Samuel Omar

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Independent investigation into
the death of Mr Samuel Omar,
a prisoner at HMP Stafford,
on 15 October 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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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. 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. Mr Samuel Omar died in a hospice of pneumonia caused by chronic obstructive
pulmonary disease (COPD, lung disease) on 15 October 2025, while a prisoner at
HMP Stafford. He was 77 years old. We offer our condolences to his family and
friends.
4. The clinical reviewer concluded that the clinical care Mr Omar received at Stafford
was of a good standard and equivalent to that which he could have expected to
receive in the community. She found there had been a joined-up approach to Mr
Omar’s care which ensured high-quality treatment.
5. Mr Omar was inappropriately restrained during two emergency hospital transfers on
8 and 9 October, after he fell during the night. As a frail, 77-year old man with poor
mobility and a terminal illness, he posed no risk of escape and there was no
justification for applying restraints.
6. We have previously made recommendations to Stafford about the inappropriate use
of restraints on frail, terminally ill prisoners. The prison told us that the risk
assessment process had been amended but this case shows that poor decision
making around use of restraints persists.
Recommendations
• The Governor and Head of Healthcare should:
• Ensure that all healthcare professionals informing escort risk assessments
provide clear, accurate details of a prisoner’s current health and mobility.
• Review how effective previous work to educate managers about the risk
assessment process and the Graham judgement has been and provide
additional measures, including additional training, where necessary.
• Consider reintroducing a ‘non-cuffing’ list.
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The Investigation Process
7. HMPPS notified us of Mr Omar’s death on 15 October 2025.
8. NHS England commissioned an independent clinical reviewer, to review Mr Omar’s
clinical care at HMP Stafford.
9. The PPO investigator investigated the non-clinical issues relating to Mr Omar’s
care.
10. The prison was unable to trace a next of kin for Mr Omar. Therefore, the
Ombudsman’s office did not contact anyone about this investigation.
11. We shared our initial report with HMPPS and the prison’s healthcare provider,
Practice Plus Group. They found no factual inaccuracies. HMPPS provided an
action plan, which is annexed to this report.
Previous deaths at HMP Stafford
12. Mr Omar was the 27th prisoner to die at Stafford since October 2022. Of the
previous deaths, 23 were from natural causes and three were self-inflicted. Up to
the end of January 2026, there have been no further deaths.
13. During our investigation into a previous death at Stafford, we found that restraints
had been used inappropriately on a terminally ill, category D prisoner who was
receiving palliative chemotherapy. In March 2025, the prison told us that the risk
assessment process had been amended to ensure that decisions were made in line
with the Graham judgment. Restraint risk assessments had also been added to the
agenda for preventing future death (PFD) meetings with security to ensure a
prisoner’s current health was considered when assessing their risk.
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Key Events
14. On 20 September 2012, Mr Samuel Omar was given an imprisonment for public
protection (IPP) sentence for sexual offences, with a tariff (minimum term he had to
serve before he could be considered for release by the Parole Board) of three
years.
15. Mr Omar had chronic obstructive pulmonary disease (COPD, a lung condition that
restricts airflow and causes breathing difficulties). He also had type 2 diabetes and
had multiple falls due to frailty and poor mobility.
16. At around 6.30am on 3 September 2025, an officer found Mr Omar on the floor of
his cell. Mr Omar said he had fallen while trying to get to the toilet. A nurse attended
and assessed him for injuries. She observed his speech was slurred, he was unable
to move and had weakness down his left side, which indicated he might have had a
stroke. The nurse checked his blood oxygen levels, which were very low, and gave
him oxygen and a salbutamol nebuliser (a machine that helps someone breathe
more easily), but his oxygen levels continued to fall. An ambulance arrived and took
him to hospital. Mr Omar was not handcuffed for his transfer to hospital as his risk
assessment stated he had mobility issues and needed walking aids.
17. At the hospital, Mr Omar had a CT scan which confirmed he had had a stroke.
Hospital staff continued to give him oxygen as his blood oxygen levels remained
low. He also had a CT scan of his lungs, which showed suspected lung cancer. Due
to Mr Omar’s poor health, doctors agreed with him that he would not start treatment.
18. Mr Omar remained in hospital until his blood oxygen levels were stable. On 12
September, he was discharged back to Stafford.
19. On 22 September, staff at Stafford submitted an application for Mr Omar’s Early
Release on Compassionate Grounds (ERCG) to the Public Protection Casework
Section (PPCS) of HMPPS. PPCS did not make a decision before Mr Omar died.
