Brian Fletcher

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Independent investigation into
the death of Mr Brian Fletcher,
a prisoner at HMP Hewell,
on 15 December 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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© 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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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. Mr Brian Fletcher died of heart failure on 15 December 2025, at HMP Hewell. He
was 57 years old. We offer our condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Fletcher received at Hewell
was not of a good standard and was not equivalent to that which he could have
expected to receive in the community. Mr Fletcher’s blood pressure, which was high
when he arrived at Hewell, was never rechecked and Mr Fletcher never had care
plans put in place for his long-term conditions, which included heart disease and
diabetes. Also, Mr Fletcher asked for pain relief in the days leading up to his death,
but the reasons for administering pain relief were not recorded.
5. There was a delay in discovering that Mr Fletcher had died as the officer who
unlocked Mr Fletcher’s cell on the morning of 15 March did not check on his
welfare.
Recommendations
• The Head of Healthcare should ensure that all clinicians follow the healthcare
provider policy for blood pressure monitoring and that this is audited within the
quality schedule.
• The Head of Healthcare should establish long term condition management as per
national guidance, which includes a register, care plans, clinic monitoring and
education opportunities for staff, and audit this within the quality schedule.
• The Head of Healthcare should ensure that all staff administering pain relief enter
the reason why it has been requested into the clinical system and that this process
is audited within the medicines management schedule.
• The Governor should ensure that:
• The prison’s local security strategy (LSS) reflects HMPPS requirements that a
welfare check is completed at morning unlock and that clear guidance is
provided to staff on what is expected of them.
• A robust quality assurance process is implemented to ensure that welfare
checks are carried out at morning unlock.
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The Investigation Process
6. HMPPS notified us of Mr Fletcher’s death on 15 December 2025.
7. NHS England commissioned an independent clinical reviewer to review Mr
Fletcher’s clinical care at HMP Hewell.
8. The PPO investigator investigated the non-clinical issues relating to Mr Fletcher’s
care.
9. The Ombudsman’s office wrote to Mr Fletcher’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She had no questions
but asked for a copy of our report.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. They provided an action
plan which is annexed to this report.
11. We sent a copy of our initial report to Mr Fletcher’s sister. She did not notify us of
any factual inaccuracies.
Previous deaths at HMP Hewell
12. Mr Fletcher was the eleventh prisoner to die at Hewell since December 2022. Of the
previous deaths, five were from natural causes, four were self-inflicted, and one is
still awaiting classification. There are no similarities between the findings in our
investigation into Mr Fletcher’s death and the findings from our investigations into
the previous deaths.
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Key Events
13. On 16 October 2025, Mr Brian Fletcher was remanded in prison, charged with
sexual offences. He was taken to HMP Hewell.
14. During his reception screening, Mr Fletcher told a nurse that he had chronic
obstructive pulmonary disease (COPD, a long-term lung condition), hypertension
(high blood pressure) and type two diabetes. He also said he had had a heart attack
15 years earlier and had coronary bypass surgery in 2016. The nurse took his blood
pressure, which was high. The nurse did not create any care plans for Mr Fletcher’s
long-term conditions and did not arrange for his blood pressure to be checked
again.
15. On 17 October, a healthcare support worker saw Mr Fletcher for his second
reception screening. They did not check his blood pressure or create any care
plans.
16. On 19 November, a GP saw Mr Fletcher for a review of his COPD, after a
pharmacy technician raised concerns that he was overusing his inhalers. Mr
Fletcher told the GP he had both COPD and asthma and had hit his chest on his
bed two weeks before so was using his inhalers more because of this. He also said
he had angina (chest pain caused by reduced blood flow to the heart) and used
GTN spray (medication that improves blood flow to the heart to manage symptoms).
The GP examined Mr Fletcher’s chest and had no concerns. Mr Fletcher said he did
not need his next inhaler until 5 December. The GP did not check Mr Fletcher’s
blood pressure or create any care plans.
17. Between 4 December and 15 December, Mr Fletcher asked for pain relief
medication three times. A pharmacist technician recorded in Mr Fletcher’s medical
record that he gave him the pain relief medication on each occasion but did not
record the reason why Mr Fletcher had asked for it.
