Paul Mallin

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Paul Mallin,
on 3 February 2024, following
his release from HMP/YOI High
Down.
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, 2025
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Summary
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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. 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.
4. Mr Paul Mallin died of a neuroendocrine tumour of the ileo-anal pouch and direct
bladder invasion on 3 February 2024, following his release from HMP High Down
on 1 February 2024. He was 59 years old. We offer our condolences to those who
knew him.
5. The clinical reviewer concluded that the clinical care Mr Mallin received at High
Down was of a good standard and equivalent to what he could have expected to
receive in the community. The clinical reviewer made recommendations not related
to Mr Mallin’s cause of death which the Head of Healthcare will wish to address.
6. We did not find any issues of concern relating to the pre and post-release planning.
We are satisfied that prison and probation staff supported Mr Mallin with the
deterioration of his health. We make no recommendations.
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The Investigation Process
7. HMPPS notified us of Mr Mallin’s death on 3 February 2024.
8. The PPO investigator obtained copies of relevant extracts from Mr Mallin’s prison
and probation records.
9. NHS England commissioned an independent clinical reviewer to review Mr Mallin’s
clinical care at High Down.
10. We informed HM Coroner for South London of the investigation. We have sent the
Coroner a copy of this report.
11. The Ombudsman’s office contacted Mr Mallin’s family to explain the investigation
and to ask if they had any matters they wanted us to consider. They did not have
any questions but asked for a copy of our report.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Mallin’s family received a copy of the draft report. They did not make any
comments.
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Background Information
HMP High Down
14. HMP High Down is a category C training and resettlement prison which holds male
prisoners aged over 18 who have either been convicted or are on remand. It is
managed by HMPPS. The physical and mental health provider is Central and
Northwest London NHS Foundation Trust.
Probation Service
15. The Probation Service work with all individuals subject to custodial and community
sentences. During a person’s imprisonment, they oversee their sentence plan to
assist in rehabilitation, as well as prepare reports to advise the Parole Board and
have links with local partnerships to whom, where appropriate, they refer people for
resettlement services. Post-release, the Probation Service supervise people
throughout their licence period and post-sentence supervision.
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Key Events
16. On 7 September 2015, Mr Paul Mallin was remanded to HMP Pentonville. On 21
April 2016, he was sentenced to 19 years in prison for two counts of manslaughter.
17. On 29 September 2020, Mr Mallin was transferred to HMP High Down.
18. During the reception health screen, significant health diagnoses were identified,
including ulcerative colitis (inflammatory bowel disease).
19. On 12 January 2021, healthcare staff saw Mr Mallin after he reported that he had
been having bowel motions with a fluid consistency up to twelve times a day. The
clinical practitioner examined his abdomen and noted it was soft. He provisionally
diagnosed Mr Mallin with a colitis flare up in the ileal (anal) pouch and referred him
for further assessment.
20. On 26 January, prison staff escorted Mr Mallin to hospital for an appointment with a
Gastroenterology specialist. On 22 February, Mr Mallin underwent surgery to
remove polyps in his ileal pouch.
21. On 8 August, the prison’s primary care team assessed and managed Mr Mallin for
gastroenteritis (infection of the gut). They transferred him to the inpatient unit at
High Down until his symptoms settled. On 17 August, Mr Mallin went back to a
standard wing. Over the months that followed, Mr Mallin attended hospital for
further investigation. He received a long course of antibiotics and a further
appointment to see the specialist in six months.
22. On 16 February 2022, Mr Mallin went to the clinical hatch and told healthcare staff
that he was bleeding from his back passage and was in severe pain. The GP at the
prison assessed him on 22 February and increased his pain relief medication.
23. On 17 March, the clinical practitioner at the prison made an urgent referral to the
hospital’s Gastroenterology department. On 4 August, Mr Mallin was escorted to
hospital for an appointment with the Consultant Gastroenterologist for further
investigations. The findings suggested that there might be cancer present.
24. On 26 September, prison staff escorted Mr Mallin to a pouchoscopy appointment
(where a camera is used to examine part of the bowel) at the hospital. The
pouchoscopy showed inflammation. The specialist doctor referred Mr Mallin for a
follow-up appointment with the Gastroenterology department.
25. On 13 October, Mr Mallin declined to attend a hospital appointment with the
consultant as he felt unwell. The appointment was rescheduled for 19 October.
26. On 18 October, healthcare staff received a letter from the Consultant
Gastroenterologist which said that the biopsies they took from Mr Mallin in August
showed cancer was present. The next day, Mr Mallin attended hospital where his
cancer diagnosis was explained to him.
27. On 27 October, Mr Mallin had a Magnetic Resonance Imaging (MRI) scan, and on
28 October, a Positron Emission Tomography and Computerised Tomography (PET
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CT) Scan. The results showed a large cancer starting from the rectum and
spreading into the prostate.
28. On 4 November, a multidisciplinary team meeting was held about Mr Mallin’s recent
cancer diagnosis. It was noted that he was waiting for an assessment for treatment
and his care was transferred to the hospital for ongoing treatment.
