Oliver Mulangala

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Independent investigation into the
death of Mr Oliver Mulangala,
a prisoner at HMP High Down,
on 13 July 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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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.
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.
Mr Oliver Mulangala died from synthetic cannabinoid (spice) toxicity on 13 July 2024, at
HMP High Down. He was 40 years old. I offer my condolences to Mr Mulangala’s family
and friends.
The clinical reviewer concluded that Mr Mulangala’s clinical care was of a good standard
and equivalent to that which he could have expected to receive in the community.
Mr Mulangala experienced several drug-induced seizures and was therefore aware of the
risks and possible adverse consequences of using illicit substances. I am satisfied that he
was offered appropriate support and information.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman October 2025
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 2
Background Information ................................................................................................... 2
Key Events ....................................................................................................................... 5
Findings ......................................................................................................................... 10
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Summary
Events
1. Mr Oliver Mulangala was recalled to prison on 7 December 2022 and taken to HMP
Wormwood Scrubs. He was later convicted of violent offences and sentenced to 30
months imprisonment. He transferred to HMP High Down on 5 June 2023.
2. Mr Mulangala had high blood pressure and diabetes, as well as a longstanding
history of substance misuse. He was given information about the risks of using illicit
substances, but repeatedly declined formal support.
3. Between May and November 2023, Mr Mulangala had at least six drug-induced
seizures. The most serious incidents, in May and September, led to him being
admitted to the intensive care unit of a local hospital. On 15 November 2023, Mr
Mulangala agreed to receive formal support and was allocated to a substance
misuse practitioner. A mandatory drug test taken on 13 December was negative
and there were no further reports of drug taking in the following months.
4. At 8.58am on 13 July 2024, a prisoner found Mr Mulangala lying on the floor of his
cell, unresponsive. A prison officer radioed a medical emergency code and an
ambulance was requested. Paramedics saw obvious signs of rigor mortis (stiffening
of the body after death) and pronounced life extinct at 9.15am.
Findings
5. The clinical reviewer concluded that Mr Mulangala’s clinical care was of a good
standard and equivalent to that which he could have expected to receive in the
community. However, he made recommendations on matters not directly linked to
Mr Mulangala’s cause of death, which the Head of Healthcare will need to consider.
6. High Down has an up-to-date drug strategy, as well as a separate protocol for
managing and supporting prisoners who use psychoactive substances. There are
many initiatives in place to reduce drug trafficking and the demand for drugs,
including swabbing all mail and staff parcels; increasing the use of drug detection
dogs; greater collaboration with the police to reduce the incidence of drones; and
locating prolific users together as a cohort, with rewards for abstinence.
7. The substance misuse service has a solid collaborative relationship with other
areas of the prison. It is well integrated into the prison’s communication channels
and is consulted on strategic issues. Each time Mr Mulangala was found under the
influence of drugs, offers of psychosocial support were timely. However, due to
increased demand and a shortage of staff, the substance misuse service was not
always able to meet the expected timescales for subsequent reviews.
8. The staff member who conducted the early morning count of prisoners did not
check Mr Mulangala and the officer who later unlocked him did not seek a verbal
response to indicate that he was safe and well. The prison took prompt action to
address these failures.
9. We make no recommendations.
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The Investigation Process
10. HMPPS notified us of Mr Mulangala’s death on 13 July.
11. The investigator issued notices to staff and prisoners at HMP High Down, informing
them of the investigation and asking anyone with relevant information to contact
her. One prisoner replied, raising concerns about staff responding to cell call bells.
This was considered during the investigation and there was no evidence of Mr
Mulangala pressing his cell bell during the days before his death.
12. The investigator obtained copies of relevant extracts from Mr Mulangala’s prison
and medical records, as well as local policy and operational documents.
13. NHS England commissioned an independent clinical reviewer to review Mr
Mulangala’s clinical care at the prison. The investigator and the clinical reviewer
interviewed seven members of staff via Microsoft Teams on 24 and 25 October.
The investigator also held meetings with Head of Security and, Head of Drug
Strategy.
14. We informed HM Coroner for Surrey of the investigation. The Coroner gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
15. The Ombudsman’s office contacted Mr Mulangala’s brother to explain the
investigation. Mr Mulangala’s brother raised several concerns and observations,
some are summarised below and have been addressed in either the PPO or the
clinical review report. Additional issues have been dealt with in correspondence:
• What healthcare did Mr Mulangala receive for seizures?
• Why was Mr Mulangala in a single cell and is there a policy on cell sharing
for prisoners at risk of seizures.
