Uziel Mendoza-Sillerico

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Independent investigation
into the death of
Mr Uziel Mendoza-Sillerico,
a prisoner at HMP Lowdham
Grange, on 18 November 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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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 Uziel Mendoza-Sillerico, a Bolivian national, died in hospital from sigmoid
perforation (a hole or tear in the sigmoid colon, part of the large intestine) on 18
November 2024, while a prisoner at HMP Lowdham Grange. This was caused by
disseminated tuberculosis (TB – a serious bacterial infection that spread from his
lungs to other parts of his body). He was 32 years old. We offer our condolences to
his family and friends.
4. The clinical reviewer concluded that the clinical care Mr Mendoza-Sillerico received
at Lowdham Grange was poor and was not equivalent to that which he could have
expected to receive in the community. Healthcare staff did not investigate his
significant weight loss, failed to follow up missed appointments and did not escalate
concerns about his deteriorating condition.
5. We found that there was a poor working relationship between prison and healthcare
staff, despite Mr Mendoza-Sillerico being under Prison Service suicide and self-
harm procedures, known as ACCT. Key information about his isolation, missed
appointments and worsening health was not shared promptly, leading to missed
opportunities for intervention.
6. We have other serious concerns about Mr Mendoza-Sillerico’s care. He was
intermittently restrained while in hospital despite being critically ill and having limited
mobility. The use of restraints was not proportionate to the actual risk he presented.
7. We also found that language barriers may have impacted Mr Mendoza-Sillerico’s
access to health information, including TB screening letters provided only in
English. Following his death, interpretation support was delayed for his sister and
the family liaison officer lacked clear guidance on repatriation procedures.
8. This is a troubling case. We consider that there is significant learning from this
investigation and urgent action is required to ensure that the serious omissions we
have identified are addressed. Similar shocking failings occurred in a death at
Lowdham Grange four months after that of Mr Mendoza-Sillerico, which reinforces
the need for systemic change.
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Recommendations
• The Governor and Head of Healthcare should ensure that prison and healthcare
staff are fully informed of the procedures for monitoring food and fluid intake. This
includes completing the necessary documentation and ensuring that all relevant
information is effectively communicated to healthcare staff.
• The Head of Healthcare should ensure that all electronic tasks are regularly
monitored, with a documented plan in place to track actions and escalate concerns
promptly.
• The Head of Healthcare should implement structured multi-disciplinary safety
huddles and ensure all complex cases are discussed and minuted with entries
recorded in the medical records.
• The Governor and Head of Healthcare should establish a formal process for sharing
information about missed appointments and safeguarding concerns between prison
and healthcare teams.
• The Head of Healthcare should ensure that, where concerns regarding mental
capacity arise, staff undertake a formal two-stage mental capacity assessment.
• The Head of Healthcare, in collaboration with the UK Health Security Agency
(UKHSA), should ensure that translated letters are provided for all prison-wide
health concerns and screening initiatives.
• The Governor and Head of Healthcare should ensure that Lowdham Grange’s
Isolator Regime Strategy (2025) is being consistently applied to all isolating
prisoners and that there is a robust quality assurance process to monitor this.
• The Governor and Head of Healthcare should ensure that all staff completing and
authorising risk assessments justifying the use of restraints on prisoners taken to
hospital understand the legal position and that assessments fully consider the
health of a prisoner and are based on the actual risk the prisoner presents at the
time.
• The Governor and Head of Healthcare should ensure that restraint risk
assessments are documented and retained whenever there is a change in a
prisoner’s restraints.
• The Governor should ensure family liaison officers receive training and guidance on
bereavement procedures, including support for families with limited English. Family
liaison officers should offer repatriation and funeral options in line with policy and
use professional interpretation services where appropriate.
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The Investigation Process
9. HMPPS notified us of Mr Mendoza-Sillerico’s death on 18 November 2024.
10. NHS England commissioned an independent clinical reviewer to review Mr
Mendoza-Sillerico’s clinical care at HMP Lowdham Grange. The clinical review was
attached as Annex 1.
