Derek Holmes

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Derek Holmes, a
prisoner at HMP Birmingham,
on 8 December 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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
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. In August 2003, Mr Derek Holmes was sentenced to life imprisonment for wounding
with intent. He was released in August 2017, but recalled to prison for breach of his
licence in September 2022. He died in hospital of pneumonia caused by frailty of
old age on 8 December 2023, while a prisoner at HMP Birmingham. Clostridium
difficile (a bacterial infection) and dementia were noted by the Coroner as issues
that contributed to but did not cause Mr Holmes’ death. He was 80 years old. We
offer our condolences to those that knew him.
4. We have not consulted Mr Holmes’ family or friends about our investigation as
neither the prison nor the police were able to identify any. After our report was
published on our website, Mr Holmes daughter contacted us. She received a copy
of the clinical review.
5. NHS England commissioned an independent clinical reviewer to review Mr Holmes’
clinical care at Birmingham.
6. The clinical reviewer concluded that the clinical care Mr Holmes received at the
Birmingham was of a good standard and equivalent to that which he could have
expected to receive in the community. She made a recommendation not related to
Mr Holmes’ death that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Holmes’
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The inquest into Mr Holmes’ death concluded that he died of natural causes.
Adrian Usher
Prisons and Probation Ombudsman May 2024
Prisons and Probation Ombudsman 1
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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
OFFICIAL - FOR PUBLIC RELEASE