James O’Brien

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr James O’Brien,
a prisoner at HMP Littlehey,
on 18 July 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
OFFICIAL - FOR PUBLIC RELEASE
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
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 process failures.
3. Mr James O’Brien died at HMP Littlehey on 18 July 2023, of mixed vascular
disease (reduced blood flow to the brain, which damages and eventually kills brain
cells) and Alzheimer's dementia. He was 83 years old. We offer our condolences to
Mr O’Brien’s family and friends.
4. The PPO family liaison officer wrote to Mr O’Brien’s next of kin to explain the
investigation and to ask if she had any matters she wanted us to consider. She did
not respond.
5. NHS England commissioned independent clinical reviewers to review Mr O’Brien’s
clinical care at HMP Littlehey. They interviewed seven healthcare staff as part of the
PPO investigation.
6. The clinical reviewers concluded that the clinical care Mr O’Brien received at
Littlehey was of a very good standard and equivalent to that which he could have
expected to have received in the community. While the clinical reviewers did not
make any recommendations, they identified that Littlehey was an inappropriate
environment for Mr O’Brien, given his dementia and deteriorating health.
Considerable effort was made to transfer Mr O’Brien to a prison with 24-hour
healthcare facilities, but this was not possible due to a lack of beds. Healthcare staff
also considered that a transfer might increase Mr O’Brien’s agitation and confusion
and that he might therefore benefit from remaining at Littlehey.
7. The clinical reviewers identified several areas of good practice, including
multidisciplinary working between healthcare and custodial staff to provide
overnight care for Mr O’Brien. They also identified several positive actions taken
since Mr O’Brien’s death, including the provision of dementia training for staff.
8. The PPO investigator investigated the non-clinical issues relating to Mr O’Brien’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
Inquest
9. The inquest into Mr O’Brien’s death concluded on the 14 May 2024. The coroner
confirmed that Mr O’Brien died of natural causes.
Adrian Usher July 2024
Prisons and Probation Ombudsman
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