11. The PPO investigator investigated the non-clinical issues relating to Mr Mendoza-
Sillerico’s care. She interviewed two prison staff in April and May 2025 via Microsoft
Teams. The investigator, the clinical reviewer and an Assistant Ombudsman jointly
interviewed two prison and four healthcare staff by Microsoft Teams between April
and June 2025.
12. We informed HM Coroner for Nottingham City and Nottinghamshire of the
investigation. The Coroner gave us the cause of death. There was no post-mortem
examination. We have sent the Coroner a copy of this report.
13. The Ombudsman’s office contacted Mr Mendoza-Sillerico’s sister to explain the
investigation and to ask if she had any matters she wanted us to consider. She had
no questions but asked for a copy of our report.
14. The initial report was shared with HM Prison and Probation Service (HMPPS) and
the prison’s healthcare provider, Northamptonshire Healthcare NHS Foundation
Trust. HMPPS pointed out three factual inaccuracies. These have been reviewed
and the information contained within this report has been confirmed as accurate so
no changes have been made. The action plan has been annexed to this report.
Mr Mendoza-Sillerico’s family received a copy of the draft report. They did not make
any comments.
Previous deaths at HMP Lowdham Grange
15. Mr Mendoza-Sillerico was the tenth prisoner to die at Lowdham Grange since
November 2021. Of the previous deaths, two were due to natural causes, two were
drug related and five prisoners took their own lives. There are no similarities
between the findings in our investigation into Mr Mendoza-Sillerico’s death and
those from our investigations into previous deaths.
16. Since Mr Mendoza-Sillerico’s death up to mid-November 2025, there have been a
further eight deaths. Two of these died of natural causes, five are suspected to be
drug related and the cause of the remaining death is unascertained at present. We
identified similar issues in a death at Lowdham Grange four months after Mr
Mendoza-Sillerico, where significant weight loss was not investigated and missed
appointments were not followed up.
Assessment, Care in Custody and Teamwork (ACCT)
17. ACCT is the Prison Service care-planning system used to support prisoners at risk
of suicide or self-harm. The purpose of ACCT is to try to determine the level of risk,
how to reduce the risk and how best to monitor and supervise the prisoner. After an
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initial assessment of the prisoner’s main concerns, levels of supervision and
interactions are set according to the perceived risk of harm. Checks should be
irregular to prevent the prisoner anticipating when they will occur. There should be
regular multidisciplinary review meetings involving the prisoner.
18. As part of the process, a care plan (a plan of care, support and intervention) is put
in place. The ACCT plan should not be closed until all the actions of the care plan
have been completed. All decisions made as part of the ACCT process and any
relevant observations about the prisoner should be written in the ACCT booklet,
which accompanies the prisoner as they move around the prison. When Mr
Mendoza-Sillerico was at Lowdham Grange, guidance on ACCT procedures was
initially set out in the Prison Service Instruction PSI 64/2011. From January 2025,
this was superseded by the Prison Safety Policy Framework, in which the principles
of how an ACCT is managed remain largely unchanged.
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Key Events
19. On 1 February 2018, Mr Uziel Mendoza-Sillerico was remanded to prison and taken
to HMP Thameside, charged with murder. Mr Mendoza-Sillerico was from Bolivia,
having moved to the UK in 2014. English was not his first language but prison staff
told the investigator that he could understand and communicate in English. On 1
March, Mr Mendoza-Sillerico transferred to HMP Belmarsh.
20. On 30 January 2019, Mr Mendoza-Sillerico was convicted and sentenced to life
imprisonment with a minimum tariff of 17 years. (This is the minimum time he had to
serve in prison before being considered for release by the Parole Board.)
21. On 20 January 2021, Mr Mendoza-Sillerico transferred to HMP Lowdham Grange,
where he remained until 7 October 2025. When Mr Mendoza-Sillerico arrived at
Lowdham Grange in January 2021, he weighed 72.2kg, which is 0.2kg over a
healthy weight on the body mass index (BMI)
22. During his first reception screening, a nurse recorded a full set of clinical
observations (temperature, blood pressure, pulse and respiratory rate), all of which
were within the normal range. The nurse also recorded his height and weight, which
were within a healthy range. Mr Mendoza-Sillerico disclosed previous cannabis use.