• The officer who unlocked Mr Mulangala’s cell on the morning of his death did
not check him, or notice that he had died and he was found by another
prisoner.
16. We sent a copy of our report to the solicitor acting on behalf of Mr Mulangala’s next
of kin. She identified an inaccuracy, which has been amended, and raised issues
which have been dealt with in correspondence. We sent a copy of our report to the
solicitor acting on behalf of Mr Mulangala’s next of kin. She identified an inaccuracy,
which has been amended, and raised issues which have been dealt with in
correspondence.
17. The initial report was shared with HM Prison and Probation Service (HMPPS). They
found no factual inaccuracies but some sensitive security information in the section,
“Drug Strategy at HMP High Down” has been edited at their request.
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Background Information
HMP High Down
18. HMP High Down is a category C prison in Surrey. It was re-categorised from a local
to a training and resettlement prison in April 2022. Central and North-West London
NHS Foundation Trust provide the physical and mental healthcare services at High
Down. Healthcare staff work in the prison between 7.30am and 8.00pm from
Monday to Friday and from 8.00am to 8.00pm on Saturday and Sunday. Forward
Trust provides substance misuse services. The prison has a substance misuse
treatment unit and an incentivised substance-free living unit.
HM Inspectorate of Prisons
19. The most recent inspection of HMP High Down was in July and August 2023.
Inspectors found that drugs, particularly psychoactive substances, were widely
available. Insufficient priority had been given to reducing drug trafficking and this
posed a critical threat to safety. They noted that 45% of prisoners had said that it
was easy to get hold of drugs (compared to 31% in comparable prisons). Mandatory
drug testing had only resumed in February 2023 and the positive drug testing rate in
the previous three months was very high at 33.73%, with the rate for psychoactive
substances alone at 21.08%. This was among the highest rates in adult male
prisons in England and Wales.
20. Inspectors reported that very few tests were taken when prisoners were suspected
of using or found under the influence of drugs and adjudications were often
withdrawn. Therefore, those concerned faced no formal consequences for their
actions. The prison had made some changes, such as photocopying prisoners’ mail
and using the body scanner on men suspected of possessing drugs and they were
working with the police to reduce the flow of items smuggled on drones. Staff
shortages meant that there were significant delays in analysing and taking action on
security intelligence, and only a quarter of suspicion drug tests were carried out.
21. After an independent review of progress in May 2024, inspectors said that the
availability of illicit drugs continued to be a serious concern that undermined safety
and stability. The level of positive drug tests was as high as it had been at the
previous full inspection, but the arrangements for drug testing had improved,
including suspicion testing. Enhanced gate procedures had been introduced but
were not always applied thoroughly. Dedicated security staff promptly processed
and acted on security intelligence and more frequent searching had led to
significant finds of contraband.
22. The provision of purposeful activity was still not good enough and some prisoners
said they took drugs due to boredom. However, there was good focus on drug
treatment and support, as well as joint working with community and criminal justice
agencies. Inspectors concluded that reasonable progress had been made on the
concerns they had previously identified.
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Independent Monitoring Board
23. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report for the year to December 2023, the IMB reported
that security intelligence indicated an overwhelming presence of illicit items, with
drugs ‘finds’ increasing from 195 in 2022 to 1,641 in 2023.
24. The IMB said that drones and ‘throwovers’ (where items were thrown over the
prison walls) appeared to be the main source of illicit items entering the prison, as
well as items being passed by visitors. It was noted that towards the end of 2023,
perimeter patrols were undertaken and the prison had worked with external partners
to deal with the drones.
Previous deaths at HMP High Down
25. Mr Mulangala was the seventh prisoner to die at High Down since July 2021. Four
of the previous deaths were due to natural causes and two were drug related. In a
previous investigation, we found that the morning welfare check of the prisoner had
not been completed. Up to the end of March 2025, there have been five deaths at
High Down since that of Mr Mulangala, all of which were due to natural causes.
Psychoactive Substances (PS)
26. The term psychoactive substances is a broad term that refers to a drug or other
substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazenes) are substances that mimic the effects of traditional
controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
27. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
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Key Events
28. Mr Oliver Mulangala was recalled to prison after being charged with threats to kill
and several violent offences. He had been released in 2020, but had breached his
licence conditions by committing new offences. Mr Mulangala was taken to HMP
Wormwood Scrubs on 7 December 2022.
