Mark Penfold

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Independent investigation into
the death of Mr Mark Penfold,
a prisoner at HMP Highpoint,
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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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. On 29 January 2025, Mr Mark Penfold was sentenced to three years imprisonment
for fraud. He died of heart failure caused by various heart and lung conditions on 10
March, at HMP Highpoint. He was 65 years old. We offer our condolences to Mr
Penfold’s family and friends.
4. The Ombudsman’s office wrote to Mr Penfold’s next of kin to explain the
investigation. The only specific question was about the cause of Mr Penfold’s death.
5. NHS England commissioned an independent clinical reviewer to review Mr
Penfold’s clinical care at Highpoint.
6. The clinical reviewer concluded that in his relatively short time at Highpoint, the
clinical care Mr Penfold received was of a good standard and equivalent to that
which he could have expected to receive in the community. The clinical reviewer
made a recommendation not related to Mr Penfold’s death, about clinical
observations on reception, that the Head of Healthcare will wish to address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Penfold’s
care. We did not find any non-clinical issues of concern. We make no
recommendations.
8. A copy of the initial report was sent to Mr Penfold’s next of kin. She reported no
factual inaccuracies but queried a matter of detail, which has been addressed in
correspondence.
9. We shared the initial report with HMPPS. They found no factual inaccuracies.
Governor to note
10. The investigation found that the operational support night staff who conducted the
early morning welfare check did not call an emergency code as they genuinely
believed Mr Penfold was in a deep sleep, as was common for a lot of the men, so
they radioed for help to rouse him. There was a significant delay of around eight
minutes before the response officers arrived at the cell, as they were unlocking the
prison’s front gate and had to draw keys and radios before returning to the wing,
which was some distance away.
Prisons and Probation Ombudsman 1
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11. We are satisfied that the staff involved were fully conversant with the procedures to
be followed in the event of concerns and their decision not to call an emergency
code was a matter of fine judgement. Indeed, having reflected, they volunteered
that in a similar situation in future, they would err on the side of caution and radio a
code to ensure a timely response. We therefore make no further comment, but the
Governor might wish to review the location of response staff during night shifts.
Inquest
12. At an inquest held on 30 March 2026, the coroner concluded that Mr Penfold died
from natural causes.
Adrian Usher January 2026
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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