Daniel Brown

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Independent investigation into
the death of Mr Daniel Brown,
a prisoner at HMP High Down,
on 16 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
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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 23 August 2023, Mr Daniel Brown was remanded to HMP Wandsworth for
sexual offences. On 25 January 2024, he was sentenced to four years in prison. On
19 April, Mr Brown transferred to HMP High Down.
4. On 16 January 2025, Mr Brown died in hospital of multi organ failure caused by
necrotising pneumonia. Mr Brown had been an inpatient for around three weeks
when he died. He was 32 years old. We offer our condolences to Mr Brown’s family
and friends.
5. Mr Brown did not name a next of kin and none could be identified following his
death.
6. The PPO investigator investigated the non-clinical issues relating to Mr Brown’s
care. We did not find any non-clinical issues of concern.
7. NHS England commissioned an independent clinical reviewer to review the clinical
care Mr Brown received at High Down. The clinical reviewer’s report is attached as
Annex 1. The clinical reviewer concluded that the clinical care Mr Brown received at
High Down was not of the required standard and therefore not equivalent to that
which he would have received in the community.
8. The clinical reviewer noted that there was a progressive decline in Mr Brown’s
physical health from September 2024. She found that there were several missed
opportunities for timely intervention, a lack of clinical escalation and a failure to act
on deteriorating clinical observations in line with national guidelines. The clinical
reviewer concluded that Mr Brown’s physical deterioration was visible and
measurable, with clear clinical markers indicating the need for intervention that were
not acted upon.
9. We make the following recommendations:
The Head of Healthcare should ensure that all staff are trained in the use of
National Early Warning Score (NEWS2) and understand their responsibilities
regarding clinical escalation processes.
The Head of Healthcare should ensure that there is a clear follow-up process
when a prisoner with known vulnerabilities misses a healthcare appointment.
The Head of Healthcare should review local processes to ensure that
prisoners requiring clinical follow-up are properly identified.
Prisons and Probation Ombudsman 1
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10. We shared the initial report with HMPPS and the prison’s healthcare provider, North
West London NHS Foundation Trust. They found no factual inaccuracies. The
healthcare provider provided an action plan which is annexed to this report.
11. The inquest into Mr Brown’s death concluded on 11 May 2026, and recorded a
verdict of natural causes.
Adrian Usher December 2025
Prisons and Probation Ombudsman
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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