29. Mr Mulangala had initial and second-stage health assessments on 7 and 8
December, respectively. His long-term medical conditions included high blood
pressure, type 2 diabetes and migraine. He had a long history of substance misuse
in the community and in prison, using cocaine, opioids, benzodiazepines and PS.
However, he told healthcare staff that the only drug he used was cannabis and he
wanted to stop.
30. During his induction, Mr Mulangala told a substance misuse support worker that he
had no problems with drugs and did not want support from the service. He was
given advice about harm minimisation, the risks of taking illicit drugs and the
process for self-referral if he changed his mind and wished to engage in the future.
31. Between May and November 2023, Mr Mulangala had multiple drug induced
seizures. Some of the specific incidents are summarised in this report. In addition,
several security intelligence reports indicated that he was involved in dealing drugs
and other illicit activity. When suspicious payments were attempted, the funds were
withheld.
32. On 7 May, Mr Mulangala was found unresponsive after using PS and taken to
hospital. He was admitted to the intensive care unit, sedated and ventilated. He
remained in the unit for nine days and was discharged from hospital on 19 May.
(While he was in hospital, officers searched his cell and found tobacco, hash and
cannabis.) The discharge letter reported diagnoses of sepsis, myocardial infarction
(heart attack) and drug induced seizures (noting it was the first known seizure). The
hospital excluded epilepsy as the cause but prescribed levitiracetam, a medication
to prevent further seizures. This prescription was continued in prison.
33. On 26 May 2023, Mr Mulangala was sentenced to 30 months imprisonment.
Transfer to HMP High Down
34. On 5 June, Mr Mulangala transferred to HMP High Down. Healthcare staff recorded
his existing medical conditions, as well as forthcoming cardiology and neurology
appointments. They also noted that he had been to hospital the previous day with
chest pain. A referral was made to the GP and Forward Trust, the substance
misuse service. Mr Mulangala was categorised as a complex case and discussed at
a multidisciplinary complex case meeting on 13 June.
35. After an outpatient hospital appointment on 16 June, a security body scan was
positive. Mr Mulangala was taken to the segregation unit under the secreted items
protocol until the scanner indicated it had passed through his system.
36. On 4 July, a Forward Trust practitioner followed up the reception referral and
completed an initial assessment. Mr Mulangala said he had used cannabis daily for
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25 years, but did not need to work with the service as he had not used drugs in six
months, so it was no longer a problem. They discussed harm minimisation,
including the risks associated with lower tolerance levels and safer using
techniques, such as using small test amounts and with a trusted person around.
They explored the risks of spice and hooch, such as seizures, psychosis and debt,
as well as the risks associated with sharing personal items, such as vapes and
razors.
37. On 14 July, Mr Mulangala was referred to the mental health team, as he said that
he was struggling being in prison.
38. During the evening of 16 July, Mr Mulangala had two severe episodes of seizures.
Paramedics attended each time and, on the second occasion, took him to hospital,
where it was confirmed that the seizures were drug-induced. Mr Mulangala
discharged himself from hospital in the early hours of 17 July. While he was in
hospital, staff removed ‘spice paper’ from his cell and moved him to a different cell
when he returned. The information was shared with relevant staff and he was
added to the database for suspicion testing. A member of the Forward Trust team
went to see Mr Mulangala on 2 August and he declined to engage with the service.
39. On 19 August, Mr Mulangala had three (drug-induced) seizures and was again
taken to hospital. (Hooch was found in his cell.)
40. At a GP appointment on 29 August, Mr Mulangala said that he had problems
sleeping, he had self-medicated with cannabis for ten years and took spice to help
him sleep. He also thought that he might have ADHD and was referred to the
mental health team for an ADHD assessment.
41. On 18 September, after further drug-induced seizures, Mr Mulangala was admitted
to hospital, where he was intubated and placed on a ventilator in the intensive care
unit. A referral was made to Forward Trust, but the support worker found he was
still in hospital when they went to see him.
42. Mr Mulangala returned to High Down on 21 September. Staff noted that the three
most recent incidents had happened at around the same time of the month and
considered whether it was a regular monthly supply.
43. On 25 September, the complex case meeting discussed Mr Mulangala’s hospital
admissions. It was agreed that as there was no formal neurological diagnosis, he
should see the substance misuse service for advice on harm minimisation.
44. While escorting Mr Mulangala at a hospital visit on 28 September, officers noted
that he made comments about trying his own supply of spice, bullying other
prisoners and allegedly knowing which staff could be “conditioned”.