20. On 23 September, Mr Omar saw a doctor at the lung cancer clinic. He was not
handcuffed for the transfer to hospital as his risk assessment stated he was an
elderly category C prisoner with poor health and mobility. The doctor told Mr Omar
that the mass on his lungs was likely lung cancer, but due to his severe COPD and
poor health after a stroke, they would not do any further tests. They referred him to
the community palliative care nurses for supportive care.
21. At around 1.30am on 8 October, Mr Omar fell in his cell and pressed his wrist alarm
to call for help. An officer radioed a code blue (a medical emergency code used
when a prisoner is unconscious or having breathing difficulties that alerts healthcare
staff to attend and the control room to call an ambulance) and a nurse responded.
The nurse took Mr Omar’s clinical observations and calculated a NEWS2 score of
two, due to his blood oxygen being low and his heart rate being high. (The National
Early Warning Score (NEWS2) is a tool used to assess clinical deterioration. A
score is calculated from the clinical observations taken and the higher the score, the
higher the risk. A score of two is low risk.). Mr Omar was complaining of chest pain
but was not breathless. As Mr Omar had hit his head and was on blood thinning
medication, the nurse decided he needed to go to hospital for further assessment. A
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prison manager completed the escort risk assessment and decided to apply an
escort chain (a long cable with cuffs at either end, attached at one end to the
prisoner and at the other to a prison officer) to Mr Omar. He was taken to hospital
and returned to Stafford later that day.
22. At around 1.12am on 9 October, a nurse found Mr Omar on the floor of his cell. He
was unable to sit up and was complaining of back and neck pain. The nurse took
his clinical observations and calculated a NEWS2 score of six (medium to high risk).
He observed that Mr Omar’s blood oxygen levels were low and he had a crackling
sound in his chest. The nurse arranged for an ambulance which took Mr Omar to
hospital for further assessment. The same prison manager as the night before
completed the risk assessment and decided to apply an escort chain to Mr Omar.
Mr Omar returned to the prison later that day.
23. At around 9.26pm on 10 October, a nurse and healthcare assistant went to Mr
Omar’s cell to help him into bed. He was sitting in his chair, and they struggled to
get a response from him. They radioed a code blue and took his clinical
observations while awaiting the ambulance. They calculated a NEWS2 score of 10,
which indicates high risk, and gave him oxygen. An ambulance arrived and the
paramedics assessed Mr Omar. They gave him a salbutamol nebuliser and he
became more alert. They advised that he could have another nebuliser at 3.00am if
needed, and for a GP to prescribe antibiotics the next day.
24. At around 3.00am, a nurse checked on Mr Omar. He was asleep and breathing
well, so did not need another nebuliser.
25. At around 7.50am, Mr Omar’s carer found him slumped on his bed struggling to
breathe. They alerted a nurse who saw he was short of breath, radioed a code blue
and gave him oxygen. A paramedic responded and helped take Mr Omar’s
observations. They calculated a NEWS2 score of eight, which indicated high risk.
The ambulance arrived and the paramedic at Stafford said they were concerned
that he was not taken to hospital during the night despite having a NEWS2 score of
10. The ambulance crew agreed to take him to hospital.
26. On 12 October, a nurse at Stafford phoned the hospital and spoke to a nurse on Mr
Omar’s ward. The hospital nurse said that Mr Omar had not improved and he was
struggling to breathe when they tried to reduce his oxygen levels. They were giving
him intravenous antibiotics and continued oxygen.
27. On 14 October, a palliative care consultant told the healthcare team at Stafford that
Mr Omar had deteriorated and would be transferred to a hospice for end-of-life
care.
28. At 1.45pm on 15 October, Mr Omar died.
Cause of death
29. The Coroner accepted the cause of death provided by a hospice doctor and no
post-mortem examination was carried out. The doctor gave the cause of death as
pneumonia caused by COPD.
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Findings
Clinical findings
30. The clinical reviewer concluded that the care Mr Omar received at Stafford was of a
good standard and equivalent to that which he could have expected to receive in
the community.
31. The clinical reviewer found the joined-up approach to Mr Omar’s care between the
complex care team, safer custody, and palliative care team, ensured he had
proactive care and treatment. She made one recommendation about healthcare
staff input to escort risk assessments which we have addressed in our
recommendations.
