Dean Leach

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Independent investigation into
the death of Mr Dean Leach,
a prisoner at HMP Forest Bank,
on 4 January 2023
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, 2025
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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.
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.
Mr Dean Leach died of peritonitis (inflammation of the inner abdominal wall) caused by a
perforated duodenal ulcer on 4 January 2023 at HMP Forest Bank. He was 37 years old. I
offer my condolences to Mr Leach’s family and friends.
The clinical reviewer concluded that the clinical care Mr Leach received at Forest Bank
was equivalent to that which he could have expected to receive in the community.
We found that the non-clinical care provided to Mr Leach was of a good standard. We
make no recommendations.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman March 2024
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 3
Key Events ....................................................................................................................... 5
Findings ........................................................................................................................... 8
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Summary
Events
1. On 29 December 2022, Mr Dean Leach was charged with assault and remanded to
HMP Forest Bank. No pre-existing physical medical conditions were listed in his
medical records and his observations were all within normal ranges.
2. On 31 December officers asked for healthcare assistance when Mr Leach reported
that he was vomiting and not eating. He became aggressive during the assessment
and threatened to stop eating. Nursing staff advised Mr Leach to stay hydrated and
created a food refusal care plan to manage the risks, which involved regular GP
appointments. The plan was closed the next day when healthcare and officers
established Mr Leach had been eating small amounts. Healthcare staff advised
officers to seek assistance if they had any concerns.
3. On 3 January 2023, officers called for assistance when they saw Mr Leach rolling
around the floor of his cell in pain and holding his stomach. He said he had been
given medication for his symptoms in the community but had not taken it recently.
Nursing staff found that Mr Leach’s pulse and heart rates were high, so they took
him to see the GP. Mr Leach told the GP he had a history of stomach ulcers for
which he had taken medication in the past. The GP completed a thorough
assessment for serious illness and found that Mr Leach’s observations were all
within normal ranges, although he had lost 3kg of weight since his arrival at Forest
Bank. A care plan was created to manage the symptoms and Mr Leach’s
medication was re-prescribed.
4. Later in the afternoon Mr Leach was checked by nursing staff. He said he had
ongoing abdominal pain, but it was less severe. Nursing staff completed a test to
identify the risk of deterioration, the result indicated a low risk. No concerns were
raised by Mr Leach for the remainder of the evening.
5. At 4.15am the following day, a nurse contacted Mr Leach’s wing to request staff
check on him. An Operational Support Grade (OSG) went to his cell before the
morning roll check and found him semi-naked on his cell floor. When the OSG
called his name Mr Leach was unresponsive, so he called an emergency code
requesting assistance from staff and triggering a call for an ambulance. Healthcare
staff and other officers responded quickly and found rigor mortis was present so
made the decision not to commence resuscitation. Paramedics pronounced Mr
Leach’s death at 5.32am.
Findings
6. The clinical reviewer concluded that the clinical care Mr Leach received at HMP
Forest Bank was at least equivalent to that which he could have expected to receive
in the community. The clinical reviewer made no recommendations.
7. We found no non-clinical issues of concern.
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The Investigation Process
8. We were notified of Mr Leach’s death on 4 January 2023.
9. The investigator issued notices to staff and prisoners at HMP Forest Bank informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
10. The investigator obtained copies of relevant extracts from Mr Leach’s prison and
medical records.
11. NHS England commissioned a clinical reviewer to review Mr Leach’s clinical care at
the prison. The clinical reviewer and investigator jointly conducted six interviews
with healthcare staff in February and March 2023. The investigator interviewed a
prison manager.
12. We informed HM Coroner for Greater Manchester West of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
13. The Ombudsman’s family liaison officer contacted Mr Leach’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Leach’s father responded and requested a copy of our report. He shared that Mr
Leach had seen a nurse and a doctor and had a history of stomach problems which
he was on medication for. He said that for his son to complain, it must have been
really bad, and told us that he was supposed to be watched closely by prison staff
because of mental health issues. We have addressed these concerns in our report.
14. We shared the initial report with HM Prison and Probation Service and NHS
England, who identified one factual inaccuracy, which we have amended.
15. We also share the initial report with Mr Leach’s family. They did not provide any
feedback.
