Mark Jones

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Independent investigation into
the death of Mr Mark Jones,
a prisoner at HMP Oakwood,
on 14 June 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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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 Mark Jones died in a hospice of pancreatic cancer on 14 June 2025, while a
prisoner at HMP Oakwood. He was 54 years old. We offer our condolences to his
family and friends.
4. The clinical reviewer concluded that the clinical care Mr Jones received at Oakwood
was not equivalent to that which he could have expected to receive in the
community. She found that the care Mr Jones received in the weeks prior to his
diagnosis was poor as despite healthcare staff seeing him ten times between 22
and 27 April, they did not review previous records to build a full clinical picture. The
Head of Healthcare has already taken steps to address the clinical reviewer’s
recommendation on this. The clinical reviewer made three other recommendations
relating to the wider care Mr Jones received, which the Head of Healthcare will wish
to address.
5. We found that Release on Temporary Licence (ROTL) was not considered for Mr
Jones, despite him being in a hospice since 21 May for end-of-life care. Mr Jones’
sister told us that she and her brother had no privacy as two officers were there
throughout. This had a significant impact on her final weeks with him. Given that an
application for early release on compassionate grounds (ERCG) was in progress,
we can see no reason why ROTL was not considered in the meantime to provide
dignity and privacy.
Recommendation
• The Governor should ensure that staff understand the requirements for Release on
Temporary Licence for medical purposes and a robust process is implemented to
ensure applications are made when appropriate.
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The Investigation Process
6. HMPPS notified us of Mr Jones’ death on 14 June 2025.
7. NHS England commissioned an independent clinical reviewer, to review Mr Jones’
clinical care at HMP Oakwood. The clinical review is attached as Annex 1.
8. The PPO investigator investigated the non-clinical issues relating to Mr Jones’ care.
She interviewed one member of prison staff on 19 August.
9. The Ombudsman’s office wrote to Mr Jones’ sister to explain the investigation and
to ask if she had any matters she wanted us to consider. She asked several
questions about Mr Jones’ care in the lead up to his diagnosis and raised concerns
about his treatment in hospital. We have addressed these questions and comments
in this report and in a separate letter.
10. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group (PPG). They found no factual inaccuracies. HMPPS provided
an action plan which is annexed to this report.
11. We sent a copy of our initial report to Mr Jone’s sister. She provided comments
which we have addressed in a separate letter.
Previous deaths at HMP Oakwood
12. Mr Jones was the nineteenth prisoner to die at HMP Oakwood since June 2022. All
the previous deaths were from natural causes. There are no similarities between
the findings in our investigation into Mr Jones’ death and the findings from our
investigations into the previous deaths.
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Key Events
13. On 21 August 2023, Mr Mark Jones was sentenced to four years in prison for
assault. He was taken to HMP Oakwood.
14. Mr Jones had a longstanding injury to his left arm and right leg from an accident
before entering custody. He often requested pain medication for this and was under
the care of a bone specialist at the hospital.
15. On 22 April 2025, Mr Jones went to the healthcare unit for a blood test. He told the
healthcare assistant that he had black stools and had been vomiting. The
healthcare assistant took Mr Jones’ clinical observations and calculated a NEWS2
score of three (The National Early Warning Score (NEWS2) is a tool used to assess
clinical deterioration. A score is calculated from the clinical observations taken and
the higher the score, the higher the risk. A score of three is low to medium risk.)
She asked him to provide a stool sample.
16. Later that day, a nurse repeated Mr Jones’ clinical observations and calculated a
NEWS2 score of zero. She advised him to contact healthcare staff if his symptoms
worsened.
17. On 23 April, Mr Jones complained of chest pain. An officer radioed a code blue (a
medical emergency code used when a prisoner is unconscious or having breathing
difficulties that alerts healthcare staff to attend and the control room to call an
ambulance). A nurse attended his cell. Mr Jones said the pain was mainly in his
stomach, and he had been vomiting. The nurse took his clinical observations and
calculated a NEWS2 score of one. As he showed no signs of shortness of breath or
difficulty breathing, she stood down the code blue. She suspected that Mr Jones
had a sickness bug and asked a GP to prescribe anti-sickness tablets.
18. On 24 April, Mr Jones collected his anti-sickness tables from the medications hatch.
He told the nurse at the hatch that he had been vomiting every 30 minutes.
19. Later that day, a nurse saw Mr Jones in his cell. She took his clinical observations
and calculated a NEWS2 score of two. She arranged for him to have a blood test
the following morning and advised him to contact healthcare if his symptoms
worsened overnight.
20. On 25 April, Mr Jones did not attend his blood test appointment.
21. On 26 April, a nurse visited Mr Jones in his cell. He said he had stomach pain for
the past three weeks that was worsening, along with nose bleeds, black stools, and
vomiting. The nurse took his clinical observations and calculated a NEWS2 score of
two. She discussed Mr Jones’ condition with the designated emergency response
nurse and agreed to review him again within four hours.
