Nigel Malt

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Independent investigation into
the death of Mr Nigel Malt,
a prisoner at HMP Gartree,
on 29 April 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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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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 September 2022, Mr Nigel Malt received a life sentence for murder. He died of
heart failure on 29 April 2025, at HMP Gartree. He was 47 years old. We offer our
condolences to Mr Malt’s family and friends.
4. The prison told us that Mr Malt’s next of kin did not wish to be contacted as part of
our investigation.
5. The PPO investigator investigated the non-clinical issues relating to Mr Malt’s care.
6. NHS England commissioned an independent clinical reviewer, to review Mr Malt’s
clinical care at Gartree. They interviewed two members of healthcare staff on 16
and 22 July.
7. The clinical reviewer concluded that the clinical care Mr Malt received at Gartree
was of a reasonable standard and was equivalent to that which he could have
expected to receive in the community. She found that there was clear evidence of
care planning for the management of Mr Malt’s long-term conditions. However, she
made several recommendations about the wider care Mr Malt received which the
Head of Healthcare will wish to address.
8. We did not find any significant non-clinical issues of concern. We make no
recommendations.
9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Governor to note
10. Despite Mr Malt having a DNACPR (Do Not attempt Cardiopulmonary
Resuscitation) in place, the officers who found him carried out CPR on him for
approximately four minutes. While we appreciate that it was their natural reaction to
start CPR, they should have been aware that Mr Malt had a DNACPR in place and
respected his wishes. We bring this to the attention of the Governor and Head of
Healthcare.
11. At an inquest held on 28 October 2025, the Coroner concluded that Mr Malt died of
natural causes.
Adrian Usher October 2025
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