Isaac Ayeni

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Independent investigation into
the death of Mr Isaac Ayeni,
a prisoner at HMP Aylesbury,
on 16 May 2022
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 HMPPS in ensuring the standard of care received by those
within service in remit is appropriate then our recommendations should be focussed,
evidenced and viable. This is especially the case if there is evidence of systemic failure.
Mr Isaac Ayeni died in hospital on 16 May 2022, after being found unresponsive in his cell
at HMP Aylesbury just over an hour earlier. He was 23 years old. A post-mortem
concluded that Mr Ayeni died from natural causes, but the exact cause could not be
ascertained. I offer my condolences to Mr Ayeni’s family and friends.
Establishing Mr Ayeni’s cause of death was a complex process that took around a year
and a half, and my investigation was significantly delayed as a result.
Mr Ayeni was a young man who appeared to be in relatively good physical health, and his
death was unexpected. The clinical reviewer concluded that the healthcare provided to Mr
Ayeni at Aylesbury was equivalent to that which he could have expected to receive in the
community.
The investigation identified issues with the management of the emergency response. Staff
on the scene of the incident did not provide full information to their colleagues in the
control room. There was a significant delay in escorting the ambulance through the prison
to Mr Ayeni’s wing, seemingly caused by some confusion about how to manage the escort
during prisoner movements.
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 April 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 23 August 2021, Mr Isaac Ayeni was remanded in custody for drug offences. He
was also required to serve a 28-day fixed term recall as he had breached an earlier
release licence. Mr Ayeni spent time at HMP Pentonville and HMP Thameside
before he transferred to HMP Aylesbury on 27 April 2022.
2. Mr Ayeni had asthma and was prescribed his usual medications in prison.
3. At around 1.53pm on 16 May 2023, prisoners saw Mr Ayeni lying awkwardly and
unresponsive on his bed, so they alerted staff. An officer radioed a medical
emergency code and healthcare staff started cardiopulmonary resuscitation (CPR).
Paramedics continued resuscitation and Mr Ayeni was taken to hospital. At 3.14pm,
hospital staff declared that Mr Ayeni had died.
Findings
4. The clinical reviewer concluded that the care Mr Ayeni received was equivalent to
that which he could have expected to receive in the community.
5. When Mr Ayeni was discovered, the control room staff called for an ambulance
immediately. However, despite repeated requests, staff at the scene did not provide
them with updates on Mr Ayeni’s condition. When paramedics arrived there was an
18-minute delay before they reached Mr Ayeni.
Recommendations
• The Governor should review the Local Operating Policy for Emergency Response to
include guidance for escorting an emergency ambulance during movements.
• The Governor should ensure that all staff are aware of and understand their
responsibilities during a medical emergency, including that information about the
prisoner’s medical condition is provided to the control room in a timely manner.
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The Investigation Process
6. We were informed of Mr Ayeni’s death on 16 May 2022.
7. The investigator issued notices to staff and prisoners at HMP Aylesbury informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
8. The investigator visited Aylesbury on 25 May, and obtained copies of relevant
extracts from Mr Ayeni’s prison and medical records. She also visited the wing
where Mr Ayeni lived and briefly spoke to three prisoners who had alerted staff on
the day he died. The investigator also interviewed two prison staff who were on duty
in the communications room.
9. NHS England commissioned the clinical reviewer to review Mr Ayeni’s clinical care
at the prison. The investigator, together with the clinical reviewer, interviewed 12
healthcare and prison staff in July 2022. The investigator also interviewed a
custodial manager, prison officer and nurse in August 2022. The three prisoners
who alerted staff to check on Mr Ayeni declined to be interviewed but did provide
statements to the police on the day he died, which were shared with the
investigator.
10. We suspended our investigation between May 2022 and October 2023, awaiting
confirmation of the cause of Mr Ayeni’s death.
11. We informed HM Coroner for Buckinghamshire of the investigation, who provided
information about the cause of death. We have sent the Coroner a copy of this
report.
12. The PPO’s family liaison officer contacted Mr Ayeni’s family to explain the
investigation and to ask if they had any matters they wanted us to consider. Mr
Ayeni’s family wanted to know the sequence of events on the day he died, how he
was discovered, who alerted staff and if he was unconscious. Mr Ayeni’s family
asked a question which we have addressed in separate correspondence. Mr
Ayeni’s family also asked some questions about the care provided by paramedics,
which is outside the remit of our investigation.
