Lukasz Strag

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Independent investigation into
the death of Mr Lukasz Strag,
a prisoner at HMP Birmingham,
on 26 January 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, 2025
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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. In March 2024, Mr Lucasz Strag was sentenced to 19 years imprisonment for
conspiracy to supply class A drugs. He died of urosepsis (infection that starts in the
urinary tract and spreads to the bloodstream) on 26 January, in a hospice, while a
prisoner at HMP Birmingham. Metastatic gastric cancer (cancer of the stomach that
spreads to other parts of the body) contributed to but did not cause his death. He
was 44 years old. We offer our condolences to Mr Strag’s family and friends.
4. The Ombudsman’s office wrote to Mr Strag’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 Strag’s
clinical care at Birmingham. The clinical reviewer’s report is attached as Annex 1.
6. The clinical reviewer concluded that the clinical care Mr Strag received at
Birmingham was of a good standard and equivalent to that which he could have
expected to receive in the community. She found that prison healthcare staff were
caring and advocated for Mr Strag. The clinical reviewer made recommendations
not related to Mr Strag’s cause of death that the Head of Healthcare will wish to
consider.
7. The PPO investigator investigated the non-clinical issues relating to Mr Strag’s
care. We did not find any non-clinical issues that warranted a recommendation but
bring the Governor and Head of Healthcare’s attention to the below.
Governor and Head of Healthcare to note
Pain relief
8. On 19 January at around 9.30pm, Mr Strag told staff he was in pain. However,
healthcare staff were unable to give him pain relief medication for three hours as his
cell was locked. According to Birmingham’s local security strategy, at least three
officers must be present to open a cell door during night state (when there are
reduced numbers of staff in the prison). A nurse recorded that she contacted
Custodial Manager (CM) and told him Mr Strag was in pain. The CM said he had
other priorities at the time (there was a fire on another wing) and was unable to
attend. Three hours later, after the nurse had asked prison staff several times to
open the door, she radioed an emergency code. The CM attended promptly and the
nurse gave pain medication to Mr Strag. We bring this to the attention of the
Governor and the Head of Healthcare to consider the need for a process that allows
Prisons and Probation Ombudsman 1
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healthcare staff to access prisoners under palliative care promptly during the night
state.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Inquest
10. The inquest hearing was held on 4 September 20225. The Coroner concluded that
Mr Strag died of natural causes.
Adrian Usher September 2025
Prisons and Probation Ombudsman
2 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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