Brian Heron

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Brian Heron,
a prisoner at HMP Frankland, on
14 January 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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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 8 August 2019, Mr Brian Heron was sentenced to 14 years in prison for sexual
offences. He died in hospital of respiratory failure due to respiratory syncytial virus
infection on a background of chronic obstructive pulmonary disease, on 14 January
2025, while a prisoner at HMP Frankland. He was 78 years old. We offer our
condolences to Mr Heron’s family and friends.
4. The Ombudsman’s office wrote to Mr Heron’s next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They had no
questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer to review Mr Heron’s
clinical care at HMP Frankland.
6. The clinical reviewer concluded that the clinical care Mr Heron received at
Frankland was of a reasonable standard and least equivalent to that which he could
have expected to receive in the community. He found that Mr Heron medical
records contained evidence of excellent individualised end of life care planning. The
clinical reviewer made recommendations not related to Mr Heron’s death that the
Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Heron’s
care. We did not find any non-clinical issues of concern.
8. The initial report was shared with HMPPS, Healthcare (Spectrum, Community
Health CIC) and Mr Heron’s next of kin. They did not identify any factual
inaccuracies.
9. At the inquest held on 23 March 2026, the coroner concluded that Mr Brian Heron
died of natural causes.
Adrian Usher March 2026
Prisons and Probation Ombudsman
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