29. On 24 November, healthcare staff received a histopathology report from the
hospital which indicated that Mr Mallin had a severe type of cancer which was fast-
growing and aggressive.
30. On 28 November, a palliative care consultant from St Raphael’s Hospice saw Mr
Mallin. She said that he was unsuitable for surgery due to the risks. She outlined
the plans, made pain medication recommendations and supported his ongoing care
and emotional wellbeing.
31. On 6 December, healthcare staff received a letter from the hospital which outlined
Mr Mallin’s treatment plan for chemotherapy which he commenced the next day.
32. On 8 May 2023, Mr Mallin was admitted to hospital due to having constipation, a
lack of appetite and feeling sick. He was discharged back to the prison on 11 May.
33. On 20 August, Mr Mallin was taken to hospital by emergency ambulance due to
having diarrhoea and a lack of appetite. The specialist consultant saw him. During
his time in hospital, Mr Mallin underwent surgery, chemotherapy and a single
fraction radiotherapy session. There was regular contact between healthcare staff
at the prison and hospital staff.
34. On 6 September, prison staff started Mr Mallin’s Early Release on Compassionate
Grounds (ERCG) application. The application was submitted on 5 December.
However, it was rejected because there was no clear prognosis.
35. On 6 November, the prison held a complex care forum in preparation for Mr Mallin’s
discharge from hospital. During the meeting, they discussed Mr Mallin’s
compassionate release application, return to the prison and a Do not Resuscitate
with Cardiopulmonary Resuscitation (DNACPR).
36. On 8 November, Mr Mallin was discharged from hospital and returned to the prison.
37. On 16 November, a palliative care consultant spoke to Mr Mallin about where he
wished to die. Mr Mallin said he wanted to go to a hospice for end of life care.
38. On 17 November, the hospital called the healthcare team to tell them that Mr Mallin
had told them that he had blood in his urine. Healthcare staff attended his cell and,
following assessment, referred him to the emergency department. Mr Mallin
attended hospital for bladder irrigation. He was discharged back to the prison on 20
November.
39. On 22 November, Mr Mallin said he did not want anyone to resuscitate him if his
heart or breathing stopped and signed an order (DNACPR) to that effect.
40. On 22 December, prison staff escorted Mr Mallin to hospital for chemotherapy
however he required additional care due to complications and remained in hospital
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until 29 December. During his time in hospital, the consultant told Mr Mallin that he
would not be continuing with chemotherapy. Mr Mallin returned to High Down on 30
December. The palliative care team and healthcare staff continued to care for Mr
Mallin over the weeks that followed.
41. On 23 January 2024, healthcare staff noted that Mr Mallin appeared confused and
in pain. The GP at the prison assessed him and said he should be transferred to
hospital, but Mr Mallin declined to go.
42. On 27 January, prison staff called a medical emergency as Mr Mallin had slipped in
his cell. Healthcare staff attended, and then spoke to St Raphael’s hospice to
update them, as Mr Mallin had stated that his preferred place of death was a
hospice. Prison staff escorted Mr Mallin to St Raphael’s hospice later that day.
43. On 30 January, the prison submitted another ERCG application for consideration.
44. On 1 February, Mr Mallin was granted early release on compassionate grounds. He
was released from High Down to St Raphael’s Hospice.
Circumstances of Mr Mallin’s death
45. On 3 February, St Raphael’s hospice called the prison’s healthcare department to
notify them that Mr Mallin had died at 8.15pm that day.
Contact with Mr Mallin’s family
46. On 6 September 2023, the prison appointed a family liaison officer. She contacted
Mr Mallin’s next of kin to inform them that Mr Mallin had been admitted to hospital.
She maintained regular contact with Mr Mallin’s next of kin. As Mr Mallin was
released on compassionate release to St Raphael’s hospice, staff at the hospice
notified the next of kin of Mr Mallin’s death. On 4 February 2024, she called Mr
Mallin’s next of kin to offer her condolences.
Post-mortem report
47. A post-mortem examination was not carried out as the coroner accepted the cause
of death provided by a doctor. The doctor gave the cause of death as a
neuroendocrine tumour of the ileo-anal pouch and direct bladder invasion.
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Findings
Clinical Findings
48. The clinical reviewer concluded that the clinical care Mr Mallin received at High
Down was of a good standard and equivalent to what he could have expected to
receive in the community. She made recommendations not related to Mr Mallin’s
cause of death that the Head of Healthcare will wish to address.
Non-clinical findings
49. We did not find any issues of concern relating to the pre and post-release planning.
We are satisfied that prison and probation staff supported Mr Mallin with the
deterioration of his health, ensured he was transferred to a hospice when his health
deteriorated and made suitable applications for early release. We make no
recommendations.
Adrian Usher
Prisons and Probation Ombudsman October 2024
At the inquest held on 13 December 2024, the Coroner concluded that Mr Mallin died of
natural causes.
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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
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