John Rose

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Independent investigation into
the death of Mr John Rose,
a prisoner at HMP Parc,
on 27 February 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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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 30 September 2016, Mr John Rose was convicted of sexual offences and
sentenced to 11 years in prison.
4. Mr Rose died in hospital on 27 February 2024, while a prisoner at HMP Parc. His
cause of death was heart failure and chronic kidney disease, with diabetes mellitus
and peripheral vascular disease (reduced circulation of blood to the body) as
contributory factors. We offer our condolences to Mr Rose’s family and friends.
5. The Ombudsman’s office contacted Mr Rose’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Rose’s family did
not respond.
6. The initial report was shared with HM Prison and Probation Service
(HMPPS). HMPPS did not find any factual inaccuracies.
7. Healthcare Inspectorate Wales commissioned an independent clinical reviewer, to
review Mr Rose’s clinical care at Parc. The clinical reviewer’s report is attached as
Annex 1.
8. The clinical reviewer concluded that the clinical care Mr Rose received at Parc was
equivalent to that which he could have expected to receive in the community. The
clinical reviewer made five recommendations not related to Mr Rose’s death that
the Head of Healthcare has addressed.
9. The PPO investigator investigated the non-clinical issues relating to Mr Rose’s care.
We did not find any non-clinical issues of concern. We make no recommendations.
Inquest
10. The inquest into Mr Rose’s death concluded on the 8 November 2024. The coroner
confirmed that Mr Rose died of natural causes.
Adrian Usher December 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