Aravindan Balakrishnan

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of
Mr Aravindan Balakrishnan,
a prisoner at HMP Dartmoor,
on 8 April 2022
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, 2024
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
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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 Aravindan Balakrishnan died of a lower respiratory tract infection on 8 April 2022 at
HMP Dartmoor. He was 81 years old. I offer my condolences to Mr Balakrishnan’s family
and friends.
The clinical reviewer concluded that the clinical care Mr Balakrishnan received at Dartmoor
was equivalent to that which 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 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 4
Findings ........................................................................................................................... 6
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Summary
Events
1. On 4 December 2015, Mr Aravindan Balakrishnan was sentenced to 23 years
imprisonment for sexual offences. He spent time in several prisons as he
progressed through his sentence. On 11 December 2020, he was transferred to
HMP Dartmoor.
2. At previous prisons, healthcare staff suspected Mr Balakrishnan had diabetes, but
he refused tests or medication for this. Healthcare staff at Dartmoor also arranged
for a mental health assessment and diagnosed possible dementia. Mr Balakrishnan
agreed to begin medication to control his diabetes. He was supported with social
care and received help from wing buddies (prisoners who are trained in providing
additional support).
3. When his health began to deteriorate, Mr Balakrishnan declined tests or medication
to explore the reason for this. On 4 March 2021, a consultant forensic psychiatrist
completed an assessment and diagnosed Mr Balakrishnan with dementia with
diminished capacity.
4. From March 2022 onwards, healthcare staff noted that Mr Balakrishnan appeared
frail, had lost weight and had a very small appetite. They arranged for blood and
urine tests to be taken and the results were all within a normal range.
5. On the evening of 7 April, Mr Balakrishnan fell in his cell. He told staff that he was
fine. They helped him back into bed and monitored him during the night.
6. Just before 9.00am on 8 April, Mr Balakrishnan’s prison buddy found him
unresponsive in bed. He immediately alerted staff. A prison officer entered the cell,
radioed a medical emergency code and started cardiopulmonary resuscitation
(CPR). Healthcare staff attended and stopped CPR as it was evident Mr
Balakrishnan had died. The nurse contacted the Ambulance Service to notify them,
and a GP at the prison confirmed Mr Balakrishnan’s death.
7. The post-mortem report concluded that Mr Balakrishnan died from a lower
respiratory tract infection.
Findings
8. The clinical reviewer concluded that the clinical care Mr Balakrishnan received at
Dartmoor was equivalent to what he could have expected to receive in the
community. The clinical reviewer noted examples of good clinical practice, despite
Mr Balakrishnan’s frequent refusal to engage with staff.
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The Investigation Process
9. HMPPS notified us of Mr Balakrishnan’s death on 8 April 2022.
10. The investigator issued notices to staff and prisoners at HMP Dartmoor informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
11. The investigator obtained copies of relevant extracts from Mr Balakrishnan’s prison
and medical records.
12. NHS England commissioned an independent clinical reviewer to review Mr
Balakrishnan’s clinical care at the prison.
13. We informed HM Coroner for Devon and Cornwall of the investigation. We
suspended the investigation from 25 August 2022 until 29 March 2023, while we
waited for the post-mortem results. We have sent the Coroner a copy of this report.
14. The Ombudsman’s family liaison officer contacted Mr Balakrishnan’s wife to explain
the investigation and to ask if she had any matters she wanted us to consider. She
did not respond.
15. The initial report was shared with HMPPS. They raised a question that does not
impact on the factual accuracy of this report and has been addressed through
separate correspondence.
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Background Information
HMP Dartmoor
16. HMP Dartmoor is a Category C training prison in Devon, which holds up to 640
prisoners. In 2013, HMPPS announced plans to close the prison in 2023, which
impacted on investment in infrastructure. However, the plans were dropped in
December 2021, and Dartmoor remains open for the foreseeable future. Healthcare
services are provided by Practice Plus Group and their staff are on site seven days
a week from 7.45am to 6.30pm.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Dartmoor was in September 2020, which was
during a time when the prison regime was severely impacted by the COVID-19
pandemic (which also limited the extent of the inspection), and at a time when the
prison was scheduled to close in the near future. Inspectors found good
arrangements for the care of older and disabled prisoners on F Wing (Mr
Balakrishnan’s’ wing).
Independent Monitoring Board
18. 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 30 September 2022, the IMB
reported that following the decision not to close the prison, there had been a
disappointing amount of investment and as a consequence, the prisoner experience
at Dartmoor was inferior to that at other prisons.
19. The IMB noted that Dartmoor had a significant number of older prisoners and that
the prison did not have the capability, capacity or budget to fully support prisoners
with dementia and neurodiversity issues with consistent and specialist services.
They said that the lack of 24-hour healthcare cover made it difficult to meet the
increasing needs of an elderly population. They called for an older persons’
strategy.
Previous deaths at HMP Dartmoor
20. Mr Balakrishnan was the seventh prisoner to die at Dartmoor since April 2020. Of
the previous deaths, four were from natural causes and two were self-inflicted.
Since Mr Balakrishnan’s death, there have been six deaths, four were from natural
causes, one was self-inflicted, and one is still under investigation. There are no
similarities between our findings in our investigation into Mr Balakrishnan’s death
and our findings from the previous investigations.
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Key Events
21. On 4 December 2015, Mr Aravindan Balakrishnan was sentenced to 23 years
imprisonment for sexual offences. He was 75 years old.
