Joseph Murphy

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Independent investigation into
the death of Mr Joseph Murphy,
a prisoner at HMP Liverpool,
on 1 March 2025
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 22 August 2024, Mr Joseph Murphy was remanded to HMP Altcourse for
robbery. On 6 September, he transferred to HMP Liverpool. On 28 November, Mr
Murphy was sentenced to two years and nine months.
4. On 1 March 2025, Mr Murphy died of Class III obesity with cardiomegaly (an
enlarged heart) and coronary artery atheroma (accumulation of fatty material in the
coronary arteries). He was 49 years old. We offer our condolences to Mr Murphy’s
family and friends.
5. The Ombudsman’s office wrote to Mr Murphy’s sister to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Murphy’s sister
had no questions but asked for a copy of our report.
6. NHS England commissioned an independent clinical reviewer to review Mr
Murphy’s clinical care at HMP Liverpool. The clinical reviewer’s report is attached
as Annex 1.
7. The clinical reviewer concluded that the clinical care Mr Murphy received at
Liverpool was of a good standard and was equivalent to that which he could have
expected to receive in the community. She concluded that the physical healthcare
he received was of a good quality with a person-centred approach.
8. The clinical reviewer found that Mr Murphy had long term health conditions,
including hypothyroidism (an underactive thyroid) and statin/lipid treatment and that
there was ongoing management and monitoring of these conditions. She also noted
that staff recorded that Mr Murphy was obese when he was admitted to Liverpool
and provided him with advice on his diet and maintaining a healthy lifestyle. The
clinical reviewer noted that there was no specific targeted discussion in respect of
obesity but acknowledged that, from December 2024 onwards, Mr Murphy’s
complex mental health needs took precedence.
9. The clinical reviewer made recommendations not related to Mr Murphy’s cause of
death which the Head of Healthcare will wish to address.
10. The PPO investigator investigated the non-clinical issues relating to Mr Murphy’s
care. We did not identify any non-clinical issues of sufficient concern to warrant a
recommendation.
11. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
12. We also shared the initial report with Mr Murphy’s sister. She did not have any
comments.
Prisons and Probation Ombudsman 1
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13. At the inquest, held on 19 December 2025, the Coroner concluded that Mr Murphy
died of natural causes.
Governor to note
Location of emergency code
14. The officer who initially radioed a medical emergency code blue (used to indicate a
life-threatening emergency) set out that this was in Cell H, after which the radio
transmission ended. (We do not know whether the officer stopped speaking or
whether there was an issue with the radio transmission.)
15. A control room officer then broadcast that the code blue was on H wing (not the
healthcare wing where Mr Murphy lived.) Around forty seconds later, staff at the
emergency confirmed that the correct location was the healthcare wing.
16. Additional healthcare staff arrived within two minutes of officers calling the initial
code blue and we do not therefore consider that this miscommunication caused a
significant delay. However, we bring this to the Governor’s attention.
Hot debrief
17. The Follow up to Deaths in Custody Policy Framework sets out that a hot debrief
must be held as soon as possible after the death. It notes that this should be
chaired by a senior member of staff and all staff directly involved in the incident,
including healthcare staff, should be invited. The Post-Incident Care user guide
notes that the debrief provides an opportunity to understand and deal with chaotic
and distressing thoughts to help prevent psychological damage.
18. A custodial manager held a hot debrief following Mr Murphy’s death which involved
some operational and healthcare staff. However, a number of staff members who
had been involved in the emergency were not present at the debrief. Three officers
were sent home after the emergency response and some healthcare staff told the
investigator they were not invited to a joint debrief. Healthcare staff were told they
could go home if they wished.
19. While it is clear that managers were thinking of staff wellbeing by sending them
home, the Governor and Head of Healthcare will want to highlight the importance of
a joint hot debrief following a death in custody and ensure that those who are
unable to attend receive follow-up care as necessary.
Adrian Usher March 2026
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
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