23. A nurse asked Mr Mendoza-Sillerico the standard tuberculosis (TB) screening
questions during his reception screening. He answered ‘no’ to all questions. These
questions include whether the person has travelled abroad, had TB previously,
been in contact with someone with TB in the past year, or has symptoms such as
persistent cough, fever, night sweats, or unexplained weight loss. If a prisoner
answers ‘yes’, healthcare staff must refer them to the GP.
24. On 30 November 2021, staff issued letters to all prisoners, including Mr Mendoza-
Sillerico, informing them of a TB outbreak at Lowdham Grange, where three cases
had been confirmed. The letter invited prisoners to opt in or out of voluntary TB
screening, which included a blood test and chest X-ray. The letter was only made
available in English. Mr Mendoza-Sillerico did not respond to the letter and staff did
not screen him for TB.
25. On 2 March 2022, Mr Mendoza-Sillerico reported feeling hot. A nurse observed him
through the cell observation panel, as cells were locked, gave him paracetamol and
later took a COVID-19 swab. The test confirmed that Mr Mendoza-Sillerico tested
positive for COVID-19. There is no evidence of any further health problems over the
following months.
26. On 4 April, during a key work session, Mr Mendoza-Sillerico told the officer that he
was employed as a wing cleaner, having waited several months for a job and
enjoyed the role. (Key workers provide prisoners with an allocated officer that they
can meet regularly to discuss how they are and any day-to-day issues they would
like to address.)
27. On 9 June, during a key work session, Mr Mendoza-Sillerico told the officer that he
had no issues or concerns. The officer observed that he appeared safe and happy
on the wing, got along well with other prisoners and often socialised throughout the
day. He enjoyed playing snooker and cutting other prisoners’ hair.
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28. On 17 August, staff found fermented liquid (a substance made by fermenting fruit or
other items, often referred to as ‘hooch’ in prisons) in Mr Mendoza-Sillerico’s cell.
The following day, staff issued him warnings for missing education sessions. On 27
August, during a key work session, an officer confirmed that he had been made
unemployed.
29. On 18 August, Mr Mendoza-Sillerico told a substance misuse worker that he had no
problems with alcohol and only drank when he was stressed because he missed his
children. He declined substance misuse support and the referral was closed.
30. On 14 December, Mr Mendoza-Sillerico told the officer that he was employed in the
industrial units but preferred working on the wing. On 24 December, officers found
him in possession of fermented liquid and gave him a disciplinary warning but
allowed him to continue working.
31. Mr Mendoza-Sillerico attended dental appointments over the next 18 months. No
other healthcare appointments were documented in his medical record until August
2024.
32. On 6 March 2023, during a key work session, Mr Mendoza-Sillerico told the officer
that he was settled on the wing and no longer receiving negative behaviour
warnings. He said he enjoyed working full-time and making new friends.
33. On 6 June, an officer described Mr Mendoza-Sillerico as a ‘model prisoner’ because
of his positive behaviour. All key work sessions throughout 2023 reported no
concerns or issues regarding his safety or behaviour on the wing.
34. On 8 February 2024, officers found fermented liquid in Mr Mendoza-Sillerico’s cell.
Further incidents involving fermented substances were recorded on 2 May and 18
May, after which he was placed on a basic regime, meaning he lost some of his
privileges. On 28 May, Mr Mendoza-Sillerico tested positive for cannabis in a
mandatory drug test.
35. On 26 August, Mr Mendoza-Sillerico told an officer that he was under threat on the
wing. The officer recorded that Mr Mendoza-Sillerico believed his life was in danger
and that these threats were affecting his mental health. The officer later told the
investigator that Mr Mendoza-Sillerico did not provide further details about the
threat. Mr Mendoza-Sillerico requested to speak to a prison manager, who
authorised his transfer from Houseblock 2 to Houseblock 5 the same day.
36. On 29 August, Mr Mendoza-Sillerico did not attend an appointment with a nurse for
concerns about weight loss. Healthcare staff rebooked the appointment for 30
September. It is unclear who had initially requested the appointment or noted the
weight loss as this was not recorded in his medical records.