Use of restraints
32. The Prison Service has a duty to protect the public when escorting prisoners
outside prison, such as to hospital. It also has a responsibility to balance this by
treating prisoners with humanity. The level of restraints used should be necessary
in all the circumstances and based on a risk assessment, which considers the risk
of escape, the risk to the public and takes into account the prisoner’s health and
mobility. A judgment in the High Court in 2007 (known as the Graham judgement)
made it clear that prison staff need to distinguish between a prisoner’s risk of
escape when fit (and the risk to the public in the event of an escape) and the
prisoner’s risk when suffering from a serious medical condition. It said that medical
opinion about the prisoner’s ability to escape must be considered as part of the
assessment process and kept under review as circumstances change.
33. Mr Omar was taken to hospital on 8 and 9 October after he had fallen in his cell.
Staff applied an escort chain to Mr Omar for his transfer to hospital, despite him
being a 77-year-old man who was terminally ill with very poor mobility. Also, he had
not had restraints applied for previous hospital transfers due to his frailty.
34. The nurse who completed the medical section of both escort risk assessments
indicated that Mr Omar was a wheelchair user with limited mobility and serious
illness but did not include any details of his medical conditions, as they did in the
Person Escort Record (PER).
35. The investigator spoke to the Head of Security at Stafford, who said that the
authorising manager for both restraints decisions was a custodial manager (the
senior prison officer in charge at night), rather than a duty governor, as both
transfers took place during the night shift. (Prisons operate with minimal staff during
the night and no governors are on site.)
36. The authorising manager had decided to apply an escort chain to Mr Omar on 8
October as they were concerned that he had had an unwitnessed fall during the
night (when far fewer staff are on duty so the security risks of moving prisoners are
greater) and had asked whether he would be handcuffed. The following evening, Mr
Omar had a second unwitnessed fall during the night. The authorising manager
decided to apply an escort chain and submitted an intelligence report as Mr Omar
had asked several times why he was being handcuffed. The manager spoke to the
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ambulance crew and asked if there was any medical reason why Mr Omar should
not be handcuffed, and they said no.
37. The Head of Security at Stafford reflected that if Mr Omar had gone to hospital
during the daytime, then due to his health and mobility issues, he likely would not
have been restrained, as there would not be the same security concerns as during
the night.
38. The Head of Security at Stafford told us that there was no longer a ‘non-cuffing’ list
at Stafford. There used to be an approach where no one over the age of 65 was
handcuffed. However, this had since changed to a dynamic risk assessment based
on an individual’s health, age and overall risk, as they found that this varied across
the age group.
39. While we appreciate that a ‘non-cuffing’ list for all prisoners over the age of 65
would not be appropriate, it would seem sensible for there to be a list of prisoners
for whom restraints should not be applied due to their negligible risk of escape due
to their health and mobility. This would mean that regardless of the time of day or
night that they are taken to hospital, the authorising manager would know not to
apply restraints.
40. In a previous investigation into a death at Stafford, we found that a terminally ill
category D prisoner had been inappropriately handcuffed when receiving palliative
chemotherapy. We were told in March 2025 that the escort risk assessment
process had been amended to ensure that decisions are made in line with the
Graham judgment and risk assessments were discussed at preventing future
deaths (PFD) meetings with security to reinforce the importance of balancing a
prisoner’s risk with their current health.
41. There was an inconsistent approach to Mr Omar’s cuffing arrangements that
seemed to be based on the time of the transfer, and the grade of the authorising
manager, as opposed to the risk he posed. Mr Omar was not handcuffed for
daytime hospital transfers on 23 September and 2 October on the grounds of his
poor mobility and terminal illness. There was no justification for applying restraints
on 8 and 9 October when if anything, Mr Omar’s risk of escape had decreased even
further. We recommend:
The Governor and Head of Healthcare should:
• Ensure that all healthcare professionals informing escort risk
assessments provide clear, accurate details of a prisoner’s current health
and mobility.
• Review how effective previous work to educate managers about the risk
assessment process and the Graham judgement has been and provide
additional measures, including additional training, where necessary.
• Consider reintroducing a ‘non-cuffing’ list.
Adrian Usher
Prisons and Probation Ombudsman April 2026
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Inquest
42. At the inquest, held on 26 May 2026, the Coroner concluded that Mr Omar died
from natural causes.
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Third Floor, 10 South Colonnade Email: mail@ppo.gov.uk T l 020 7633 4100
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