John Brumpton

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr John Brumpton,
a prisoner at HMP Holme House,
on 9 October 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
© 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 1 July 2015, Mr John Brumpton was sentenced to 18 years in prison for sex
offences. He died from locally advanced urethral cancer on 9 October 2023, while a
prisoner at HMP Holme House. He was 74 years old. We offer our condolences to
Mr Brumpton’s family and friends.
4. The Ombudsman’s office wrote to Mr Brumpton’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond.
5. NHS England commissioned an independent clinical reviewer to review Mr
Brumpton’s clinical care at HMP Holme House.
6. The clinical reviewer concluded that the clinical care Mr Brumpton received at HMP
Holme House was of a good standard and at least equivalent to that which he could
have expected to receive in the community. She found that healthcare staff adhered
to the Dying Well in Custody Charter to prepare for Mr Brumpton’s death and to
ensure his wishes were taken into account. The clinical reviewer made
recommendations not related to Mr Brumpton’s death that the Head of Healthcare
will want to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Brumpton’s
care.
8. We did not find any non-clinical issues of concern and 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. At an inquest held on 26 April 2024, the Coroner concluded that Mr Brumpton died
of natural causes.
Adrian Usher May 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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