Patrick Mugford

Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Patrick Mugford,
a prisoner at HMP Littlehey,
on 17 December 2023
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
© 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. On 6 May 2022, Mr Patrick Mugford was sentenced to seven years in prison for
sexual offences.
4. Mr Mugford died in hospital from aspiration pneumonia (an infection caused by
inhaling food or liquid into the lungs) on 17 December 2023, while a prisoner at
HMP Littlehey. This was caused by bilateral multiple cerebral infarctions (strokes on
both sides of the brain, which occur because of disrupted blood flow to the brain).
This was in turn caused by Type 2 diabetes. He was 69 years old. We offer our
condolences to Mr Mugford’s family and friends.
5. NHS England commissioned an independent clinical reviewer to review Mr
Mugford’s clinical care at HMP Littlehey.
6. The clinical reviewer concluded that the clinical care Mr Mugford received at HMP
Littlehey was of a good standard and was at least equivalent to that which he could
have expected to receive in the community. She found evidence in his medical
records that healthcare staff responded appropriately and proactively to Mr
Mugford’s healthcare needs.
7. The PPO investigator investigated the non-clinical issues relating to Mr Mugford’s
care.
8. We did not find any 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.
Adrian Usher June 2024
Prisons and Probation Ombudsman
At an inquest held on 13 June 2024, the Coroner concluded that Mr Mugford died of
natural causes.
Prisons and Probation Ombudsman 1
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