths, two were self-inflicted, one was drug related, seven were from
natural causes and one was of unknown cause. Since Mr Aldoescu’s death and up
to the end of August 2025, there have been four further deaths at Gartree, three
from natural causes and one self-inflicted. There were no similarities between any
of these and Mr Aldoescu’s death.
Psychoactive substances (PS)
21. Psychoactive substances are substances that affect mental processes. Synthetic
cannabinoids are substances that mimic the effects of cannabis. They can be hard
to detect as the compounds used in their manufacture can vary and use of these
substances presents a serious problem across the prison estate.
22. PS can affect people in several ways, including increasing heart rate, raising blood
pressure, reducing blood supply to the heart and vomiting. Prisoners under the
influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
Parole Board
23. The Parole Board for England and Wales is an independent public body. Its role is
to make risk assessments about prisoners to assess their suitability for transfer to
open conditions and to decide whether they can safely be released into the
community once they have served the minimum sentence imposed by the courts.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
24. On 14 April 2005, Mr Anthony Aldoescu was sentenced to life imprisonment with a
minimum term of five years and three months for possession of a firearm with intent
to cause fear of violence. He was sent to HMP Gloucester.
25. Over the next 18 years, Mr Aldoescu progressed through his sentence and spent
time at various prisons. He had ten Parole Board reviews, and, on each occasion,
the panel did not direct release or transfer to an open prison.
HMP Gartree
26. On 25 July 2023, Mr Aldoescu transferred from HMP Lowdham Grange to HMP
Gartree. A nurse conducted an initial reception screen and noted that he had a
history of illicit substance use. Mr Aldoescu said he would be willing to work with the
prison’s substance misuse team and the nurse referred him.
27. On 28 July, a substance misuse recovery worker, visited Mr Aldoescu to conduct an
initial assessment, but he declined. There is no evidence that staff observed him
under the influence of illicit substances again that year.
2024
28. On 28 February 2024, prison staff submitted an intelligence report stating that they
had observed Mr Aldoescu under the influence. There is, however, no record that
staff considered a referral to the substance misuse team.
29. On 6 April, prison staff submitted an intelligence report stating that Mr Aldoescu and
another prisoner were facilitating drugs coming onto the wing. Again, there is no
record that staff considered a substance misuse referral.
30. On 7 July, prison staff moved Mr Aldoescu to the therapeutic community (TC Plus,
a 12-bed therapeutic unit within Gartree for prisoners with learning difficulties and/or
disabilities), for an induction period. However, he was subsequently deselected
from the unit when he admitted to using illicit substances. There is no record that
prison staff considered a substance misuse referral. Mr Aldoescu moved to the over
50s section of H wing on 31 October.
31. On 16 November, prison staff submitted an intelligence report stating that since Mr
Aldoescu’s arrival on H wing, there had been several reports of prisoners under the
influence and inferring that he was responsible for bringing drugs to the wing. Once
more, there is no record that staff considered a substance misuse referral.
32. On 28 November, an officer recorded that he met with Mr Aldoescu and introduced
himself as his new key worker. He noted that Mr Aldoescu had a prison job and
spoke weekly to his family and friends.
33. On 20 December, prison staff submitted an intelligence report stating that around
two hours after they observed Mr Aldoescu associating with a prisoner suspected of
having significant involvement in the supply of illicit substances around the prison,
two prisoners on H wing required hospital treatment for the effects of substance
use.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
2025
34. On 12 January, an officer noted that prison staff conducted an intelligence led
search of Mr Aldoescu’s cell but did not find anything suspicious.
35. On 24 January, an officer saw Mr Aldoescu for a keywork session and noted that he
continued to get on well with his peers on the wing and had daily phone contact with
his mother. He added that TC Plus had asked Mr Aldoescu to meet with them to
discuss their outreach programme, but he declined, stating that he did not want to
talk to them.
36. On 21 February, an officer visited the wing to see Mr Aldoescu for a keywork
session. He noted that Mr Aldoescu expressed frustration about his work as an in-
cell food-packer ending (when the contract was withdrawn) and that he would see
what other opportunities were available.
