Jason Barnes

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Jason Barnes,
a prisoner at HMP Elmley,
on 21 November 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
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© Crown copyright, 2024
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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 10 March 2021, Mr Jason Barnes was sentenced to four years and four months
in prison for attempted robbery and common assault. On 21 November 2023, Mr
Barnes died in hospital from multiple organ failure caused by biliary sepsis (an
infection in the bile duct) which was in turn caused by gallstone pancreatitis and
biliary obstruction, while a prisoner at HMP Elmley. He was 49 years old. We offer
our condolences to Mr Barnes’ family and friends.
4. The PPO family liaison officer wrote to Mr Barnes’ 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 Barnes’
clinical care at HMP Elmley.
6. The clinical reviewer found that the clinical care Mr Barnes received at HMP Elmley
was of a good standard and was at least equivalent to that which he could have
expected to receive in the community. In particular, the clinical reviewer highlighted
the good and compassionate medical care provided at Elmley.
7. The clinical reviewer made a number of recommendations not related to Mr Barnes’
death which the Head of Healthcare will want to address.
8. The PPO investigator investigated the non-clinical issues relating to Mr Barnes’
care. We did not find any non-clinical issues of concern and make no
recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
10. However, while we note that Mr Barnes was not restrained in hospital in the month
he died, the medical information in his escort risk assessment was not completed
as it should have been when he was taken to hospital, restrained, on 9 October
2023. HMP Elmley told us that they were unable to explain why this had not
happened. We draw this to the attention of the Governor and Head of Healthcare.
11. At an inquest held on 8 December 2023, the Coroner concluded that Mr Barnes’
died of natural causes.
Adrian Usher August 2024
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