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Background Information
HMP Forest Bank
16. HMP Forest Bank is a local prison in Salford, serving courts in north-west England.
It holds 1,460 remanded and sentenced men. The prison is operated by Sodexo
Justice Services. At the time of Mr Leach’s death, primary care and substance
misuse services at Forest Bank were provided by Sodexo and mental health
services were provided by Greater Manchester Mental Health (GMMH) Foundation
Trust. On 1 April 2023, it was announced that Spectrum Community Health CIC had
been awarded a contract to provide primary care and substance misuse services at
the prison.
HM Inspectorate of Prisons
17. HM Inspectorate of Prisons (HMIP) most recently inspected Forest Bank in January
2023, to complete an independent review of progress (IRP). In their previous
inspection in February 2022, HMIP identified deterioration in two of their healthy
prison tests: purposeful activity and rehabilitation, and release planning. Shortly
before the February inspection, HM Prison and Probation Service (HMPPS) had
issued Sodexo with a formal rectification notice because of concerns about the
safety of prisoners and the conditions in which they were held. Sodexo responded
promptly, recruiting a new director, and decisive action had seen improvements in
living conditions with a renewed focus on improving safety.
18. In January’s IRP, HMIP assessed progress against 12 recommendations about
issues including safety, early days in custody and health, wellbeing, and social care.
There had been good or reasonable progress in five of the recommendations that
they examined, although there remained insufficient or no meaningful progress
against three. These were staff-prisoner relationships, health, wellbeing and social
care, and education, skills, and work.
Independent Monitoring Board
19. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to October 2022, the IMB noted that
significant improvements in the prison regime had taken place in the last four to five
months. They reported a reduction in incidents of both self-harm and violence and
noted that purposeful activity and out of cell time had increased.
Previous deaths at HMP Forest Bank
20. Mr Leach was the thirteenth prisoner to die at Forest Bank since January 2020. Of
the previous deaths, seven were from natural causes, two were self-inflicted and
three were drug related. There are no similarities between our findings in the
investigation into Mr Leach’s death and our investigation findings for the previous
deaths.
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21. Since Mr Leach’s death, one further prisoner has died at Forest Bank, however the
cause of death has not yet been ascertained.
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Key Events
22. On 29 December 2022, Mr Dean Leach was remanded in custody at HMP Forest
Bank after being charged with assault by beating. It was not his first time in prison.
23. At the initial health screening, a nurse completed basic observations and recorded
that Mr Leach’s weight, blood pressure and other readings were within normal
ranges. Mr Leach had no known physical medical conditions according to his
medical record, but he had not been in regular contact with a GP in the community.
24. On 31 December, a nurse recorded on Mr Leach’s medical record that she had
been asked to urgently examine him due to concerns raised by officers. Mr Leach
had been vomiting and refusing food for three days and could not sit up in bed.
When the nurse arrived at Mr Leach’s cell, he immediately sat up in his bed. She
told us that his immediate presentation contradicted the telephone call she had
received. Mr Leach told her that he had not been eating anything and had been
vomiting. She told Mr Leach to take regular sips of water, to stay hydrated. Mr
Leach asked for medication, but she said it was not necessary at that point. Mr
Leach became verbally abusive, started swearing and made threats that he would
stop eating. In response, the nurse commenced a food refusal care plan, which
involved keeping a food diary, daily visits by a nurse and regular GP appointments.
25. On 1 January 2023, after discussion with officers on Mr Leach’s wing, the nurse
established that he had been eating biscuits and drinking tea with other prisoners.
She considered that Mr Leach was just angry in the moment when he threatened to
refuse food, so chose not to continue with the food refusal care plan. The nurse
advised officers to contact the healthcare emergency responder or use the
healthcare triage system if they had any concerns.
26. On the morning of 3 January, prison officers asked healthcare staff to urgently
examine Mr Leach. Officers had found Mr Leach grunting and rolling around in his
cell, holding his stomach. Mr Leach told a nurse that he was supposed to be on
omeprazole (a medication taken for gastritis, inflammation of the lining of the
stomach) but that he had not taken it for some time because he had been “on the
run” while resisting police arrest in the community. Mr Leach explained that the pain
was worse if he ate, so he had not eaten for a few days. The nurse assessed Mr
Leach and found that he was breathing quickly and had a fast pulse.
