James Farrell

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr James Farrell,
a prisoner at HMP/YOI Forest
Bank, on 8 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 concern
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 August 2023, Mr James Farrell was sentenced to 36 months in prison for sexual
offences. He died of pneumonia on 8 January 2025, while a prisoner at HMP Forest
Bank. He was 77 years old. We offer our condolences to Mr Farrell’s family and
friends.
4. The Ombudsman’s office wrote to Mr Farrell’s next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They had no
questions but asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer, to review Mr Farrell’s
clinical care at Forest Bank. The clinical reviewer’s report is attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Farrell received at Forest
Bank was of a good standard and equivalent to what he could have expected to
receive in the community. Mr Farrell was at Forest Bank for a very short period
before he was admitted to hospital where he stayed for 16 months until his death on
8 January 2025. The clinical reviewer found that healthcare staff were responsive to
his needs and recognised changes in his health. While Mr Farrell was in hospital,
healthcare staff asked for regular updates, and communication and key
developments were documented well in his medical records. The clinical reviewer
did not make any recommendations.
7. The PPO investigator investigated the non-clinical issues relating to Mr Farrell’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
10. Mr Farrell’s family received a copy of the initial report. They did not make any
comments.
11. At the inquest held on 29 July 2025, the coroner concluded Mr Farrell died of
natural causes.
Adrian Usher
Prison and Probation Ombudsman July 2025
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