37. On 28 February, prison staff submitted an intelligence report stating that they had
observed Mr Aldoescu under the influence of an illicit substance. They suggested a
Mandatory Drug Test (MDT), but there is no record that it took place. There is also
no record that staff considered a substance misuse referral.
Events of 6 March
38. The investigator watched CCTV and body worn video camera (BWVC) footage,
obtained prison statements and Ambulance Service records. The following account
is taken from all those sources.
39. At 4.29pm, CCTV shows Mr Aldoescu entered the cell of another prisoners, and left
around a minute later. At interview, Mr Hudson-Jones told the investigator that Mr
Aldoescu replaced some vapes that he had given him. Mr Aldoescu then went in
and out of his own cell, before finally entering his cell and shutting the door at
4.51pm.
40. At 5.40pm, the other prisoner approached Mr Aldoescu’s cell, looked through the
observation panel and walked away. He did not tell us why he went to Mr
Aldoescu’s cell, but said the TV was on and that he did not see anything else.
41. At around 6.00pm, an officer looked through the observation panel on Mr
Aldoescu’s cell door to check he was there and to lock the door. He told us that he
saw Mr Aldoescu sat on his bed, leant against the wall, with his head facing away
from the cell door. He said that he believed he saw Mr Aldoescu move and decided
to lock up the other prisoners on the landing before going back to check on him, as
he suspected he might have been asleep or under the influence of illicit substances.
42. At 6.03pm, the officer returned and opened Mr Aldoescu’s cell door to check on
him. He requested assistance from another officer, who was nearby. Both officers
entered the cell, closely followed by a third officer. They noticed vomit around Mr
Aldoescu’s mouth, and their efforts to rouse him were unsuccessful. At 6.08pm, an
officer radioed a medical emergency code blue (indicating that a prisoner is
unconscious or has breathing difficulties) and staff in the control room called an
ambulance. They laid Mr Aldoescu on his back on the bed and started
cardiopulmonary resuscitation (CPR).
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
43. At 6.10pm, two nurses arrived with the medical emergency response bags and
entered the cell. They used suction to help clear Mr Aldoescu’s airway and assisted
with CPR. At around 6.17pm, they moved Mr Aldoescu on to the floor and
continued CPR.
44. At 6.23pm, paramedics arrived at the main gate. At 6.26pm, they arrived at Mr
Aldoescu’s cell. The paramedics took over the resuscitation effort but at 6.43pm,
pronounced life extinct.
Events after Mr Aldoescu’s death
45. On 6 March, prison staff submitted an intelligence report stating that prisoners had
said that just before evening lock-up on 6 March, Mr Aldoescu had allegedly gone
around the wing asking other prisoners for drugs.
46. In July the Coroner received an anonymous letter purporting to be from a member
of staff at Gartree expressing concern at the response when Mr Aldoescu was
found unconscious.
Contact with Mr Aldoescu’s family
47. At 8.30pm, the prison appointed a Custodial Manager (CM) as the family liaison
officer FLO and an officer as her deputy. They identified that Mr Aldoescu had
named his mother as his next of kin and arrived at her address at 1.35am on 7
March. They broke the news and offered support.
48. Both the FLO and deputy provided ongoing support to Mr Aldoescu’s family until his
funeral, which took place on 2 April. The prison contributed towards the cost, in line
with national policy.
Support for prisoners and staff
49. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case-by-case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
50. On 6 March, a prison manager, debriefed the staff involved in the emergency
response and staff and prisoners were offered support. The local Samaritans
branch attended the prison, and Listeners were deployed to offer support to
prisoners. We are satisfied that the postvention response was adequate.
Post-mortem report
51. The post-mortem report found that Mr Aldoescu died from the toxic effects of the
synthetic cannabinoid MDMB-FUBINACA in combination with left ventricular
hypertrophy (thickening of the heart muscle of the left ventricle).
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Illicit substances
52. The post-mortem examination confirmed that Mr Aldoescu died from the effects of
synthetic cannabinoids in combination with left ventricular hypertrophy.
53. Mr Aldoescu had a history of substance use and was suspected of being involved in
the distribution of illicit drugs around the prison. We are satisfied that, for the most
part, prison staff submitted appropriate intelligence reports and acted on them by
conducting a cell search and requesting a suspicion-based drug test.