12 September – 5 October 2024
37. On 12 September, an officer started Prison Service suicide and self-harm
monitoring procedures, known as ACCT. Mr Mendoza-Sillerico reported feeling low
in mood and believed he was under threat from prisoners on his previous wing.
38. On 13 September, an officer completed an ACCT assessment. He noted that Mr
Mendoza-Sillerico appeared very low in mood and cried when asked if he was okay.
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He told the officer that he felt unsafe on the wing because other prisoners had false
information about his conviction. The officer recorded that Mr Mendoza-Sillerico
was isolating and wanted to continue isolating for his own safety. He offered him a
move to L wing, which was for isolators. Mr Mendoza-Sillerico said he would think
about it but later declined the offer. He told the officer he had no thoughts of suicide
or self-harm and had never self-harmed before. Staff placed him on hourly checks
and three conversations daily.
39. On 15 September, Mr Mendoza-Sillerico was suspended from work after telling staff
that he was under threat and unable to leave the wing.
40. On 16 September, a Custodial Manager (CM) noted during ACCT checks that Mr
Mendoza-Sillerico had not had an ACCT review as he should have done within 25
hours of the ACCT being opened. She checked on Mr Mendoza-Sillerico and told
him that a review would take place the following day. This also did not take place
and there was no reason recorded for the omission.
41. On 17 September, an officer conducted a key work session with Mr Mendoza-
Sillerico. He told her that there were rumours about his sexuality and, as a result, he
did not feel safe in the prison. He said he refused to go to work because he had
been threatened by prisoners from his previous houseblock.
42. On 18 September, the CM chaired an ACCT case review with Mr Mendoza-
Sillerico, an officer and a Supervising Officer (SO). During the review, Mr Mendoza-
Sillerico stated that he felt unsafe due to hearing on the staff radio false rumours
regarding his sexuality and his belief that he had been labelled as a dangerous
prisoner. This account differed from information he had previously provided to staff.
He remained on hourly checks and agreed to be referred to the mental health team.
43. Later that day, a nurse recorded in the medical notes that the mental health team
had been unable to attend the ACCT review because another review had overrun.
He noted that officers had described Mr Mendoza-Sillerico’s presentation as
‘bizarre’ and that he would be assessed by the mental health team before his next
ACCT review scheduled for 23 September.
44. On 20 September, Mr Mendoza-Sillerico saw a nurse for a mental health
assessment. The nurse recorded that Mr Mendoza-Sillerico denied any history of
mental health issues and was not prescribed medication. He noted that Mr
Mendoza-Sillerico was isolating in his cell due to fear of being attacked by other
prisoners but could not provide a reason why they would target him. This was the
third different explanation he had given for feeling under threat. Mr Mendoza-
Sillerico also reported a poor appetite and significant weight loss and admitted to
using psychoactive substances (PS). The nurse observed that he appeared
delusional and paranoid, referred him to the GP regarding his weight loss and
planned to refer him to the substance misuse team and a psychiatrist.
45. On 23 September, the CM chaired a second ACCT review, attended by Mr
Mendoza-Sillerico, a nurse and an SO. Mr Mendoza-Sillerico told staff that he had
started leaving his cell when fewer prisoners were around and had no current
thoughts of suicide or self-harm. He confirmed that he was eating meals but
remained concerned about his weight loss. The nurse confirmed that he had been
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referred to the GP and psychiatrist. The next ACCT review was scheduled for 18
October.
46. On 30 September, Mr Mendoza-Sillerico did not attend his scheduled appointment
with a nurse to discuss his weight loss. Staff recorded no reason for the missed
appointment.
47. On 1 October, Mr Mendoza-Sillerico did not attend his scheduled dentist
appointment. A healthcare assistant noted in the medical records that he had been
unlocked for the appointment that morning but chose not to attend.
