Mardan Halimi

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Independent investigation into
the death of Mr Mardan Halimi,
a prisoner at HMP Pentonville,
on 10 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
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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 Mardan Halimi died in hospital of hospital acquired pneumonia caused by
metastatic pancreatic cancer (pancreatic cancer that has spread to other parts of
the body) on 10 March 2025, while a prisoner at HMP Pentonville. He was 46 years
old. We offer our condolences to his family and friends.
4. The clinical reviewer found that the clinical care Mr Halimi received at Pentonville
was equivalent to that he could have expected to receive in the community.
5. Mr Halimi spent the last two and a half weeks of his life as a hospital inpatient. We
found that, for much of this time, restraints were used on Mr Halimi without due
consideration for his increasingly poor mobility and difficulty breathing.
Recommendations
• The Governor should ensure that all prison staff undertaking management checks
during hospital bedwatches understand the legal position on the use of restraints
and that:
• Managers fully consider the prisoner’s current health and mobility and base
their decision on the actual risk the prisoner poses at the time.
• A robust quality assurance process is implemented to check that these
measures are in place and effective.
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The Investigation Process
6. HMPPS notified us of Mr Halimi’s death on 10 March 2025.
7. NHS England commissioned an independent clinical reviewer, to review Mr Halimi’s
clinical care at HMP Pentonville. The clinical review is attached as Annex 1.
8. The PPO investigator investigated the non-clinical issues relating to Mr Halimi’s
care.
9. The Ombudsman’s office wrote to Mr Halimi’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. Mr Halimi’s brother said
that he emailed and phoned Pentonville several times to highlight concerns about
his brother’s health.
10. We also shared the initial report with Mr Halimi’s family. They did not make any
comments.
11. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is an additional
annex to this report.
Previous deaths at HMP Pentonville
12. Mr Halimi was the seventh prisoner to die at Pentonville since March 2022. Of the
previous deaths, one was from natural causes, two were drug related deaths and
three were self-inflicted. There are no significant similarities between the findings in
our investigation into Mr Halimi’s death and the findings from our investigations into
the previous deaths.
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Key Events
13. On 25 September 2024, Mr Mardan Halimi was sentenced to two years in prison for
drugs offences. On 28 November, he was released on licence. On 2 December, Mr
Halimi was arrested for rape, strangulation and actual bodily harm. On 4 December,
he was admitted to HMP Pentonville on licence recall and on remand for the new
offences.
14. A nurse completed a reception health screen assessment, at which Mr Halimi said
that he had high blood pressure and cholesterol. The nurse referred him to a GP.
15. On 19 February 2025, Mr Halimi told prison staff that he had pain in his kidney and
his head, and said that he had felt unwell for three days. A nurse assessed him, and
Mr Halimi said that he had not opened his bowels for five days and had pain in the
right side of his stomach with a loss of appetite. A urine test was completed and
identified a presence of urobilinogen (excess urobilinogen in urine may indicate liver
diseases, such as viral hepatitis, cirrhosis, or liver damage). Mr Halimi’s clinical
observations identified an elevated pulse rate. He had an electrocardiogram (ECG -
test that records the electrical activity of your heart, including the rate and rhythm)
completed which identified sinus tachycardia (heart is beating faster than normal)
and it was planned to discuss Mr Halimi with a GP. It was also planned to repeat
blood tests, and these were requested.
16. On the same day, a GP saw Mr Halimi and described him as appearing to be in
obvious discomfort, appearing slightly dehydrated and holding his right side in pain.
The GP prescribed codeine to help with the pain and recorded that there was a low
threshold to send Mr Halimi to hospital if his symptoms had not improved later that
day. Mr Halimi was also prescribed a course of antibiotics.
17. Staff asked Mr Halimi about the pain in his head. Mr Halimi stated that over a year
ago while in the community he had hit himself over the head with an ashtray until it
smashed. He stated he had been waiting for an MRI to see what was wrong.
18. On 20 February, a nurse reviewed Mr Halimi. He said that he still felt unwell, was
holding his right side, and said the pain was getting worse. Mr Halimi’s clinical
observations showed an ongoing elevated pulse rate. He had a NEWS2
(determines degree of illness of a patient and prompts critical care
intervention) score of two, which indicated a low clinical acute risk.
19. Shortly afterwards, Mr Halimi experienced severe pain and staff arranged for him to
be taken to hospital by ambulance. Before transfer to hospital, a nurse completed
the healthcare section of the escort risk assessment and did not object to the use of
restraints. A senior prison officer authorised double cuff restraints on Mr Halimi, to
be removed only for life threatening emergencies. (Double cuffs is when the
prisoner’s hands are cuffed together with one set of handcuffs and a second set of
cuffs is used to cuff one of the prisoner’s wrists to an officer’s wrist.) Mr Halimi
remained in hospital on bedwatch (with two officers present) and did not return to
prison.
20. On 28 February, bedwatch officers considered completing another risk assessment
on Mr Halimi to assess whether he should still be restrained. They contacted the
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prison and the duty operational manager called the hospital for an update on Mr
Halimi’s health. The consultant treating Mr Halimi was present when the duty
manager called. He said that Mr Halimi was not “imminently dying”. After this no
further action was taken and Mr Halimi remained in restraints. There was no
consideration for his mobility, ongoing treatment and wider health, including that by
this stage he was receiving oxygen therapy due to difficulty breathing and required
personal care in bed and assistance to use a commode.