27. At around midday, officers escorted Mr Leach to the healthcare centre for an
appointment with a GP. Mr Leach reported that he was suffering from indigestion,
burping, and vomiting. He explained that he had a history of stomach ulcers for
which he had been prescribed omeprazole in the past, however he had not taken it
recently. The GP noted that Mr Leach had lost 3kg in weight since his arrival. He
completed a thorough examination of Mr Leach and checked for signs of serious
illness. He did not find any issues of concern, other than Mr Leach’s trouble opening
his bowels. The GP noted that Mr Leach’s breathing, blood pressure and
temperature were within the normal ranges. He diagnosed Mr Leach with gastritis
and created a care plan to monitor his treatment, which included a prescription for
omeprazole. The GP explained the red flag symptoms Mr Leach should look out for
and refer to staff, using his emergency cell bell where necessary.
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28. At 3.05pm, a nurse noted in Mr Leach’s medical record that he had returned to the
wing and should be reviewed by a night nurse later in the evening.
29. At 6.05pm, a nurse attended Mr Leach’s cell to check on him and noted that he was
fully alert and orientated, lying on his bed. Mr Leach reported ongoing abdominal
pain but said it was less severe. He said he had not vomited again. The nurse
recorded that Mr Leach had eaten a bowl of cereal and a warm drink. She
administered his medication and completed a set of checks on the severity of illness
and risk of deterioration, which indicated a low risk.
30. Shortly before 10.00pm, an operational support grade (OSG) completed a routine
check of prisoners on Mr Leach’s wing. He had a brief conversation with Mr Leach
and did not raise any concerns.
4 January
31. At around 4.45am, a duty nurse called the OSG to ask if he could check on Mr
Leach during his early morning routine check. Mr Leach had been sick the previous
day and the early morning roll check was due in 15 minutes.
32. At interview, the OSG told us that following the nurse’s telephone call, he decided to
check on Mr Leach straightaway. At 4.58am, the OSG attended Mr Leach’s cell and
opened the cell observation panel. He turned on the cell light and saw that Mr
Leach was semi-naked on the cell floor. The OSG banged on the door and called
Mr Leach’s name, but he was unresponsive.
33. The OSG radioed a medical emergency ‘code blue’, and officers and healthcare
staff, including the duty nurse, responded quickly. The code blue triggered a call for
an ambulance. At interview, the nurse told us that Mr Leach’s body was rigid, cold
to the touch and had no pulse. He noted that rigor mortis was present. As there
were no signs of life, cardiopulmonary resuscitation (CPR) was not started.
34. At 5.26am, paramedics arrived at the cell. At 5.32am, they confirmed that Mr Leach
had died.
Contact with Mr Leach’s family
35. At around 9.00am on 4 January, prison family liaison officers travelled to Mr Leach’s
next of kin’s home address and broke the news of Mr Leach’s death.
36. Forest Bank contributed to the costs of Mr Leach’s funeral, in line with Prison
Service instructions.
Support for prisoners and staff
37. After Mr Leach’s death, the duty governor debriefed the staff involved in the
emergency response, to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
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38. The prison posted notices informing other prisoners of Mr Leach’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
self-harm in case they had been adversely affected by Mr Leach’s death.
Post-mortem report
39. The post-mortem report concluded that Mr Leach died of peritonitis, secondary to a
perforated duodenal ulcer and Chronic Obstructive Pulmonary Disease.
40. Peritonitis secondary to a perforated duodenal ulcer means a burst stomach ulcer
which has caused an infection in the fluid that surrounds the organs in the space
below the ribs and above the legs.
41. Chronic Obstructive Pulmonary Disease is the name for a group of lung conditions
that cause breathing difficulties.
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Findings
42. The clinical reviewer concluded that the clinical care Mr Leach received at Forest
Bank was equivalent to that which he could have expected to receive in the
community. He highlights areas of good practice and makes no recommendations.
43. We found that the non-clinical care provided to Mr Leach was of also of a good
standard. Staff addressed Mr Leach’s needs and responded swiftly and with
compassion when they found him unresponsive. The outcome was unexpected and
shocking for everyone involved.
Inquest
44. The inquest into Mr Leach’s death concluded on 23 May 2025, returning a verdict of
natural causes.
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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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