Neil Maddox

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Neil Maddox,
a prisoner at HMP Manchester,
on 17 June 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, 2024
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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. In July 2011, Mr Neil Maddox was sentenced to 15 years imprisonment for sexual
offences. Mr Maddox had Advanced Parkinson’s disease. He died in hospital of
aspiration pneumonia (the inhalation of stomach contents) caused by
oropharyngeal dysphagia (a disorder in which you cannot properly swallow food,
liquid or saliva) on 17 June 2024, while a prisoner at HMP Manchester. He was 76
years old. We offer our condolences to Mr Maddox’s family and friends.
4. The Ombudsman’s office contacted Mr Maddox’s brother to explain the
investigation and to ask if he had any matters he wanted us to consider. He raised
no issues and asked for a copy of our report.
5. NHS England commissioned an independent clinical reviewer to review Mr
Maddox’s clinical care at HMP Manchester.
6. The clinical reviewer concluded that the clinical care Mr Maddox received was
equivalent to that which he could have expected to receive in the community. She
made one recommendation about falls risk assessments, which is not directly
related to Mr Maddox’s death but which the Head of Healthcare will wish to
address.
7. The PPO investigator investigated the non-clinical issues relating to Mr Maddox’s
care.
8. We did not find any non-clinical issues of concern. We make no recommendations.
9. At the inquest held on 2 July 2024 the coroner concluded that Mr Maddox died of
natural causes.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
11. Mr Maddox’s family received a copy of the draft report. They did not make any
comments.
Adrian Usher October 2024
Prisons and Probation Ombudsman
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
OFFICIAL - FOR PUBLIC RELEASE