Paul Ward

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Independent investigation into
the death of Mr Paul Ward,
a prisoner at HMP Fosse Way,
on 22 March 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 January 2019, Mr Paul Ward was remanded to HMP Hewell after being charged
with burglary. In March 2019, he was sentenced to 13 years in prison.
4. In January 2024, Mr Ward was transferred to HMP Fosse Way.
5. On 22 March 2025, Mr Ward died of hemopericardium (a build-up of blood in the
pericardial sac of the heart), at Fosse Way. He was 70 years old. We offer our
condolences to Mr Ward’s family and friends.
6. The Ombudsman’s office wrote to Mr Ward’s family to explain the investigation and
to ask if they had any matters they wanted us to consider. They asked about Mr
Ward’s funeral arrangements and his valuables. These questions have been
addressed in separate correspondence.
7. NHS England commissioned an independent clinical reviewer to review Mr Ward’s
clinical care at Fosse Way. The clinical reviewer’s report is attached as Annex 1.
8. The clinical reviewer concluded that the clinical care Mr Ward received at Fosse
Way was of a reasonable standard and at least equivalent to what he could have
expected to receive in the community. He found that the healthcare team
implemented steps to monitor and manage Mr Ward’s chronic physical health
conditions. They recognised the deterioration in his clinical condition and managed
this appropriately. The clinical reviewer made no recommendations.
9. The PPO investigator investigated the non-clinical issues relating to Mr Ward’s
care.
10. We did not find any non-clinical issues of concern.
Governor to note
11. PSI 03/2013, Medical Emergency Response Codes, sets out the actions staff
should take in a medical emergency. It requires all prisons to have a medical
emergency response code protocol in place to ensure a timely, appropriate and
effective response to medical emergencies. When a medical emergency is
discovered, staff should call the appropriate medical emergency code straightaway
so that relevant staff are alerted, the correct equipment is brought, and an
ambulance is called immediately. Most prisons, including Fosse Way, use codes
blue (for breathing problems) and red (for bleeding).
12. Officer A was the first on scene officer. In his written statement, he said that at
approximately 4.20pm, he found Mr Ward lying on his back, he was grey in colour
Prisons and Probation Ombudsman 1
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and unresponsive. He said he immediately radioed the healthcare team to attend
the wing but he did not radio a code blue. Officer B attended Mr Ward’s cell
immediately and radioed a code blue.
13. The Investigations Manager at Fosse Way told the investigator that the prison is
conducting an internal investigation into Officer A’s actions on 22 March 2025. This
has not yet been concluded.
14. Although Officer A did not adhere to the medical emergency response code policy,
this did not affect the emergency care given to Mr Ward because a code blue was
called within one minute of discovery. However, it is important prison staff are
aware of their responsibilities when they find a prisoner unresponsive, so it does not
lead to a delay in staff arriving promptly to medical emergencies and calling an
ambulance.
15. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
16. Mr Ward’s family received a copy of the initial report. They did not make any
comments.
Inquests
17. At the inquest held on 17 November 2025, the coroner concluded Mr Ward died of
natural causes.
Adrian Usher November 2025
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
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