45. On 10 October, Mr Mulangala told his prison key worker, that he would never take
spice again. The next day, he submitted a complaint that he had decided to stop
using drugs, but had been placed on a houseblock “flooded” with them. He added
that frequent disruption because of this, often deprived him of exercise and
association, which had affected his mental health. He said he was willing to move to
any other houseblock and had applied for voluntary drug testing to prove that he
was drug free.
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46. On 14 October, Mr Mulangala and a Forward Trust practitioner discussed his recent
use of PS and its effects. He said after three incidents he realised that he could no
longer use it due to the serious health consequences which he did not want to go
through again. He declined psychosocial support, but was given advice on risks,
such as the variation in the content of each batch of PS.
47. The head of residence replied to Mr Mulangala’s complaint on 18 October. He
explained that the options for a cell move were limited, as there were prisoners on
other wings with whom Mr Mulangala was not allowed to associate. He advised him
to apply for a place on the Incentivised Substance-Free Living unit (a dedicated unit
for those who want to live drug-free) and ask for additional support while he waited
for a decision. Mr Mulangala does not appear to have made an application.
48. On 3 November, Mr Mulangala was taken to hospital after another seizure. At a
review when he returned the next day, he told a nurse that he had stopped taking
his anti-epileptic medication. The nurse noted that the medication had been
dispensed and referred him to the substance misuse service. At a key work meeting
on 7 November, Mr Mulangala told an officer that the seizure had been triggered by
him not receiving his medication.
49. Forward Trust completed an initial assessment on 15 November and Mr Mulangala
agreed to psychosocial support. A recovery worker was assigned to him and
created a plan. Mr Mulangala said he used drugs to help him sleep as believed he
had ADHD. (It was noted that referrals had been made for ADHD screening, yoga
and art sessions to help manage the risks around ADHD.) He was again given
advice on risks and harm minimisation.
50. On 28 November, Mr Mulangala was assaulted by a prisoner known to use PS, who
owed him vapes. An officer discussed this with him as part of the violence reduction
procedures, but he declined a support plan.
51. A mandatory drug test taken on 13 December was negative. At a key work meeting
on 28 December, Mr Mulangala said that he had managed to stay drug free for four
months and intended to remain so, as he felt so much better in himself.
2024
52. Mr Mulangala lost his job and started education, but his attendance was poor.
There were no further reports of seizures or drug taking. However, intelligence
reports suggested that Mr Mulangala was involved in drug trafficking and other
suspicious behaviour linked to illegal activities.
53. On 5 January 2024, Mr Mulangala refused to move from a single cell to a double
cell. At a disciplinary hearing the next day, he said that he needed to use the toilet
frequently due to a medical condition and that his seizures sometimes caused him
to wet himself. The hearing concluded that there was no medical evidence to
support his need for a single cell and he was told he would have to share. However,
did not move to a shared cell. (Cell moves recorded in February, March and June
were due to Mr Mulangala attending hospital but he returned to the same cell.)
54. A Forward Trust practitioner had a follow up meeting with Mr Mulangala on 15
March to review his care plan. Risk and harm minimisation advice was reiterated.
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55. On 18 April, an officer noted that in the previous few months since Mr Mulangala
had made the effort to stop using drugs, his behaviour had improved considerably
and he had become a well-regarded member of the wing.
56. On 8 July, a Forward Trust wellbeing practitioner, reviewed Mr Mulangala’s
recovery plan and they discussed other suitable interventions. Ms Morgan noted
that Mr Mulangala appeared well, with no concerns but he did not want to join any
groups. The next appointment was scheduled for 30 August.
57. On 12 July, an officer locked Mr Mulangala’s cell at around 5.15pm. He recalled that
they had a jovial conversation and Mr Mulangala was in good spirits.
Events of 13 July 2024
58. At around 5.40am on 13 July, an Operational Support Grade (OSG) counted and
checked prisoners. CCTV footage showed that he walked past a row of cells,
including Mr Mulangala’s, without checking the prisoners. In a statement, the OSG
did not explain why he had missed those cells, but said that most prisoners cover
their observation panels, which made checks difficult. (We have no evidence to
confirm whether Mr Mulangala had covered his observation panel that morning.)
59. An officer unlocked Mr Mulangala’s cell at around 8.35am that morning, but did not
look into the cell or speak to him.
60. At 8.58am, a prisoner went into Mr Mulangala’s cell and found him lying face down
on the floor in a pool of blood. Another prisoner followed and they shouted for staff.