18. CCTV shows that at around 8.30am on 16 December, Officer A unlocked Mr
Fletcher’s cell. He pushed the door open but did not look in or enter the cell. He
then continued walking around the landing.
19. At around 9.24am, Mr Fletcher’s cellmate realised that Mr Fletcher, who was lying
in his bed, was unresponsive. He left the cell to ask for help from Officer A. Officer
A walked back to the cell with him and they both entered. Officer A was unable to
get a response from Mr Fletcher. He then left the cell to find help and locked the
door, with Mr Fletcher’s cellmate inside.
20. Officer A asked a senior officer outside the main office for help. He told her that he
thought Mr Fletcher had died. They returned to the cell, unlocked and entered it,
and the senior officer immediately radioed a code blue (a medical emergency code
used when a prisoner is unconscious or having breathing difficulties that alerts
healthcare staff to attend and the control room to call an ambulance). She saw that
Mr Fletcher had waxy, mottled skin and was very cold to the touch.
21. Healthcare staff arrived at the cell but did not start CPR because there were clear
signs Mr Fletcher had died some time ago. At 9.33am, a paramedic at Hewell
assessed Mr Fletcher for Recognition of Life Extinct (ROLE) features and observed
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rigor mortis (stiffening of the body that occurs two to six hours after death) and
hypostasis (blood settling in the body after death).
22. The ambulance crew arrived at 9.37am and agreed that CPR was not appropriate
as Mr Fletcher had been dead for several hours. The ambulance crew pronounced
life extinct at 9.52am.
Post-mortem report
23. The post-mortem report concluded that Mr Fletcher died of cardiac failure caused
by ischaemic heart disease (lack of blood flow to the heart), which was caused by
severe coronary artery atherosclerosis (narrowing of arteries). COPD was listed as
a contributory factor.
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Findings
Clinical findings
24. The clinical reviewer concluded that the care Mr Fletcher received at Hewell was
not of the required standard and therefore was not equivalent to that which he could
have expected to receive in the community.
25. When Mr Fletcher had his first reception screening, the nurse recorded that he had
high blood pressure. This was not rechecked during his second health screen or
during his GP appointment on 19 November, as per national guidance. We
recommend:
The Head of Healthcare should ensure that all clinicians follow the healthcare
provider policy for blood pressure monitoring and that this is audited within
the quality schedule.
26. When Mr Fletcher arrived at Hewell he had several long-term health conditions
including COPD, diabetes, and high blood pressure. Mr Fletcher did not have any
care plans in place for managing these conditions while at Hewell and was not
referred to a long-term condition clinic for monitoring as per national guidance.
27. The Head of Healthcare told the clinical reviewer that they were unable to run any
long-term condition clinics due to staffing issues. A complex care nurse had recently
been employed, and an advanced care practitioner was being employed to lead and
manage complex conditions going forward. We recommend:
The Head of Healthcare should establish long term condition management as
per national guidance, which includes a register, care plans, clinic monitoring
and education opportunities for staff, and audit this within the quality
schedule.
28. Mr Fletcher asked for pain relief medication three times between 4 December and
15 December, in the lead up to his death. The pharmacy technician gave Mr
Fletcher the medication but did not record the reason Mr Fletcher had asked for it.
We recommend:
The Head of Healthcare should ensure that all staff administering pain relief
enter the reason why it has been requested into the clinical system and that
this process is audited within the medicines management schedule.
29. The clinical reviewer also found that Mr Fletcher’s second reception screening was
completed by a healthcare support worker instead of a nurse, which is not in line
with national guidance. The Head of Healthcare told her that from 1 February 2026,
only qualified nurses would complete first and second reception screenings.
Welfare checks at unlock
30. Prison Service Instruction (PSI) 75/2011, Residential Services, sets an expectation
that staff will check on the welfare of prisoners at morning unlock by, for example,
obtaining a verbal response from them. Prisons are required to have clearly
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understood systems in place for staff to assure themselves of the well-being of
prisoners during “or shortly after” morning unlock. The PSI also deems it
unacceptable for staff completing morning unlock not to notice that a prisoner has
died overnight.
