Michael Dawson

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of
Mr Michael Dawson,
a prisoner at HMP Lindholme,
on 14 February 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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© Crown copyright, 2026
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 23 March 2023, Mr Michael Dawson was sentenced to five years imprisonment
for arson.
4. Mr Dawson died of an epileptic seizure on 14 February 2024 at HMP Lindholme. He
was 39 years old. We offer our condolences to Mr Dawson’s family and friends.
5. The Ombudsman’s office contacted Mr Dawson’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. Mr Dawson’s family
asked about the healthcare Mr Dawson received in prison and whether he took his
medication. The family’s questions have been addressed in the clinical review.
6. NHS England commissioned a clinical reviewer to review Mr Dawson’s clinical care
at the prison. She concluded that the clinical care Mr Dawson received at
Lindholme was not of the required standard and therefore not equivalent to what he
could have expected to receive in the community, because healthcare staff failed to
put a care plan in place to manage Mr Dawson’s epilepsy.
7. We make the following recommendations:
The Head of Healthcare should ensure that when patients refuse to attend
outside hospital against medical advice that a two-stage mental capacity
assessment is undertaken to ensure the patient fully understands their
decision making and this is documented into the SystmOne medical records
for the wider multi-disciplinary team.
The Head of Healthcare should ensure that all staff are trained and competent
in NEWS2 assessment, scoring, and calculation. This will ensure that patients
who are deteriorating, or at risk of deteriorating will have a timely initial
assessment by a competent clinical decision maker.
The Head of Healthcare should ensure that all patients with long-term
conditions including epilepsy have an individualised management plan that
includes the out of hours provision.
The Head of Healthcare should ensure that when there is an increase in
seizures in individuals with a diagnosis of epilepsy that a seizure chart is
used to ensure that patients are monitored to see if there is a pattern to the
seizures and further escalation of treatment can be planned.
Prisons and Probation Ombudsman 1
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8. The PPO investigator investigated the non-clinical issues relating to Mr Dawson’s
care. While healthcare staff suggested that Mr Dawson be placed in a shared cell
as he had epilepsy, we found that Mr Dawson refused to move. We did not find any
non-clinical issues of concern.
9. The initial report was shared with HM Prison and Probation Service (HMPPS) and
the healthcare provider, Practice Plus Group. No factual inaccuracies were
identified.
10. At the inquest held on 20 January 2026, the coroner concluded that Mr Michael
Dawson died of natural causes.
Adrian Usher
Prisons and Probation Ombudsman December 2024
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
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