Brian James

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Independent investigation into
the death of Mr Brian James,
a prisoner at HMP/YOI Elmley,
on 23 February 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 18 November 2024, Mr Brian James was remanded into custody, charged with
murder. He died in hospital from acute ischaemia of the bowel, liver and spleen (a
reduced blood flow to the organs) on 23 February 2025 while a prisoner at HMP
Elmley. This was caused by extensive atherosclerotic disease (a
hardening/narrowing of the arteries). He was 81 years old. We offer our
condolences to Mr James’ family and friends.
4. The Ombudsman’s office wrote to Mr James’ 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. The PPO investigator investigated the non-clinical issues relating to Mr James’
care. We were concerned that Mr James was restrained using a single cuff (where
the prisoner is attached to an escort officer by a set of handcuffs) when he was
escorted to hospital on 22 February. We note that the healthcare team
subsequently identified that the nurse failed to object to the use of restraints and
they have since provided training to staff on restraints and escort risk assessments.
Given this and that the restraint was removed shortly after Mr James’ arrival at
hospital, we do not make a recommendation.
6. NHS England commissioned an independent clinical reviewer, to review Mr James’
clinical care at HMP Elmley. The PPO investigator and clinical reviewer interviewed
two members of staff on 11 April.
7. The clinical reviewer concluded that the clinical care Mr James received at Elmley
was of a good standard and equivalent to that which he could have expected to
receive in the community. However, this did not extend to the assessment and
management of Mr James’ acute abdominal issues on 22 February, the day before
he died. The clinical reviewer was concerned that some clinical features may not
have been fully recognised and staff’s reliance on NEWS2 scores may have limited
a more comprehensive clinical interpretation. We make the following
recommendation:
The Head of Healthcare should review the current guidance on the
assessment and management of acute abdominal pain and provide
healthcare staff with relevant training.
8. Mr James’ family received a copy of the draft report. They did not make any
comments.
Prisons and Probation Ombudsman 1
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9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
Adrian Usher October 2025
Prisons and Probation Ombudsman
Inquest
10. The inquest into Mr James’ death was held on 19 January 2026 and a verdict of
natural causes was recorded. The coroner concluded that Mr James’ death was
due to acute ischemia of bowel, liver and spleen and extensive atherosclerotic
disease.
.
2 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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