Brian Holland

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Independent investigation into
the death of Mr Brian Holland,
a prisoner at HMP Liverpool,
on 8 July 2024
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
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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 Holland died of pulmonary emphysema (a chronic lung disease) and heart
disease, on 8 July 2024, while a prisoner at HMP Liverpool. He was 53 years old.
We offer our condolences to his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Holland received at
Liverpool was equivalent to that which he could have expected to receive in the
community. The clinical reviewer made no recommendations directly related to the
cause of Mr Holland’s death. However, the Head of Healthcare will wish to consider
recommendations on unrelated matters.
5. We found that officers who conduct welfare checks do not routinely hold radios and
we are concerned that this could cause delays in communicating medical
emergencies.
Recommendation
• The Governor should review the provision of radios to ensure that staff conducting
welfare checks can radio emergency medical codes promptly.
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The Investigation Process
6. HMPPS notified us of Mr Holland’s death on 8 July 2024.
7. NHS England commissioned an independent clinical reviewer to review Mr
Holland’s clinical care at HMP Liverpool. The clinical review is attached as Annex 1.
8. The PPO investigator investigated the non-clinical issues relating to Mr Holland’s
care. The investigator and the clinical reviewer interviewed six members of staff and
a prisoner from HMP Liverpool on 20/27 August and 6 September 2024.
9. The Ombudsman’s office wrote to Mr Holland’s next of kin, his sister, to explain the
investigation. She had no specific matters for the investigation to consider.
10. We sent a copy of our report to Mr Holland’s sister. She did not report any factual
inaccuracies.
11. The initial report was shared with HM Prison and Probation Service (HMPPS). They
found no factual inaccuracies and accepted our recommendation.
Previous deaths at HMP Liverpool
12. Mr Holland was the 15th prisoner to die at HMP Liverpool since July 2021. Of the
previous deaths, eight were from natural causes, four were self-inflicted and two
were drug-related. We have previously raised concerns about the allocation of
radios. Although this has led to a change in policy to ensure that all staff carry
radios during night state, we remain concerned that they are not routinely held
during the key task of welfare checks.
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Key Events
13. Mr Brian Holland was convicted of theft, threatening behaviour and possessing a
knife. On 12 February 2024, he was sentenced to 21 months imprisonment and
taken to HMP Liverpool.
14. Nurse A conducted an initial health screen. He recorded Mr Holland’s health
conditions, which included high blood pressure, heart disease, a previous heart
attack and mental health disorders. Mr Holland also had a history of substance
misuse and opioid dependence, which was managed by a buprenorphine injection
every 28 days. Nurse A referred him to the primary care, mental health and
substance misuse services. The prison pharmacist then reviewed and re-prescribed
Mr Holland’s medication.
15. On 15 February, Mr Holland had a secondary health screen and a mental health
review. (Care plans for hypertension and coronary heart disease were later created,
with annual reviews for both conditions scheduled for 31 December.)
16. On 16 February, clinical and psychosocial substance misuse assessments were
completed. Mr Holland continued to engage with the substance misuse service and
received support over the following months.
Events of 8 July 2024
17. Officer A (also known as Officer B) completed a welfare check of Mr Holland and
his cell mate, Prisoner A, at around 7.45am. He opened and looked through the cell
observation panel. Both men appeared to be asleep and he did not try to get a
response. Officer A then went to supervise the dispensing of medication.
18. At around 8.50am, Officer A heard Mr Holland’s cell mate and other prisoners
shouting for the cell door to be opened as Mr Holland was not “answering or
reacting”. When he opened the door, he immediately noticed that Mr Holland was
discoloured and his head was swollen. As Officer A had no radio, he did not go into
the cell but went to find another officer on the landing. He shouted to Officer C that
he believed there was a code blue (a medical emergency in which a prisoner is
unresponsive or has breathing difficulties) and asked if she had a radio. Officer C
went to the cell, looked in and then radioed a code blue at 8.56am. The prison
noted that an ambulance was requested at 8.58am.
19. Additional prison staff arrived, followed by several nurses and they moved Mr
Holland to the floor. As rigor mortis and other signs of death were evident, they did
not attempt resuscitation.
20. Paramedics pronounced life extinct at 9.13am.
21. A prison manager debriefed prison and healthcare staff and offered support.
Notices were issued to other staff and prisoners, informing them of Mr Holland’s
death and signposting to avenues of support. Prisoner A was moved to another cell,
where he was supported by a prison Listener (a prisoner trained by the Samaritans
to provide confidential emotional support) and the mental health team.
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22. Two prison managers visited Mr Holland’s sister to inform her of Mr Holland’s death
and offer support. In line with the national policy, the prison contributed to the
funeral expenses.
Post-mortem report
23. The report of the post-mortem examination concluded that the cause of Mr
Holland’s death was pulmonary emphysema with bronchopneumonia and
ischaemic heart disease.
24. Toxicology tests found several prescription drugs in Mr Holland’s blood. Some of
them - quetiapine, carbamazepine, amitriptyline and mirtazapine - had not been
prescribed to him but were largely within therapeutic levels. We were unable to
establish how Mr Holland obtained these drugs.
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Findings
Clinical findings
25. The clinical reviewer concluded that Mr Holland’s clinical care for his physical
conditions was of a good standard and equivalent to that which he could have
expected to receive in the community. She noted that he had multiple health
conditions with complex needs which were appropriately met by the healthcare
team.
26. The clinical reviewer considered that some elements of mental healthcare did not
meet the required standard. She also made two recommendations about record
keeping and following up incidents of self-harm which the Head of Healthcare will
wish to consider. We have not repeated those recommendations in this report, as
the issues were unrelated to Mr Holland’s death.
Non-clinical findings
Prison radios
27. Officer A was responsible for welfare checks on the morning of Mr Holland’s death.
When he was later called to the cell, he could not call an emergency code as he did
not have a radio. He alerted a colleague, who also went to the cell to check and
then radioed a code blue. Ms A, Head of Safety, said that radios are usually issued
to three roles - the Supervising Officer, cleaning officer and moves officer – and
spare radios are held that other staff can request if they wish, but it is not
compulsory.
28. We have previously raised the allocation of radios in the context of limited provision
during night state. We are pleased to note that the local policy has since been
revised so that it is now a mandatory requirement for all staff to carry a radio when
working overnight. However, we are concerned that it is not a requirement for
officers who conduct welfare checks to hold radios, particularly as they might
discover a medical emergency which needs to be communicated urgently. While
the delay of several minutes in this emergency did not affect the outcome for Mr
Holland, it could make a critical difference in other circumstances. We therefore
believe it would be beneficial to extend the allocation of radios to staff who conduct
welfare checks. We recommend:
The Governor should review the provision of radios to ensure that staff
conducting welfare checks can radio emergency medical codes promptly.
Governor to note
Requesting an ambulance in an emergency
29. The prison’s handwritten log shows that a code blue was radioed at 8.56am and an
ambulance was called at 8.58am. However, the ambulance service recorded that
the call was received at 9.02am. While this delay did not affect the outcome for Mr
Holland, the Governor will wish to establish whether it was due to a technical issue,
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such as a disparity in clock timings, or an issue that requires further guidance to
staff.
Inquest
30. At an inquest held on 6 February 2025, the coroner concluded that Mr Holland died
from natural causes.
Adrian Usher
Prisons and Probation Ombudsman December 2025
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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