Jason Rae

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Independent investigation into
the death of Mr Jason Rae,
a prisoner at HMP Forest Bank,
on 4 March 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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 16 July 2024, Mr Jason Rae was sentenced to eight years in prison for robbery,
dangerous driving and driving while disqualified. He died in hospital from a
gastrointestinal haemorrhage on 4 March 2024, while a prisoner at HMP Forest
Bank. This was caused by liver cancer which had spread to other parts of the body.
He was 54 years old. We offer our condolences to Mr Rae’s family and friends.
4. The PPO family liaison officer wrote to Mr Rae’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond
to our letter.
5. NHS England commissioned an independent clinical reviewer to review Mr Rae’s
clinical care at HMP Forest Bank.
6. The clinical reviewer concluded that the clinical care Mr Rae received at HMP
Forest Bank was of a good standard and at least equivalent to that which he could
have expected to receive in the community. The clinical reviewer made
recommendations which were not related to Mr Rae’s death but which the Head of
Healthcare will want to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Rae’s care.
We did not find any significant non-clinical learning and we make no
recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Director to note
9. The record keeping in Mr Rae’s escort risk assessment paperwork was poor and
some key entries were illegible. The terminology that staff used to explain escort
arrangements for Mr Rae during a hospital escort was unclear and incorrect. The
prison provided new information about this, which contradicted previous information
they had given us, extremely late in the investigation. This prevented us from
issuing our initial report on time.
Adrian Usher November 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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10. At an inquest held on 16 January 2025, the Coroner concluded that Mr Rae died of
natural causes.
2 Prisons and Probation Ombudsman
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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