22. In 2018, Mr Balakrishnan refused an older person’s review and refused
investigation or treatment for raised blood pressure. Tests also indicated that he
had raised sugar levels and healthcare staff suspected Mr Balakrishnan had
diabetes, but he refused tests or medication for this also. Mr Balakrishnan was not
taking any prescribed medication regularly.
23. In 2019, staff raised concerns about Mr Balakrishnan’s ability to care for himself and
reported that he had episodes of confusion. A consultant psychiatrist advised
healthcare staff to treat Mr Balakrishnan for probable diabetes, but Mr Balakrishnan
declined further investigations or treatment and signed a disclaimer to that effect.
Mr Balakrishnan was assessed as having the mental capacity to make decisions.
HMP Dartmoor
24. On 11 December 2020, Mr Balakrishnan was transferred to HMP Dartmoor.
25. On 24 December, Mr Balakrishnan was diagnosed with possible dementia. He
began medication to control his diabetes.
26. In March 2021, Mr Balakrishnan’s cognitive ability continued to deteriorate, and a
consultant psychiatrist confirmed that he had dementia with diminished capacity,
meaning he no longer had the capacity to make decisions. Staff discussed his care
needs at multi-disciplinary meetings regularly.
27. As Mr Balakrishnan’s ability to care for himself declined, he received social care
support to help him with daily living such as showering and getting dressed,
although he often refused the help that was offered. In addition, a wing buddy also
provided additional support and as time went on, his support increased to collecting
Mr Balakrishnan’s meals and cleaning his cell.
28. In July, Mr Balakrishnan accepted insulin injections to help control his diabetes.
29. In January 2022, mental health nurse completed a mental health review and noted
that Mr Balakrishnan repeatedly said that he felt fine and did not want any
assistance.
30. From March onwards, Mr Balakrishnan’s health continued to decline gradually.
Healthcare staff noted that Mr Balakrishnan appeared frail, had lost weight and had
a very small appetite. They arranged for him to have some blood and urine tests,
and the results were all within a normal range.
31. At approximately 7:45pm on 7 April, staff found Mr Balakrishnan on the floor in his
cell. Staff checked him and he had no injuries. They helped him into bed and Mr
Balakrishnan said that he felt “alright” and he went to sleep. Prison staff checked on
him at regular intervals during the night.
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Events of 8 April 2022
32. At 7.00am on 8 April, prison staff asked healthcare staff to visit and check on Mr
Balakrishnan (there is no healthcare cover at Dartmoor overnight).
33. At 8.40am, a healthcare assistant (HCA) checked on Mr Balakrishnan after
receiving an update about his fall the previous evening. She looked through the
observation panel of his cell door and noted that Mr Balakrishnan appeared to be
asleep in bed. An officer offered to open the cell door, but she declined to enter the
cell and said that she would return later for a welfare check.
34. Just before 9.00am, Mr Balakrishnan’s prison buddy went to his cell and found Mr
Balakrishnan unresponsive in bed. He immediately alerted staff. An officer entered
the cell and, when he saw Mr Balakrishnan, he radioed a medical emergency code
blue (indicating a prisoner is unconscious or is having breathing difficulties) and
started CPR.
35. A nurse and the HCA attended the cell immediately. The nurse told the officers to
stop CPR as it was clear that Mr Balakrishnan had died. The nurse contacted the
Ambulance Service to notify them of Mr Balakrishnan’s death, and a GP at the
prison confirmed that Mr Balakrishnan had died.
Contact with Mr Balakrishnan’s family
36. A prison family liaison officer (FLO) at HMP Brixton was appointed to liaise with Mr
Balakrishnan’s wife, as that prison was located closer to where she lived. The FLO
visited Mrs Balakrishnan to break the news of her husband’s death. After the visit,
the FLO at Dartmoor rang Mr Balakrishnan’s wife and offered her condolences and
support.
37. The prison offered a contribution towards Mr Balakrishnan’s funeral costs in line
with HMPPS policy.
Support for prisoners and staff
38. After Mr Balakrishnan’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
39. The prison posted notices informing other prisoners of Mr Balakrishnan’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Balakrishnan’s death.
Post-mortem report
40. The post-mortem report gave Mr Balakrishnan’s cause of death as a lower
respiratory tract infection. Vascular dementia, diabetes mellitus and ischaemic heart
disease were listed as contributory factors. The report also concluded that there
were no causative findings relating to Mr Balakrishnan’s fall on 7 April 2022.
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Findings
Clinical care
41. The clinical reviewer concluded that the clinical care Mr Balakrishnan received at
Dartmoor was equivalent to what he could have expected to receive in the
community. He found that healthcare staff had shown a considered and holistic
approach to facilitate Mr Balakrishnan’s wellbeing. Healthcare staff made a good
effort to engage Mr Balakrishnan in managing his medical conditions despite his
reluctance and refusal to engage with them.
Good practice
42. Mr Balakrishnan had a wing buddy who helped him every day with many things,
including cleaning his cell, changing his bed and collecting his meals. The wing
buddy alerted staff when Mr Balakrishnan was not eating or drinking sufficiently. He
was also the person who found him unresponsive. We would like to bring to the
Governor’s attention the good level of support Mr Balakrishnan’s wing buddy
provided to Mr Balakrishnan.
Inquest
43. The inquest, held on 1 August 2024, concluded that Mr Balakrishnan died from
natural causes.
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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