48. On 2 October, Mr Mendoza-Sillerico told an officer he wanted a healthcare
appointment. They advised him to use the kiosk system (a self-service electronic
system for submitting appointment requests). Mr Mendoza-Sillerico stated that he
had not received a response, so the officer tried to phone healthcare staff but was
unable to get through and indicated he would try again the following day. There is
no record that the officer spoke to healthcare staff the following day and no entries
appear in Mr Mendoza-Sillerico’s medical record between 1 October and 6 October,
with the next documentation occurring on 6 October.
49. On 3 October, an officer saw Mr Mendoza-Sillerico and asked how he was feeling.
He responded with a 50/50 hand gesture. Later that day, staff saw him cleaning his
cell, leaving briefly to collect water and accepting the food delivered to his cell.
50. On 4 October, another officer recorded that Mr Mendoza-Sillerico accepted food
and voiced no concerns. When asked if he was going to work, he replied ‘no.’ When
asked if he was feeling okay, he said he was fine. On 5 October, Mr Mendoza-
Sillerico told an officer that he had not been eating. He asked the officer to fill his
water bottle and gave no further verbal responses to questions.
Events of 6 October and 7 October
51. On 6 October, Mr Mendoza-Sillerico stayed in bed all morning. An officer noted that
he gave limited responses during morning wellbeing checks, covered his head with
a duvet, avoided associating with prisoners and had not eaten well. Later that
afternoon, another officer asked Mr Mendoza-Sillerico why he had not been eating,
but he did not reply. The officer recorded that Mr Mendoza-Sillerico appeared,
“malnourished, pale and seemed to be on hunger strike”.
52. At 5.34pm, an officer recorded that he spoke with Mr Mendoza-Sillerico during an
ACCT check. The officer noted that he had not met Mr Mendoza-Sillerico before. Mr
Mendoza-Sillerico said he was not feeling well, felt unsteady on his feet and had
lost his appetite. He confirmed he was still eating regularly but in very small
amounts and had lost weight. The officer requested healthcare staff assess him.
53. Around 6.00pm, a nurse assessed Mr Mendoza-Sillerico. Prison staff had obtained
authorisation from a senior prison manager to unlock his cell after the evening roll
check (a standard security procedure to account for all prisoners).
54. The nurse recorded that Mr Mendoza-Sillerico told him he had reduced energy and
was not eating as much as he would like but continued ordering food from the
prison shop and accepting meals. The nurse observed significant weight loss. The
nurse said he would make an urgent mental health referral, add him to the nurse’s
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list for the next day further assessment, including weight checks, and refer him to
the GP for nutritional supplements. Mr Mendoza-Sillerico’s oxygen saturation was
96%, which was within normal range, his temperature was 37.4 degrees Celsius,
which was slightly outside the normal range and his heart rate was 98 beats per
minute, which was normal.
55. On 7 October, an officer noted in the ACCT document that Mr Mendoza-Sillerico
would not respond to any checks and kept covering his face.
56. Around 10.50am, an officer recorded that they had asked healthcare staff to see Mr
Mendoza-Sillerico as he said he still felt unwell. At 11.00am, a nurse noted that she
attended the wing as he was listed for an urgent review due to weight loss. The
nurse observed that he was unsteady on his feet and he reported noticing weight
loss over the past two months and experiencing chest pain and shortness of breath
for the last month. Mr Mendoza-Sillerico also said he felt too weak to eat. The nurse
noted he now weighed 43.2kg. He had lost 29kg during his time at Lowdham
Grange and his BMI was now in the severely underweight category.
57. An officer radioed a code blue (which indicates a medical emergency, such as chest
pain, difficulty breathing or unconsciousness and requires an ambulance to be
called immediately). Control room staff requested an ambulance. Mr Mendoza-
Sillerco’s blood pressure was 88/56, which was very low and his oxygen saturation
was 91%, which was low. The nurse administered oxygen to him. Mr Mendoza-
Sillerico’s temperature was 37.7 degrees Celsius, which was slightly elevated and
his heart rate was 166 beats per minute, which was very elevated.
58. Mr Mendoza-Sillerico’s National Early Warning Score was 13, which indicated a
high level of risk and required immediate emergency intervention. (NEWS2 – used
to determine the level of illness of a patient and whether care needs to be
escalated.)