22. At around 9.00pm, a nurse saw Mr Jones again. She took his clinical observations
and calculated a NEWS2 score of one. Mr Jones said he had no pain or sickness at
the time. She advised him to alert healthcare staff if he felt unwell overnight.
23. On 27 April, officers radioed a code blue as Mr Jones was feeling unwell. A
paramedic responded, took his clinical observations, and checked his stomach.
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They stood down the code blue, deciding he did not need an ambulance at the time.
They arranged urgent blood and urine tests.
24. At around 11.36am, a healthcare assistant tried to take Mr Jones’ blood in his cell.
Mr Jones said he did not feel well enough, and they agreed to try again later.
25. At around 3.24pm, a nurse and paramedic returned to take Mr Jones’ blood. As he
still felt unwell, they decided to call an ambulance. Mr Jones was taken to hospital
and admitted.
26. On 30 April, while in hospital, doctors diagnosed Mr Jones with a bowel obstruction.
27. On 8 May, a nurse at Oakwood visited Mr Jones in hospital. She was told that an
MRI scan showed he had pancreatic cancer that had possibly spread to his liver,
and a blocked artery in his gut. The consultant gave a prognosis of weeks to
months. The nurse asked for a letter from the consultant to start an application for
early release on compassionate grounds (ERCG).
28. On 16 May, doctors at the hospital gave Mr Jones a prognosis of two weeks.
29. On 21 May, Mr Jones was moved to a hospice for end-of-life care.
30. On 28 May, staff at Oakwood submitted an ERCG application for Mr Jones’ to the
public protection casework section (PPCS) within HMPPS, for consideration. PPCS
had not made a decision on the application before Mr Jones’ death.
31. On 14 June, Mr Jones’ condition deteriorated, and he died later that day.
Cause of death
32. The Coroner accepted the cause of death provided by a hospice doctor and no
post-mortem examination was carried out. The doctor gave the cause of death as
metastatic pancreatic cancer (cancer which has spread to other parts of the body).
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Findings
Clinical care
33. The clinical reviewer concluded that the care Mr Jones received at Oakwood was
not of an adequate standard and was not equivalent to that which he could have
expected to receive in the community.
34. The clinical reviewer found that the care Mr Jones received in the lead up to his
diagnosis was poor. Although healthcare staff saw Mr Jones ten times between 22
and 27 April, there was little evidence that they reviewed previous entries,
considered the whole picture including Mr Jones’ reported history, or considered the
clinical observations within that context. The clinical reviewer considered that while
earlier intervention would not have changed the outcome for Mr Jones, it could have
prevented or at least mitigated the distress and anxiety he experienced before his
hospital admission on 27 April. The clinical reviewer also noted that no NEWS2 was
calculated by any of the staff who saw him on 27 April, either in response to the
code blue or when they were trying to take blood.
35. The Head of Healthcare has already created an action plan to address these issues
so we do not repeat the clinical reviewer’s recommendation. The clinical reviewer
made three other recommendations relating to the wider care Mr Jones received,
which the Head of Healthcare will wish to address.
Release on Temporary Licence (ROTL)
36. The Release on Temporary Licence (ROTL) Policy Framework sets out how a
Special Purpose Licence (SPL) can be issued in response to a specific event or
circumstances that would not usually require release on a regular basis.
37. Section 6.31 of the ROTL Policy Framework says that a SPL may be granted for
offenders to attend medical out-patient appointments, or inpatient requirements.
38. Section 6.26 says if an offender is subject to a Restricted ROTL (which sets
limitations on ROTL due to their sentence, offence, or risk) they are still eligible for a
SPL for medical treatment, providing:
• the offender needs essential medical treatment in the community; and
• a senior manager chaired ROTL board has sat; and
• the governor or deputy governor has agreed SPL is appropriate in all the
circumstances.
39. Mr Jones was in hospital from 27 April and was moved to a hospice for end-of-life
care on 21 May, where he remained until he died on 14 June. Throughout this
period, he remained on a two-officer bed watch.
40. The investigator spoke to the Head of Offender Management Services at Oakwood,
who said that ROTL was not considered for Mr Jones as staff were focusing on
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completing his ERCG application and as a hospice place had been secured, ROTL
would have had limited benefit.
41. We disagree. Mr Jones would have been eligible to apply for a Special Purpose
Licence ROTL on medical grounds and this should have been considered by
Oakwood to ensure his dignity was preserved and to offer privacy to his family in his
final weeks. We recommend:
The Governor should ensure that staff understand the requirements for
Release on Temporary Licence for medical purposes and a robust process is
implemented to ensure applications are made when appropriate.
Inquest
42. At the inquest held on 17 August 2026, the Coroner concluded that Mr Jones died
from natural causes.
Adrian Usher
Prisons and Probation Ombudsman December 2025
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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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