Malcolm Vickery

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Malcolm Vickery,
a prisoner at HMP Parc,
on 11 March 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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© Crown copyright, 2025
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Summary
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. Mr Malcolm Vickery died of heart disease on 11 March 2023 at HMP Parc. He was
76 years old. We offer our condolences to Mr Vickery’s family and friends.
4. The PPO family liaison officer wrote to Mr Vickery’s next of kin to explain the
investigation and to ask if she had any matters she wanted us to consider. She told
us that the family liaison officer (FLO) at Parc had been very helpful and supportive.
She asked for a copy of our report.
5. The PPO investigator investigated the non-clinical issues relating to Mr Vickery’s
care. We did not find any non-clinical issues of concern.
6. We found that the FLO at Parc built a good relationship with Mr Vickery’s next of
kin, who felt supported throughout the process. We consider this to be good
practice.
7. Health Inspectorate Wales (HIW) commissioned an independent clinical reviewer to
review Mr Vickery’s clinical care at HMP Parc.
8. The clinical reviewer concluded that the clinical care Mr Vickery received at Parc
was largely equivalent to that which he could have expected to receive in the
community. He found that overall, the healthcare team appeared to have displayed
a caring and compassionate approach to Mr Vickery’s care in prison. He made
several recommendations not related to Mr Vickery’s death that the Head of
Healthcare will wish to address.
9. The clinical reviewer found that the adrenaline given to Mr Vickery during the
emergency response was at the wrong dose for a suspected cardiac arrest. The
correct adrenaline dose was not available in the emergency bag so healthcare staff
gave a lower dose used for severe allergic reactions rather than cardiac arrests. We
recommend:
The Head of Healthcare should ensure that all emergency response
equipment is regularly checked to ensure that the correct stocks of
equipment and drugs are present to treat cardiac arrests.
Prisons and Probation Ombudsman 1
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10. We shared our initial report with HMPPS. They found no factual inaccuracies. They
provided an action plan which is annexed to this report.
11. We sent copies of our report to Mr Vickery’s next of kin. They did not notify us of
any factual inaccuracies.
Adrian Usher March 2024
Prisons and Probation Ombudsman
Inquest
The inquest, held on 6 January 2025, concluded that Mr Vickery died from natural causes.
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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