Paul Greatbanks

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Independent investigation
into the death of
Mr Paul Greatbanks,
a prisoner at HMP Stocken,
on 10 February 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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© Crown copyright, 2026
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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 March 2013, Mr Paul Greatbanks was sentenced to life in prison for murder. He
died of hypertensive heart disease on 10 February 2025, at HMP Stocken. He was
60 years old.
4. The prison told us that Mr Greatbanks had no identified next of kin. We offer our
condolences to those who knew Mr Greatbanks.
5. The PPO investigator investigated the non-clinical issues relating to Mr Greatbanks’
care. We did not find any significant non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer, to review Mr
Greatbanks’ clinical care at Stocken. They interviewed four members of healthcare
staff between 3 and 24 April 2025.
7. The clinical reviewer concluded that the clinical care Mr Greatbanks received at
Stocken was not equivalent to that which he could have expected to receive in the
community. He found that despite concerns about Mr Greatbanks’ hypertension, his
care plan was not reviewed and there was a lack of professional curiosity around
his attitudes to compliance with treatment. He also found that due to Mr
Greatbanks’ non-compliance, his mental capacity should have been assessed and
his medication in possession status should have been reviewed. We make the
following recommendations:
The Head of Healthcare should implement a monthly audit system, reviewing
a minimum of 10 patients’ records, to provide assurance that:
• care plan reviews are completed as required;
• mental health capacity assessments are documented where it is possible
that there is poor understanding of the implications of decisions; and
• data from home monitoring devices, such as blood pressure readings, are
reviewed and escalated appropriately.
The Head of Healthcare should ensure that a review is undertaken for the
protocols in place relating to:
• the management and review of in-possession medication status;
• the escalation process for patients reporting as unwell; and
Prisons and Probation Ombudsman 1
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• the management of non-compliance with treatment for long-term
conditions.
Governor to note
8. The officer who completed the roll check at 7.03am told us that he could only see
the side of Mr Greatbanks’ face, mainly his left cheek. This means that he did not
have a clear view of Mr Greatbanks’ face as required by the Internal Security
Procedures Policy. We do not make a recommendation on this as the guidance in
place at Stocken at the time of Mr Greatbanks’ death did not specify this
requirement. Since his death, a notice to staff has been issued which provides
clarity on roll check expectations and Stocken’s Local Security Strategy has been
updated to reflect this.
9. There was also no body worn camera footage of the emergency response. Staff
told us that this was due to the medical sensitivity of the situation. We do not make
a recommendation on this as the staff statements and CCTV footage provided a
clear account of the events, but we bring it to the Governor’s attention.
10. The initial report was shared with HM Prison and Probation Service (HMPPS).
Practice Plus Group pointed out some factual inaccuracies with the clinical review.
The investigator passed these onto the clinical reviewer who amended their report.
11. At an inquest held on 30 September 2026, the Coroner concluded that Mr
Greatbanks died of natural causes.
Adrian Usher April 2026
Prisons and Probation Ombudsman
2 Prisons and Probation Ombudsman
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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