Fiona Barnard

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Independent investigation into
the death of Ms Fiona Barnard,
a prisoner at HMP Askham
Grange,
on 15 September 2024
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 17 August 2023, Ms Fiona Barnard was sentenced to three and a half years in
prison for drug offences. She died from small bowel ischaemia (a life-threatening
condition that blocks the blood flow to the small intestine) on 15 September 2024,
while a prisoner at HMP Askham Grange. She was 59 years old. We offer our
condolences to Ms Barnard’s family and friends.
4. NHS England commissioned an independent clinical reviewer, to review Ms
Barnard’s clinical care at Askham Grange. The clinical review is attached as Annex
1.
5. The clinical reviewer concluded that the clinical care Ms Barnard received at
Askham Grange was of a good standard and was at least equivalent to that which
she could have expected to receive in the community. She found that Ms Barnard’s
episode of illness was acute and healthcare staff would not have been able to
diagnose the bowel ischaemia. She made no recommendations.
6. The PPO investigator investigated the non-clinical issues relating to Mr Barnard’s
care.
7. We did not find any non-clinical issues of concern. We make no recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS found one factual inaccuracy in the clinical review and the report has been
amended.
9. At an inquest held on 8 July 2026, the Coroner concluded that Ms Barnard died
from natural causes.
Governor to note
10. While it would not have made a difference to the outcome for Ms Barnard given her
cause of death, there is no evidence in the wing observation book that prison staff
completed welfare checks on her from 12 September, as healthcare staff had
requested.
Adrian Usher July 2025
Prisons and Probation Ombudsman
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