The officer heard the prisoners and went down to the cell. He immediately radioed a
code blue medical emergency (which indicates that a prisoner is unresponsive or
has breathing difficulties). The officer and a second officer then rolled Mr Mulangala
onto his back and began chest compressions, while a third officer went to get the
emergency medical bag.
61. Three nurses responded to the medical emergency call. With the help of the
officers, they moved Mr Mulangala to the landing and continued the resuscitation
attempts.
62. A first responder paramedic arrived at 9.07am, followed by two ambulances at
9.10am. They found signs of rigor mortis and pronounced life extinct at 9.15am.
63. A prisoner in a neighbouring cell later said that he had heard Mr Mulangala banging
and screaming at around 12.30am and 3.30am, but he was quiet after that time.
There is no evidence that staff were aware of anything untoward.
Contact with Mr Mulangala’s family
64. The Governor broke the news of Mr Mulangala’s death by telephone, as there was
no address recorded for his next of kin. She then visited his family that afternoon,
with the Supervising Officer appointed as the prison’s family liaison officer, and a
member of the chaplaincy team. The family liaison officer kept in touch with Mr
Mulangala’s family to provide support while they made the funeral arrangements.
65. In line with national policy, the prison contributed to the funeral expenses.
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Support for prisoners and staff
66. After Mr Mulangala’s death, a prison manager debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. Monitoring checks were put in place for the prisoners
who had found Mr Mulangala and the local Samaritans team was notified.
67. The prison posted notices informing other staff and prisoners of Mr Mulangala’s
death, and offering support.
Post-mortem report
68. A post-mortem examination was held and the report concluded that the cause of Mr
Mulangala’s death was MDMB-4en-PINACA (“Spice”) toxicity. Mr Mulangala had
bitten his tongue, possibly due to a seizure, causing significant blood loss. This
contributed to but did not cause his death.
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Findings
Drug strategy at HMP High Down
69. HMP High Down has an up to date and comprehensive drug strategy policy. There
is also a separate protocol on PS, providing guidance to staff on support and care
for prisoners found under the influence of those substances. The Drug Strategy
Lead told the investigator that PS and cannabis were the most prevalent drugs at
High Down, but the priority was to tackle PS because of the potentially severe
effects. Joint security committee and drug strategy meetings are held monthly and
the minutes are shared with staff across the prison.
70. Several initiatives were underway to reduce trafficking and demand. For example,
prisoners are no longer allowed to have items sent directly by friends or families,
they have to be ordered from a catalogue. There is a prolific user policy and men
found to be using substances are subject to the confiscation of vapes and a
separate regime. All prolific users are located together and staff try to encourage
them not to use PS by providing more activities and rewarding abstinence, instead
of solely applying punitive measures. Statistics provided by the safer custody team
had showed a slight reduction in prisoners found under the influence.
71. Shortly after he was appointed, the Drug Strategy Lead had invited the HMPPS
Substance Misuse Group Operational Team to complete a diagnostic assessment
to help the prison to address substance misuse. The team visited in February 2024,
and made recommendations across five key areas, which have been incorporated
into the prison’s action plan, together with seven actions previously identified by the
HM Inspectorate of Prisons.
72. The Head of Security outlined security strategies. After a recent security audit, there
had been a focus on upskilling staff. They had stopped photocopying mail and now
swab every item of social and legal correspondence. Mail is also searched by drug
detection dogs. This change had enabled the prison to build a better picture of the
volume of substances coming in by mail, as well as identifying the sources. The
prison had also introduced swabbing of staff parcels.
73. Historically, the prison had a high number of deliveries by drones, but this had
decreased significantly. The improvement was partly due to good partnership
working with the police, which had led to some arrests of drone pilots. The prison is
trying to secure funding to install wiring over the exercise yard to make it difficult for
drones to fly in. Two new houseblocks have sealed windows and in one of them,
the windows in the group room, laundry and servery are sealed, as intelligence
information suggested that drones were being commissioned by prisoners there.
74. A new CCTV system and cameras had been installed in the visits hall. Although
trafficking through visits used to be low, it had increased (usually small amounts of
drugs) due to the reduction in drones. Parcels are no longer thrown over the
perimeter wall. As well as standard patrols, drug detection dogs conduct extra
patrols three times a day. This led to most parcels being found, so it became an
unsuccessful method of trafficking.
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75. Mandatory drug test (MDT) results indicate that there is currently more use of PS
than cannabis. Much of it is made internally from materials smuggled into the
prison. The HMPPS dedicated search team visits four times a month and there is
extra searching of staff, as well as enhanced accommodation fabric checks. There
is targeted as well as ad hoc searching in response to intelligence reports. Around
45 prisoners are subject to frequent testing.