13. Mr Ayeni’s family received a copy of the initial report. They did not identify any
factual inaccuracies. However, they raised a number of points which we have
answered in separate correspondence. Mr Ayeni’s family disagreed with the clinical
reviewer’s findings that his care was equitable to that which he could have expected
to receive in the community.
14. The prison also received a copy of the report. They did not identify any factual
inaccuracies.
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Background Information
HMP Aylesbury
15. HMP Aylesbury, when fully operational, can hold 402 prisoners. All the cells are
designed for single occupancy. In February 2019, the prison was put into ‘special
measures’ by Her Majesty’s Prison and Probation Service (HMPPS), due to serious
concerns about safety, and operated at a reduced capacity. By May 2021,
Aylesbury was out of special measures and had started to increase the number of
prisoners held. At the time Mr Ayeni was at Aylesbury, they accepted men aged
between 18-27 and although the number of prisoners had increased, they were not
yet up to full capacity. Since 1 October 2022, Aylesbury now accepts Category C
adult males.
16. Practice Plus Group provide physical health services and Barnet, Enfield and
Haringey Mental Health Trust provide mental health and substance misuse
services.
HM Inspectorate of Prisons
17. The most recent inspection of HMP Aylesbury was in November/December 2022.
18. Inspectors had been consistently critical of Aylesbury prison over many years and
this inspection was no different. Inspectors found that the prison was short of about
50 officers. They reported that the healthcare situation was so dire that it had been
determined that it was an unacceptable risk to send prisoners over the age of 40 to
the prison. They found that emergency bags were regularly checked and
adequately supplied, but that ambulances were not automatically called in medical
emergencies.
19. In August 2023, inspectors returned to Aylesbury to review progress. They
commended the positive change since their last inspection. Staff vacancies had
halved. The prison had made good progress in the management of long-term health
conditions and all prisoners who required them had care plans.
Independent Monitoring Board
20. 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 most recent annual report for the year to 31 March 2023 the IMB
noted that the senior management team stayed stable through the year but staffing
at other levels did not. Throughout the year the shortage of officers in all grades
impacted negatively on the regime in the prison and as a consequence on the lives
of all the prisoners. The preparation for the prison to change from a young offenders
institution (YOI) to a category C prison was found to be seriously inadequate. The
staff had minimal opportunity to retrain to deal with this different cohort.
21. The IMB reported that there were significant staff shortages in healthcare and a
heavy reliance on agency staff. These shortages, combined with significant IT
problems, impacted service delivery, which the IMB found was unsafe at times.
They found that provision had improved by the end of the reporting year, with a new
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Head of Healthcare and several initiatives to better explain healthcare services to
prisoners.
Previous deaths at HMP Aylesbury
22. Mr Ayeni was the third prisoner to die at Aylesbury since May 2019. The previous
deaths were both from suicide. There have been three deaths since; two drug
related deaths and one not yet ascertained. There are no significant similarities with
this death.
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Key Events
23. On 23 August 2021, Mr Isaac Ayeni was remanded to prison custody charged with
drug offences and taken to HMP Pentonville. He had breached the terms of a
previous licence and also had to serve a fixed term recall of 28 days.
24. At his initial healthscreen, Mr Ayeni disclosed that he had asthma and was
prescribed an inhaler, which he said he rarely needed to use. He said that he had
no physical health concerns, and his clinical observations were all within a normal
range.
25. On 13 October, Mr Ayeni appeared in court and was taken from court directly to
HMP Thameside.
26. On 28 January 2022, Mr Ayeni was sentenced to five years and eight months in
prison.
HMP Aylesbury
27. On 27 April, Mr Ayeni moved to HMP Aylesbury as part of his sentence
progression.
28. At the initial healthscreen, the reception nurse noted that Mr Ayeni did not have any
physical health concerns, and his clinical observations were within a normal range.
Mr Ayeni was assessed as being medically fit to attend the gym.
29. On 3 May, a nurse completed Mr Ayeni’s secondary healthscreen. He did not
disclose any significant family history of physical health concerns, and he stated he
did not have any long-term conditions other than asthma. Mr Ayeni’s clinical
observations were not taken.
30. On 6 May, Mr Ayeni did not attend an asthma clinic appointment or for a first
Hepatitis B vaccination and it was documented that this would be rebooked.
31. On 15 May, Mr Ayeni received very positive feedback from prison staff. They
recorded in his prison record that he helped deescalate a violent situation on the
wing by moving other prisoners away from the incident and encouraging them not to
get involved. Officers described Mr Ayeni as showing a high level of maturity. This
is the last entry in Mr Ayeni’s prison record.
