Earl Johnson

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Earl Johnson,
a prisoner at HMP Birmingham,
on 3 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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 2006, Mr Earl Johnson was sentenced to life imprisonment for wounding with
intent to cause grievous bodily harm. He was later released but was recalled to
prison in December 2024. Mr Johnson died in hospital from a ruptured abdominal
aortic aneurysm on 3 January 2025, while a prisoner at HMP Birmingham. He was
64 years old. We offer our condolences to Mr Johnson’s family and friends.
4. The Ombudsman’s office wrote to Mr Johnson’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
5. NHS England commissioned an independent clinical reviewer to review Mr
Johnson’s clinical care at HMP Birmingham.
6. The clinical reviewer concluded that the clinical care Mr Johnson received at
Birmingham was of a reasonable standard and at least equivalent to that which he
could have expected to receive in the community. The clinical reviewer made
recommendations around record keeping that the Head of Healthcare will wish to
address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Johnson’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. We shared our initial report with HMPPS and the prison’s healthcare provider,
Birmingham and Solihull Mental Health NHS Foundation Trust. They found no
factual inaccuracies.
Adrian Usher May 2025
Prisons and Probation Ombudsman
Inquest
At the inquest, held on 28 July 2025, the Coroner concluded that Mr Johnson died from
natural causes.
Prisons and Probation Ombudsman 1
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