Mohammed Shabir

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into the
death of Mr Mohammed Shabir,
a prisoner at HMP Leeds,
on 24 September 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2026
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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 28 August 2024, Mr Mohammed Shabir was remanded to HMP Leeds on
charges of murder, attempted murder and arson.
4. Mr Shabir died in hospital of cardiac tamponade (fluid around the heart preventing it
from pumping enough blood) caused by hemopericardium (blood accumulating in
the pericardial sac which surrounds the heart) and myocardial infarction (heart
attack) on 24 September 2025, while a prisoner at Leeds. He was 45 years old. We
offer our condolences to Mr Shabir’s family and friends.
5. The Ombudsman’s office wrote to Mr Shabir’s brother to explain the investigation
and to ask if he had any matters he wanted us to consider. Mr Shabir’s brother had
no questions but asked for a copy of our report.
6. We also shared the initial report with Mr Shabir’s family. They raised a number of
issues/questions that do not impact on the factual accuracy of this report and which
we have addressed through separate correspondence.
7. We shared the initial report with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies. NHSE Spectrum also pointed out
some factual inaccuracies with the clinical review. The investigator passed these
onto the clinical reviewer who amended their report.
8. NHS England commissioned an independent clinical reviewer, to review Mr Shabir’s
clinical care at HMP Leeds.
9. The clinical reviewer concluded that the clinical care Mr Shabir received at Leeds
was partially equivalent to that which he could have expected to receive in the
community. She found that general health care and the emergency response was
equivalent and of a good standard.
10. However, the clinical reviewer found that the clinical care provided to Mr Shabir on
20 September 2025, when he told prison staff he felt unwell, was partially
equivalent. An officer said that they contacted a response nurse to assess Mr
Shabir, but no one completed this. The clinical reviewer found that it was unclear
who was holding the response radio at the time and therefore uncertain who had
responsibility to attend to Mr Shabir. While he was not seen, the clinical reviewer
found that Mr Shabir’s symptoms did not indicate that an emergency response was
required.
11. The clinical reviewer made five recommendations not related to Mr Shabir’s death,
which the Head of Healthcare will wish to address.
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
12. The PPO investigator investigated the non-clinical issues relating to Mr Shabir’s
care. We found that the officer who told us that they made a radio call on 20
September did not record this in Mr Shabir’s prison records, and there was no
additional evidence recorded that they had made a call or that Mr Shabir felt unwell.
This also meant that operational colleagues did not have the opportunity to identify
and follow-up on the officer’s request. The Governor will want to ensure that prison
staff properly record important information and requests for assistance about
prisoners’ health.
Inquest
13. The inquest into Mr Shabir’s death concluded on the 8 October 2025. The coroner
confirmed that Mr Shabir died from natural causes.
Adrian Usher
Prisons and Probation Ombudsman June 2026
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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
OFFICIAL - FOR PUBLIC RELEASE