32. All prisoners’ telephone calls, except those that are legally privileged, are recorded,
and prison staff listen to a random sample. The investigator listened to some of the
calls Mr Ayeni made to several friends in the week before he died. There was
nothing in these phone calls to suggest that Mr Ayeni was having any difficulties
with his physical or mental health.
Events on 16 May
33. At 8.00am on 16 May, Closed Circuit Television (CCTV) shows that a Supervising
Officer (SO) unlocked Mr Ayeni’s cell. Around 30 minutes later, Mr Ayeni left the
wing with other prisoners to attend the gym. The Physical Education Instructor (PEI)
said that Mr Ayeni completed his induction, used the weights room, and asked if he
could be considered for a gym orderly role before he left. The PEI said that Mr
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Ayeni was obviously used to exercising and he had no concerns about him during
the session. Mr Ayeni returned to the wing at around 10.00am and was locked in his
cell.
34. At 11.50am, Mr Ayeni was unlocked to collect his lunch and he spoke briefly with
the SO at the servery. At around 12.00pm, an officer locked Mr Ayeni back in his
cell. Mr Ayeni did not raise any concerns and prison staff did not observe anything
unusual.
35. At around 1.50pm, some prisoners were unlocked to attend activities. Three
prisoners told the police that they went to Mr Ayeni’s cell as they were all going to
attend the chapel. They looked through the observation panel in his cell and saw
him in an unusual position lying on his bed, and alerted an officer that they thought
something was wrong. The officer opened Mr Ayeni’s door and, when he did not get
a response, radioed a medical emergency. (The officer initially incorrectly called a
code red, significant blood loss, but changed this a short while later to a code blue,
when someone is not breathing or unresponsive. This did not alter the response by
prison and healthcare staff as the response to a medical emergency is the same for
either code.)
36. The officer found Mr Ayeni was laid on his bed with his legs hanging over the end.
Officers moved Mr Ayeni to the floor of his cell and placed him in the recovery
position, as they believed they could feel a pulse. Two nurses responded to the
emergency. A nurse assessed Mr Ayeni and did not feel a pulse so started
cardiopulmonary resuscitation (CPR). A defibrillator was attached to Mr Ayeni,
which advised he had no shockable rhythm, and staff continued CPR until
paramedics arrived.
37. Control room staff telephoned for an ambulance immediately on receipt of the radio
message of a medical emergency. They made several requests for staff on the
scene to update them of Mr Ayeni’s condition, in order to provide accurate, detailed
information to the ambulance service, but this was not provided (this did not delay
the dispatching of the ambulance).
38. South Central Ambulance Service records show an ambulance was requested at
1.55pm. Paramedics arrived at Aylesbury at 2.02pm, followed by two more
ambulances. Paramedics did not reach Mr Ayeni’s cell until 2.20pm. The delay was
caused because officers were not immediately made available to escort the
ambulance and because it was prisoner movements (when prisoners move from
wings to education or workshops) and staff were uncertain of the procedures to
open internal gates to allow the ambulance through.
39. On their arrival at the cell, paramedics continued resuscitation attempts, and took
Mr Ayeni to Stoke Mandeville Hospital, escorted by two officers. He arrived at the
hospital at 3.04pm. At 3.14pm, doctors declared that he had died.
Contact with Mr Ayeni’s family
40. Aylesbury appointed the prison manager as the family liaison officer (FLO). She
phoned Mr Ayeni’s sister to inform her that he had been taken to hospital as this
was the quickest way to tell her that he was seriously ill. Aware that Mr Ayeni’s
sister was on her way to the hospital, the FLO contacted her a short while later,
again by phone, to inform her that he had died. She offered her condolences and
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ongoing support. In line with Prison Service instructions, the prison contributed
towards the costs of Mr Ayeni’s funeral, which was held on 28 July 2022.
Support for prisoners and staff
41. After Mr Ayeni’s death there was not a collective debrief. The Deputy Governor
spoke individually to most prison staff involved in the emergency response but this
did not include the operational manager or healthcare staff.
42. The prison posted notices informing prisoners of Mr Ayeni’s death and offering
support. Staff reviewed all prisoners assessed as at risk of suicide and self-harm in
case they had been adversely affected by Mr Ayeni’s death.