59. Mr Mendoza-Sillerico was taken to hospital by ambulance and restrained with a
double cuff (where a prisoner’s hands are cuffed together and a second pair of cuffs
is applied, with one cuff attached to the prisoner and the other to an officer). An
officer wrote in the ACCT document on 7 October that Mr Mendoza-Sillerico
complained that the cuffs were hurting and his whole body ached.
60. A hospital nurse told healthcare staff they suspected Mr Mendoza-Sillerico had TB
based on his chest X-ray results. Hospital staff admitted him to the respiratory ward.
At 8.00pm, an officer wrote in the bedwatch log that the senior prison officer on duty
authorised changing Mr Mendoza-Sillerico’s restraint from double cuffs to an escort
chain. (An escort chain is a long chain with a handcuff at each end, one attached to
the prisoner and the other to an officer.) Staff recorded this was because of his
deteriorating health and suspected TB.
61. Following a staff handover, a nurse emailed prison and healthcare managers to
inform them that Mr Mendoza-Sillerico had been taken to hospital. He reported that
he appeared severely malnourished, with his ribs, hips, collarbone, and spine
visible through his skin.
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8 October – 18 November
62. On 8 October, Mr Mendoza-Sillerico was diagnosed with TB. During interview, a
respiratory consultant and TB specialist told the clinical reviewer that Mr Mendoza-
Sillerico was extremely unwell on arrival at hospital and described him as the
sickest patient he had seen in five years.
63. On 9 October, Mr Mendoza-Sillerico’s condition deteriorated as his oxygen
saturation levels declined. He was placed on a ventilator and transferred to the
intensive care unit (ICU). A senior prison manager authorised the removal of Mr
Mendoza-Sillerico’s restraints documenting that he was in intensive care in a
serious medical condition, required intensive treatment and had limited physical
capability. Later that day, hospital staff placed Mr Mendoza-Sillerico in a medically
induced coma.
64. On 16 October, escort staff noted Mr Mendoza-Sillerico was responsive and in and
out of sleep. A senior prison manager authorised the use of an escort chain, but by
midday he was sedated again, prompting his restraints to be removed.
65. On 18 October, Mr Mendoza-Sillerico was diagnosed with multiple organ failure. He
remained in and out of consciousness while hospital staff tried to bring him out of
sedation over the following weeks. Mr Mendoza-Sillerico was moved back to the
ICU. A senior prison manager authorised removal of the escort chain at 9.30am
after confirmation that he required ventilation and was critically ill. (It is not clear
from the records when restraints had been reapplied before this). Later that day, Mr
Mendoza-Sillerico was placed back in a medically induced coma and escort staff
were told to observe from him from outside the hospital room. Hospital staff
indicated that, at this stage, they believed Mr Mendoza-Sillerico had approximately
24 hours to live.
66. On 5 November, following management checks, staff reapplied an escort chain.
The family liaison officer recorded that a prison manager told her this was because
Mr Mendoza-Sillerico was awake and able to communicate with staff. We have not
seen any risk assessment to support this decision.
67. On 6 November, a senior prison manager noted that Mr Mendoza-Sillerico could not
move or breathe independently and authorised the removal of his restraints. He was
not restrained again after this.
68. On 16 November, Mr Mendoza-Sillerico required emergency surgery for a
perforated bowel (a hole in the bowel wall, part of the gastrointestinal tract). On 18
November, Mr Mendoza-Sillerico was placed on end-of-life care and hospital
doctors withdrew life support. He died at 5.20pm.
Family Liaison
69. A family liaison officer and a deputy was appointed on 7 October. On 9 October, the
family liaison officer spoke to Mr Mendoza-Sillerico’s mother in Bolivia and was told
he had a sister in the UK. Later that day, the family liaison officer visited the hospital
to obtain an update on his medical condition and informed his sister. She met his
sister during subsequent hospital visits and maintained contact with her. Both the
family liaison officer and the deputy family liaison officer supported Mr Mendoza-
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Sillerico’s sister when his life support was withdrawn and provided information after
his death to discuss funeral arrangements. Due to difficulties accessing interpreting
services, there was a delay in the family liaison officer being able to discuss funeral
arrangements with Mr Mendoza-Sillercio’s sister over the phone.
