Malcolm Burwood

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Malcolm Burwood,
a prisoner at HMP Holme House,
on 7 April 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, 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. In March 2019, Mr Malcolm Burwood was sentenced to ten years imprisonment for
sexual offences. He died of prostate cancer on 7 April 2024, at HMP Holme House.
He was 84 years old. We offer our condolences to Mr Burwood’s family and friends.
4. The Ombudsman’s office contacted Mr Burwood’s son to explain the investigation
and to ask if he had any matters he wanted us to consider. He wanted to know how
his father had died and asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer to review Mr
Burwood’s clinical care at HMP Holme House.
6. The clinical reviewer concluded that the clinical care Mr Burwood received was of a
good standard and equivalent to that which he could have expected to receive in
the community. She made two recommendations that were not directly related to Mr
Burwood’s death, which the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Burwood’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. At the inquest held on 30 May 2024 the coroner concluded that Mr Burwood died of
natural causes.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Burwood’s son received a copy of the draft report. He did not make any
comments.
Adrian Usher September 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