Post-mortem report
43. The pathologist concluded that Mr Ayeni died from unascertained other natural
causes. Toxicology tests showed that Mr Ayeni had not used any illicit substances
prior to his death.
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Findings
Clinical Care
44. The clinical reviewer concluded that the care Mr Ayeni received was equivalent to
that which he could have expected to receive in the community. The clinical
reviewer made some recommendations not directly related to Mr Ayeni’s death that
the Head of Healthcare will wish to address.
Emergency response
45. Prison Service Instruction (PSI) 03/2013, Medical Emergency Response Codes,
sets out the actions staff should take in a medical emergency. Two distinct codes
are used; code blue if a person is unresponsive or not breathing, and code red if
there is significant blood loss or burns. It contains mandatory instructions for
Governors to have a protocol to provide guidance on efficiently communicating the
nature of a medical emergency, ensuring staff take the relevant equipment to the
incident, that there are no delays in calling an ambulance and must prevent any
unnecessary delay in escorting ambulances and paramedics to the patient. PSI
03/2013 was amended in Sept 2021 to include requirement for staff at the scene of
an emergency to provide relevant information to the control room as soon as
possible.
46. We found, in respect of communication, the emergency response was poorly co-
ordinated. Staff radioed a medical emergency response, and the communications
room contacted the ambulance service immediately. However, information on Mr
Ayeni’s condition was not provided to the communications room. Despite Mr Ayeni
being unconscious, a custodial manager said over the radio that she had to wait for
healthcare staff to confirm his medical condition so that she could provide accurate
information to the ambulance service. Nobody provided the communications room
with an update on Mr Ayeni’s condition, despite numerous requests by staff in the
control room.
47. A custodial manager (CM) who was at the scene and who assisted with the
resuscitation attempt, said that she was unaware that the ambulance service
needed to be updated on Mr Ayeni’s condition or how they prioritised the
ambulance response, as she was just focussed on helping him.
48. It is important that staff provide clear, up to date information to the control room as
this will help them to ensure that an ambulance is despatched with appropriate
priority. Healthcare staff should not normally be required to be present before basic
information about whether a patient is conscious or breathing is provided.
49. Aylesbury’s Local Operating Policy (LOP) for Emergency Response states that:
“The Orderly Officer [senior officer in charge] will manage the incident, ensuring that
staff are available to escort the ambulance to incident location”. This did not
happen. Movement of prisoners had been allowed to continue, and there was a
delay detailing a member of staff to escort the ambulance. It took 18 minutes before
paramedics reached Mr Ayeni. Staff in the communications room spoke of their
frustration trying to obtain information about Mr Ayeni’s condition and that they felt
responsible for finding staff to escort ambulances when this should have been the
responsibility of the orderly officer.
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50. A CM, who was the orderly officer, said that stopping movements would have been
more time consuming and she would have expected Gate staff to have made an
officer available to escort the ambulance to Mr Ayeni’s wing.
51. Local guidance does not explain to staff what they should do to ensure that
ambulances are able to move through the prison quickly during movements. This is
a busy time as there are prisoners moving to different parts of the prison and prison
staff will naturally be cautious about opening internal gates to allow the ambulance
to pass. It is understandable that duty managers might be unsure about the best
way to allow the ambulance access while maintaining security, and local policy
should be amended to provide clear guidance. We make the following
recommendations:
The Governor should review the Local Operating Policy for Emergency
Response to include guidance for escorting an emergency ambulance during
movements.
The Governor should ensure that all staff are aware of and understand their
responsibilities during a medical emergency, including that information about
the prisoner’s medical condition is provided to the control room in a timely
manner.
Governor to note
Staff Support
52. The Incident Management Manual, dated 2 May 2022, sets out that there should be
a debrief for all staff involved following a serious incident. Giving staff the
opportunity to collectively discuss an incident and reflect on all aspects of how it
was managed is fundamental to providing the prison with feedback on any issues
that need to be immediately addressed. It also provides those directly involved with
an opportunity to process events and for managers to signpost sources of support.
Although most prison staff involved in the emergency response were spoken to
individually by the Deputy Governor, there was not a collective debrief as there
should have been, which we bring to the attention of the Governor.
Inquest
53. The inquest into Mr Ayeni’s death concluded in July 2025. The jury returned a
verdict of natural causes. The medical cause of death was unascertained, but was
likely to have been contributed to by unforeseeable idiopathic cardiac arrhythmia.
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Canary Wharf, London E14 4PU Web: www.ppo.gov.uk
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