76. The number of prisoners found under the influence of drugs remained high.
Intelligence reports are triaged daily and prisoners are referred for suspicion testing,
or frequent testing if they are found to have used PS twice or more within a month.
MDT results for random testing had gradually reduced from 42% in April 2024, to
18% in November.
77. Staff corruption was currently considered to be a manageable risk.
78. Forward Trust’s Service Manager told the investigator that the Trust was well
embedded at High Down. As well as the Governor’s daily morning briefing, they
were part of several other communication channels, including the Safety
Intervention Meeting (SIM), violence reduction, use of force, drug strategy and
security meetings. There are also good working relationships with healthcare
partners, including a fortnightly joint healthcare and safety meeting and
representation at the complex case meetings chaired by the mental health team.
Substance misuse support for Mr Mulangala
79. When Mr Mulangala was recalled to prison, he declined the offer of support to help
manage his substance misuse. After each known incident of drug use, he was
referred to the substance misuse service, but repeatedly declined structured
support.
80. In November 2023, Mr Mulangala agreed to psychosocial support, formalised with a
care plan. There were no further reports of drug taking. He had a meeting with his
Forward Trust recovery practitioner five days before he died.
81. Forward Trust’s policy is to review all clients within three months after assessment
and every six to eight weeks thereafter, to give further advice and repeat the offer of
support. The clinical reviewer found that Mr Mulangala was not reviewed in line with
these timescales, due to increased demand because of high levels of substance
misuse across the prison, along with insufficient staff due to vacancies and
unplanned absences. However, Mr Mulangala received advice on risks and harm
minimisation and how to contact the service if he changed his mind and wanted to
request support.
82. We are satisfied that timely and appropriate referrals were made when Mr
Mulangala was found under the influence of drugs and that he received clear advice
on the risks to his health. There was also evidence that staff had tried to assess Mr
Mulangala’s pattern of drug use.
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Clinical findings
83. The clinical reviewer concluded that Mr Mulangala’s clinical care was of a good
standard and equivalent to that which he could have expected to receive in the
community. He noted that appropriate medication was prescribed for Mr
Mulangala’s high blood pressure and seizures, but the latter would not be effective
if he used illicit substances.
84. The clinical reviewer made recommendations on reviewing patient safety incidents;
record keeping; handover of care between substance misuse workers; and the
management of hypertension, which the Head of Healthcare will wish to consider.
We have not repeated the recommendations in this report, as they were not directly
linked to the cause of Mr Mulangala’s death.
85. Mr Mulangala’s brother asked why Mr Mulangala was in a single cell, given the risk
of seizures. This was clearly Mr Mulangala’s preference, but we do not know why
he was not moved to a shared cell after it was established that there were no
medical grounds to support his request. The deputy head of safety confirmed that
the prison was developing a seizure policy.
Welfare checks
86. High Down’s local guidance on night duty tasks says that OSGs should ensure that
each prisoner is alive and well during roll counts. Additionally, officers are expected
to conduct wellbeing checks and obtain a verbal response when unlocking
prisoners’ cells in the morning.
87. Disciplinary action was taken against the OSG who failed to complete the early
morning checks of prisoners and he was dismissed.
88. The prison officer who unlocked Mr Mulangala’s cell on the morning of his death
explained that he knew him well and did not look into or attempt to get a response
as Mr Mulangala had a specific morning routine and did not like to be disturbed.
89. Although the absence of a welfare check Mr Mulangala did not affect the outcome,
as he had been dead for some time, it was distressing for the prisoners who found
him. We note that the deputy governor gave the officer words of advice and was
satisfied that he understood the requirement to conduct welfare checks and the
significance of any failure to do so.
Governor to note
90. We are concerned that there was no observation book covering the period from the
evening of 12 July to 15 July. This is a vital document for information sharing and
managing risk. It does not appear to have been mislaid, it seems likely that one was
not used during this period. After the investigator drew attention to this, it was
immediately escalated to the Heads of Safety and Residence.
12 Prisons and Probation Ombudsman
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Inquest
91. At an inquest held on 17 November 2025, the coroner concluded that Mr
Mulangala’s death was drug related. The jury highlighted several failings, including
the failure to recognise and protect Mr Mulangala from the risk of dangerous
seizures at night (spontaneous or induced by taking drugs).
Prisons and Probation Ombudsman 13
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