31. More recent guidance to staff on the HMPPS intranet sets an expectation that a
welfare check is undertaken at unlock to check that the prisoner is present and in
good health. The welfare check should include a physical check that the prisoner is
present and a gesture of acknowledgement from the prisoner that they are alive and
well. Should they fail to get a response staff should open the door to check. All
prisons are required to ensure their staff are aware of the requirements and that
every prison’s local security strategy (LSS) reflects this.
32. Officer A unlocked Mr Fletcher’s cell at around 8.30am. When Mr Fletcher was
found at 9.24am, he had rigor mortis (stiffening of the body that occurs two to six
hours after death). The ambulance crew recorded in their log that they thought Mr
Fletcher had died around six hours before he was found. The evidence indicates
that Mr Fletcher was dead at 8.30am and therefore Officer A did not carry out a
welfare check on Mr Fletcher when he unlocked his cell.
33. The Head of Residential Services told the investigator that on Mr Fletcher’s house
block, officers were not expected to obtain a positive response from each prisoner
at morning unlock. He said that if prisoners were awake, officers were generally
expected to tell them why the door had been unlocked and to say good morning,
which should elicit a response.
34. A safety hub manager told the investigator that in their experience on Mr Fletcher’s
house block, the expectation at unlock was to check that prisoners were present
and to wake those required to go to work during weekdays. They said it was not
common practice to wake prisoners if they were still in bed. (Both Mr Fletcher and
his cellmate were non-workers.)
35. However, the custodial manager (CM) for House Block One, gave a different
account. He told the investigator that during morning unlock, officers were required
to visually confirm the presence and apparent wellbeing of each prisoner. That
meant looking for signs of movement, breathing, or a verbal response. If a prisoner
was not responsive or visible, officers were expected to take further steps, which
might include entering the cell, if necessary, to make sure the prisoner was safe.
36. The CM said the quality assurance processes for unlock checks included daily
morning briefings where supervising officers outlined duties, shared relevant
intelligence, and reiterated expectations for the day, including the importance of
welfare checks during unlock. Supervising officers also conducted regular spot
checks and observations to monitor compliance with unlock procedures. He said
that any deviations from expected practice were addressed promptly through line
management and additional training if needed.
37. The investigator asked for a copy of the written policy on unlock procedures. The
Head of Safety and Diversity and Inclusion said that, if such a policy existed, it
would be contained in the local security strategy (LSS). The investigator found no
written policy on unlock procedures within the LSS and was not provided with any
separate policy during the investigation.
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38. Managers gave differing accounts of the expectations of staff carrying out morning
unlock and there was no written local policy covering the checks required. Some
staff said they were not required to wake prisoners if they were not going to work,
which is not in line with prison policy on the checks required at morning unlock. We
recommend:
The Governor should ensure that:
• The prison’s local security strategy (LSS) reflects HMPPS requirements
that a welfare check is completed at morning unlock and that clear
guidance is provided to staff on what is expected of them.
• A robust quality assurance process is implemented to ensure that welfare
checks are carried out at morning unlock.
Governor to note
39. Officer A did not radio a code blue when he found that Mr Fletcher was not
breathing. In his statement, he said he was unsure what to do because he had not
experienced that situation before. He decided to seek help and locked the cell,
leaving Mr Fletcher’s cellmate inside. This resulted in a short delay in the code blue
being called.
40. The delay in radioing the code blue did not change the outcome for Mr Fletcher,
who was dead when found. However, we are concerned that Officer A did not know
he should radio a code blue when he found Mr Fletcher was unresponsive and not
breathing. We also consider it inappropriate that Mr Fletcher’s cellmate was locked
in the cell alone with Mr Fletcher while Officer A went to get help. We bring this to
the Governor’s attention.
Inquest
41. At the inquest, held on 18 June 2026, the Coroner concluded that Mr Fletcher died
from natural causes.
Adrian Usher
Prisons and Probation Ombudsman July 2026
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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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