Surendra Patel

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Independent investigation into
the death of Mr Surendra Patel,
a prisoner at HMP Hewell,
on 31 October 2024
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. Mr Surendra Patel was remanded into custody on 15 October 2024, charged with
murder. He died in hospital of a lower respiratory tract infection, caused by
malnutrition, on 31 October 2024, while a prisoner at HMP Hewell. He was 78 years
old. We offer our condolences to Mr Patel’s family and friends.
4. The Ombudsman’s office wrote to Mr Patel’s next of kin, his daughter, to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
a number of questions about Mr Patel’s treatment at Hewell which have been
addressed in the clinical review and in separate correspondence.
5. The PPO investigator investigated the non-clinical issues relating to Mr Patel’s care.
We did not identify any non-clinical learning.
6. NHS England commissioned an independent clinical reviewer, to review Mr Patel’s
clinical care at Hewell.
7. The clinical reviewer concluded that the clinical care Mr Patel received at Hewell
was of a reasonable standard but was not equivalent to that which he could have
expected to receive in the community. When Mr Patel began refusing food,
guidelines in the food refusal policy were not fully followed and a multi-disciplinary
care plan was not completed in a timely manner. However, healthcare staff ensured
that Mr Patel received regular monitoring, observations and blood tests. The clinical
reviewer made the following recommendations:
• The Head of Healthcare should ensure that relevant care planning is
completed as soon as possible, within the guidelines outlined in the
food refusal policy.
• The Head of Healthcare and the Mental Health Team Manager should
ensure that a formal capacity assessment is completed for vulnerable
individuals in the quickest timescale possible.
• The Mental Health Team Manager should review the timescales for
assessment and referral to the Multi-Disciplinary Team or psychiatrist
for vulnerable individuals at risk of harm.
• The Head of Healthcare should ensure that the equipment used by
healthcare staff, such as weighing scales, work effectively to ensure
the accurate recording of critical physical observations.
Prisons and Probation Ombudsman 1
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8. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies and their action plan is annexed to this
report.
9. Mr Patel’s family received a copy of the draft report. The solicitor representing them
wrote to us raising a number of questions that do not impact on the factual accuracy
of this report. We have provided clarification by way of separate correspondence to
the solicitor.
10. At an inquest held on 10 March 2026, the Coroner concluded at inquest that Mr
Patel died from a lower respiratory tract infection. He found that Mr Patel had
malnutrition and type 2 diabetes which did not cause but contributed to his death.
The Coroner added that self-neglect through malnutrition contributed to his lower
respiratory tract infection.
Adrian Usher August 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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