John Foreman

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr John Foreman
a prisoner at HMP Doncaster,
on 20 December 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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OFFICIAL - FOR PUBLIC RELEASE
© 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 6 April 2017, Mr John Foreman was sentenced to 14 years in prison for sexual
offences. Mr Foreman died from a chest infection, caused by coronary artery
disease, on 20 December 2023 while a prisoner at HMP Doncaster. He was 74
years old. We offer our condolences to Mr Foreman’s family and friends.
4. The Ombudsman’s office wrote to Mr Foreman’s 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
Foreman’s clinical care at HMP Doncaster.
6. The clinical reviewer concluded that the clinical care Mr Foreman received at
Doncaster was of a reasonable standard and at least equivalent to what he could
have expected to receive in the community.
7. The PPO investigator investigated the non-clinical issues relating to Mr Foreman’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
9. Mr Foreman’s family received a copy of the initial report. They did not reply.
10. At the inquest held on 7 June 2024, the coroner concluded that Mr John Foreman
died of natural causes.
Adrian Usher September 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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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