Jeffrey Long

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Independent investigation into
the death of Mr Jeffrey Long,
a prisoner at HMP/YOI Moorland
Closed, on 5 July 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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© Crown copyright, 2026
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
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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 6 October 2023, Mr Jeffrey Long was sentenced to four years imprisonment for
sexual offences. He died in hospital of bronchopneumonia on 5 July 2024, while a
prisoner at HMP Moorland. Ischaemic heart disease, chronic kidney disease and
liver cirrhosis contributed to, but did not cause his death. He was 76 years old. We
offer our condolences to Mr Long’s family and friends.
4. The Ombudsman’s office contacted Mr Long’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They asked for a
copy of our report and asked questions about Mr Long’s health. We have answered
the family’s questions in our report and the clinical review.
5. The PPO investigator investigated the non-clinical issues relating to Mr Long’s care.
We did not find any non-clinical issues of concern.
6. NHS England commissioned independent clinical reviewers, to review Mr Long’s
clinical care at HMP Moorland. The clinical reviewers’ report is attached as Annex
1.
7. The clinical reviewers concluded that the clinical care Mr Long received at Moorland
was not of the required standard and was not equivalent to what he could have
expected to receive in the community.
8. They found that Mr Long was not appropriately referred to the long-term conditions
nurse when he transferred to Moorland on 7 May 2024. Staff missed opportunities
to identify Mr Long as a potentially deteriorating patient in the days leading up to his
death, including that his National Early Warning Score 2 (NEWS2- a tool which
improves the detection and response to clinical deterioration in adult patients)
observations were not calculated or were miscalculated during intervention, and
senior nurses did not raise sufficient concern regarding Mr Long’s deteriorating
health in a multi-agency meeting held on 28 June.
9. The clinical reviewers found that there was a significant delay in Mr Long’s
assessment and transfer to hospital on 2 July, including that a senior nurse did not
attend Mr Long’s cell when concerns regarding his deterioration were raised,
healthcare staff’s failure to call a medical emergency and delays in a senior medical
review once Mr Long was moved to the healthcare wing.
10. They also found a significant issue, which the Ambulance Service made a formal
complaint about, in the transfer of Mr Long from the healthcare wing to the
ambulance resulting in Mr Long having to be transferred on a carry chair despite
being in a critical condition.
Prisons and Probation Ombudsman 1
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11. We make the following recommendations:
The Head of Healthcare at HMP/YOI Moorland must implement:
• a robust process to ensure all relevant staff are aware of prisoners who
may be at risk of clinical deterioration.
• ensure an individualised care plan is in place so these prisoners have
appropriate reviews and a clear escalation plan.
The Head of Healthcare at HMP/YOI Moorland should ensure that all staff
document a full set of physical observations and calculate a NEWS2 score at
every encounter with unwell prisoners.
The Head of Healthcare at HMP/YOI Moorland should:
• undertake a multi-disciplinary training event with all staff involved in Mr
Long’s care.
• detail roles and responsibilities of senior staff to ensure that junior
staff are appropriately supported when asking for clinical assistance
with unwell prisoners. This should be facilitated with minimal delay.
• undertake training on assessment of the clinically unwell prisoners and
escalation process at Moorland with all healthcare staff.
The Head of Healthcare at HMP/YOI Moorland must ensure that when an
ambulance is called, healthcare staff inform the prison duty manager of the
location where the ambulance is to be received. This is to prevent
unnecessary delays in the provision of care.
The Head of Healthcare at HMP/YOI Moorland should ensure that all prisoners
living with a long-term condition are referred to the long-term condition nurse
at their reception screening. This will ensure an individualised plan of care,
follow up, and if required, referral to the MPCCC for the wider MDT.
The Head of Healthcare at HMP/YOI Moorland should ensure that if a clinical
concern is raised about a prisoner, there is a robust management plan and
the prisoner should be seen and assessed at the earliest opportunity by a
member of the healthcare team. This is to identify potentially deteriorating
prisoners and ensure they are assessed and reviewed quickly.
The Head of Healthcare at HMP/YOI Moorland should ensure that when
prisoners are reviewed at the MPCCC, all relevant clinical information is
discussed so senior members of the team are aware of changes in the
prisoner’s condition.
The Head of Healthcare and Governor at HMP/YOI Moorland should undertake
a plan for extricating prisoners from the healthcare department that is safe
and does not compromise prisoner care.
2 Prisons and Probation Ombudsman
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12. The clinical reviewers made several other recommendations related to Mr Long’s
care which the Head of Healthcare will wish to address.
13. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS pointed out some factual inaccuracies and this report has been amended
accordingly. The action plan has been annexed to this report.
14. Mr Long’s family received a copy of the draft report. They raised a number of
issues/ questions that do not impact on the factual accuracy of this report and have
been addressed through separate correspondence.
Adrian Usher
Prisons and Probation Ombudsman July 2025
Inquest
15. At the inquest held on 6 April 2026, the Coroner concluded that Mr Long died of
natural causes.
16. The jury concluded that Mr Long’s condition, as presented to healthcare
professionals on or before 28 June 2024, should have led to his admission to
hospital. They believed that, on the balance of probabilities, Mr Long would not
have died if he had been admitted to hospital on or before 28 June 2024.
17. The Coroner found that there was a gross failure to provide or procure basic
medical attention for someone in a dependent position, who could not provide for
themselves. The Coroner concluded that neglect contributed to Mr Long’s death.
Prisons and Probation Ombudsman 3
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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
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