21. On 4 March, staff recorded that Mr Halimi was fairly immobile and a physiotherapist
was helping him to practice walking. He had difficulty breathing and continued to
receive oxygen (which remained for the rest of his hospital stay). Mr Halimi also
now had a catheter in place. He remained in handcuffs.
22. On 6 March, hospital staff contacted the Deputy Head of Healthcare to make them
aware that Mr Halimi was still being restrained despite his frail and poor clinical
condition. This was raised with the duty operational manager and the restraints
were removed the next day.
23. On 7 March, Mr Halimi was admitted to the hospital intensive care unit. Hospital
staff informed the prison that Mr Halimi had been diagnosed with metastatic
pancreatic cancer, and he was not for active treatment and had a poor prognosis.
Mr Halimi continued to deteriorate in hospital.
24. On 7 March also, prison staff contacted court staff and asked to speak with the
Judge handling Mr Halimi’s current case (the outstanding offences for which he had
been remanded). They wanted to ask if bail could be granted to Mr Halimi so that
prison and healthcare staff could issue release on temporary licence (ROTL, a
means by which prisoners can temporarily be released to spend time in the
community, usually for resettlement purposes but also for essential medical
treatment) in case he needed end of life care. A court hearing was scheduled for 12
March.
25. On 8 March, Mr Halimi’s brother visited him in hospital.
26. At 9.18am on 10 March, Mr Halimi died.
Cause of death
27. A hospital doctor gave Mr Halimi’s cause of death as hospital acquired pneumonia
caused by metastatic pancreatic cancer (pancreatic cancer that has spread to other
parts of the body).
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Findings
Clinical findings
28. The clinical reviewer concluded that the clinical care Mr Halimi received at
Pentonville was equivalent to that which he could have expected to receive in the
community. She made one recommendation on medication reconciliation, not
related to Mr Halimi’s death, which the Head of Healthcare will wish to address.
Release on Temporary Licence
29. Once it was established that Mr Halimi had a poor prognosis, healthcare and prison
staff attempted to facilitate release on temporary licence (ROTL) for him. This could
be approved by the Governor if Mr Halimi was granted bail by the court for his
outstanding offences.
30. The clinical reviewer found evidence of good practice from healthcare staff in their
work to support Mr Halimi’s bail application once his poor prognosis became clear.
Prison staff quickly applied to the court and a hearing was promptly listed, but Mr
Halimi died before his case was heard.
Use of restraints
31. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 made it clear that prison staff need to
distinguish between a prisoner’s risk of escape when fit (and the risk to the public in
the event of an escape) and the prisoner’s risk when suffering from a serious
medical condition. The judgment indicated that medical opinion about the prisoner’s
ability to escape must be considered as part of the assessment process and kept
under review as circumstances change.
32. The Prevention of Escape – External Escorts policy framework says there should
be management checks initially within the first 24 hours of a bedwatch, and then at
least every 72 hours to include looking at the prisoner’s medical condition and
whether restraints are inappropriate.
33. On 20 February, Mr Halimi was taken to hospital. Before he was transferred a nurse
completed the healthcare section of the escort risk assessment and did not object
to the use of restraints. This decision appeared clinically appropriate on the day as,
while Mr Halimi was experiencing significant pain, he was a middle-aged prisoner
who retained mobility. Mr Halimi was also on remand for very serious offences and
a duty manager appropriately authorised the use of restraints.
34. By 28 February, Mr Halimi’s health had deteriorated. He was now receiving oxygen
therapy due to difficulty breathing and was considerably less mobile. A duty
manager considered the use of restraints, but this appeared to consist solely of a
conversation with a hospital consultant who said that Mr Halimi was not “imminently
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dying”. After this no further action was taken and Mr Halimi remained in restraints.
There was no consideration therefore for his mobility, poor health and ongoing
treatment.
35. By 4 March, Mr Halimi was much more immobile and a physiotherapist was helping
him to practice walking. He continued to receive oxygen therapy (which remained
for the rest of his hospital stay). He was also given personal care by nurses in bed
or had to be helped to use a commode, and had a catheter fitted. There was no
apparent reconsideration of his risk assessment and whether restraints were still
appropriate.
36. The restraints were eventually removed on 7 March, after hospital staff questioned
their use.
37. The prison records showed that bedwatch staff conducted management checks
every 72 hours, in line with policy requirements. However, they did not properly
consider Mr Halimi’s health during this time and he remained in restraints longer
than was appropriate.
38. We are not satisfied that prison staff complied with the High Court judgement or that
they fully considered Mr Halimi’s risk in light of his poor and deteriorating physical
health. Although his restraints were removed on 7 March, this was initiated by
hospital staff raising their concerns with the prison. There had been no proper prior
consideration for Mr Halimi’s current and long-term health or his current
circumstances, treatment and mobility.
39. It is important that Pentonville properly considers the prisoner’s health, mobility and
treatment when determining the appropriate level of restraints during bedwatch
management checks.
40. We make the following recommendation:
The Governor should ensure that all prison staff undertaking management
checks during hospital bedwatches understand the legal position on the use
of restraints and that:
• Managers fully consider the prisoner’s current health and mobility and
base their decision on the actual risk the prisoner poses at the time.
• A robust quality assurance process is implemented to check that these
measures are in place and effective.
Inquest
41. The inquest into Mr Halimi’s death concluded on the 9 September 2025. The
coroner confirmed that Mr Halimi died from natural causes.
Adrian Usher
Prisons and Probation Ombudsman June 2026
6 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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