Charles Pratt

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Charles Pratt,
a prisoner at HMP Leeds,
on 9 January 2025
A report by the Prisons and Probation Ombudsman
OThFFirIdC FIAloLo -r F, O10R SPUouBtLhI CC RoEloLnEnAaSdEe Email: mail@ppo.gov.uk T l 020 7633 4100
Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
OFFICIAL - FOR PUBLIC RELEASE
© 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
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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. In August 2024, Mr Charles Pratt was sentenced to 27 years in prison for sexual
offences. He died in hospital of pneumonia, caused by Influenza A infection (a viral
infection more commonly known as flu), on 9 January 2025, while a prisoner at
HMP Leeds. He was 72 years old. We offer our condolences to those who knew
him.
4. NHS England commissioned an independent clinical reviewer, to review Mr Pratt’s
clinical care at Leeds.
5. The clinical reviewer concluded that the clinical care Mr Pratt received at Leeds was
of a reasonable standard and equivalent to that which he could have expected to
receive in the community. She noted that Mr Pratt declined a flu vaccine when
healthcare staff offered it to him in October 2024. She found that a long-term
conditions nurse had reviewed him, and healthcare staff had appropriately moved
him to a social care wing due to his mobility issues. However, she also noted areas
for improvement. These include recording information more clearly in the medical
records, completing falls risks assessments, and referring prisoners with co-
morbidities (more than one health condition) to multi-professional complex case
meetings.
6. The clinical reviewer made five recommendations not related to Mr Pratt’s’ death,
which did not impact her assessment of equivalence, that the Head of Healthcare
will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Pratt’s care.
She found no non-clinical issues of concern directly impacting Mr Pratts’ death and
requiring a recommendation.
Governor and Head of Healthcare to note
8. On 30 November 2024, before taking Mr Pratt to hospital, prison staff completed an
escort risk assessment, and a senior manager authorised restraining him with a
single cuff (one wrist handcuffed to an officer’s wrist). When Mr Pratt was due to be
X-rayed, the prison officers with him in hospital asked permission from a prison
manager to change the restraint to an escort chain (a long chain with a handcuff at
each end, one attached to the prisoner and the other to an officer). Mr Pratt then
went into cardiac arrest, so staff removed the restraints but reapplied them when his
condition stabilised. He remained restrained until 4 December. Although one senior
manager authorised removing the restraints, another authorised reapplying them
until Mr Pratt was discharged on 6 December and communication with the escorting
officers was sub-optimal.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
9. The prison told the investigator that they have introduced a quality assurance
process to ensure escort staff receive updated risk assessments without delay
following a change in the restraint level.
10. We are concerned that staff restrained Mr Pratt during his hospital admission
despite his age, health condition and reduced mobility but are pleased note that he
was not restrained when he returned to hospital on 7 January 2025 and so do not
make a recommendation. The Governor and Head of Healthcare will want to
consider the learning from this case.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Adrian Usher
Prisons and Probation Ombudsman September 2025
Inquest
12. At the inquest held on the 28 January 2025, the Coroner concluded that Mr Pratt
died from natural causes.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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