54. However, Mr Aldoescu did not receive any substance misuse support at Gartree.
Other than the referral made in 2023, in which he declined to engage, there is no
record that staff made a substance misuse referral when they suspected he was
under the influence.
55. HMPPS’s Drug Strategy, published in April 2019, highlights the importance of
building a picture of the security risks to enable prisons to better to target their
resources to tackle them. At the time of Mr Aldoescu’s death, Gartree had a drug
strategy dated 2025. The strategy set out measures to target illicit drug trafficking,
including the use of intelligence, the use of drug detection dogs and drug testing. It
also set out measures to reduce the demand for drugs, which included the provision
of support services through a clearly defined and effective referral process. In terms
of educating prisoners of the risk associated with using illicit substances, the prison
told us that the substance misuse team hold welfare sessions, one-to-one session
and group work. The prison also has an incentivised substance free living unit.
56. The seven recorded incidents involving Mr Aldoescu relating to illicit substances
were spread over 20 months. However, the intelligence reports related to supply
were not shared at the multi-disciplinary drug strategy meetings (held monthly). This
meant that staff were unable to establish a complete perspective and offer Mr
Aldoescu intervention. The Head of Reducing Reoffending and Drug Strategy, told
the investigator that he had discussed the issue with the Head of Security and the
drug strategy team now received all drug related intelligence, including that for
prisoners who were suspected of being involved in the distribution of illicit drugs.
We are satisfied that this action was appropriate.
57. Prison staff did not make a substance misuse referral after seeing Mr Aldoescu
under the influence. The Head of Reducing Reoffending and Drug Strategy told us
that every prisoner observed under the influence and identified in the daily briefing,
should be referred to the substance misuse team. As there is no evidence this
happened in Mr Aldoescu’s case, over a period of months, it indicates that there is a
gap in knowledge among some staff about what action to take when they suspect a
prisoner is under the influence. We accept that Mr Aldoescu was not frequently
observed under the influence and was difficult to engage, but substance misuse
referrals would have allowed staff to offer him further opportunities to engage. We
make the following recommendation:
The Governor should ensure, through a robust quality assurance process,
that operational staff are aware of what action to take when they observe a
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
prisoner under the influence, including making a referral to the substance
misuse team.
Clinical care
58. The clinical reviewer concluded that the standard of healthcare Mr Aldoescu
received at Gartree was at least equivalent to the care he would have received in
the community. Mr Aldoescu had not presented with any cardiac issues at Gartree.
Governor and Head of Healthcare to note
The emergency response
59. When Mr Aldoescu was found unresponsive, officers spent nearly four minutes
trying to get a response from Mr Aldoescu before they established that he was not
beathing and started CPR. While we recognise the distressing nature of finding a
prisoner unresponsive, it is crucial that staff start CPR at the earliest opportunity.
60. Prison staff started CPR while Mr Aldoescu was on his bed, which continued for
around 16 minutes after healthcare staff arrived. Performing CPR on a patient who
is lying on a bed (or other soft surface) can reduce its effectiveness. The clinical
reviewer considered that staff should immediately transfer a prisoner to a hard
surface, such as a floor, to ensure optimal chest compressions. The Governor and
Head of Healthcare will want to reflect on this learning.
Head of Healthcare to note
Preparedness for medical emergencies
61. Healthcare staff responded promptly to the code blue, but a nurse noted that she
was not aware of the seriousness of the emergency prior to her arrival. In line with
PSI 03/2013 on medical response codes, Gartree’s local policy instructs staff to use
a code blue to indicate when a prisoner is unconscious or having breathing
difficulties. Healthcare staff responding to emergencies should therefore be
prepared for the possibility that CPR is in progress. While the clinical reviewer
considered that it did not materially impact on the outcome for Mr Aldoescu, in other
cases, it could be crucial. The Head of Healthcare will, therefore, wish to consider if
there is any broader learning about the use of the code systems at Gartree and
staff’s preparedness for medical emergencies.
Inquest
62. At the inquest which took place on 13 May 2026, the Coroner concluded that Mr
Aldoescu died of misadventure, compounded by the poor communication and
information sharing about his drug abuse risk in the weeks prior to his death.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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