70. Mr Mendoza-Sillerico’s mother wanted his body to be repatriated to Bolivia.
However, this did not take place and the family liaison officer was not aware of the
prison’s responsibility to cover repatriation costs.
Cause of death
71. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Mendoza-Sillerico’s
cause of death as sigmoid perforation (a hole or tear in the sigmoid colon, part of
the large intestine). This was caused by disseminated tuberculosis (a serious
bacterial infection that spreads from the lungs to other parts of the body).
Actions following TB diagnosis
72. On 11 October 2024, the UK Health Security Agency (UKSHA – the government
agency responsible for public health protection and managing infectious disease
outbreaks) was notified that Mr Mendoza-Sillerico had been diagnosed with TB.
73. Following Mr Mendoza-Sillerico’s diagnosis, the prison and UKHSA took the
following actions:
• UKHSA established a multi-agency incident management team to offer mass
screenings of all prisoners at Lowdham Grange between 1 June and 8
October 2024. They held question and answer sessions for prisoners and
staff.
• Between 9 and 10 December 2024, a TB team offered blood tests to detect
TB infection. Approximately 800 prisoners were screened for symptoms such
as a persistent cough, night sweats and weight loss. 154 prisoners declined
testing.
• The screening identified 31 prisoners with positive blood test results. All
prisoners with positive tests had chest X-rays using a mobile X-ray unit
brought into the prison.
• One prisoner had active TB and was immediately isolated, while the
remaining prisoners received treatment for latent TB (meaning the infection
was present but not causing illness). Treatment options included a six-month
treatment plan and follow-up with the TB team.
• UKSHA provided infection control advice including the use of personal
protective equipment such as respiratory masks, gloves and aprons for
escort officers to reduce the risk of infection.
• Staff were not routinely screened as close contact from TB comes from eight
hours of cumulative contact to be deemed a risk.
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• In June 2025, UKHSA formally stopped its involvement after all chest X-rays
and follow-up tests were completed.
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Findings
Clinical care
74. The clinical reviewer concluded that the care Mr Mendoza-Sillerico received at
Lowdham Grange was poor and not equivalent to that which he could have
expected to receive in the community. She listed several concerns, which are fully
considered in the clinical review report. We outline the following concerns related to
Mr Mendoza-Sillerico’s death. Some of these issues are the joint responsibility of
both prison and healthcare staff.
75. We recognise that when Mr Mendoza-Sillerico was at Lowdham Grange, healthcare
staffing levels were very low, with a 40% vacancy rate. The department was very
reliant on agency staff with no Head of Healthcare, no Mental or Physical Health
Lead and an interim matron who was temporarily promoted. At the time of interview,
the situation had improved with a 20% vacancy rate, a new Head of Healthcare and
other positions either filled or being advertised.
Management of Mr Mendoza-Sillerico’s weight loss
76. When Mr Mendoza-Sillerico arrived at Lowdham Grange in January 2021, he
weighed 72.2kg. Staff did not weigh him again until 7 October 2024, when he was
43.2kg. He had lost 29kg or 40% of his body weight since his arrival at Lowdham
Grange. His BMI had gone from just overweight to severely underweight.
77. In line with national guidance at the time, Prison Service Instruction (PSI) 64/2011,
Management of prisoners at risk of harm to self, to others and from others (Safer
Custody), staff should have taken Mr Mendoza-Sillerico’s decision to refuse food
and fluids into account. However, his refusal was not properly recorded or
communicated to all relevant staff. There is no evidence that efforts were made to
establish the reasons for his refusal or address them. Healthcare staff were not
notified immediately, formal monitoring of his food and fluid intake did not
commence and multi-disciplinary reviews were not convened as required by policy.
78. There was no documented discussion in Mr Mendoza-Sillerico’s medical records
about his significant weight loss and no evidence of accurate monitoring or
communication between healthcare and prison staff about his food or fluid intake.
Although ACCT entries and daily checks recorded that he continued to collect
meals, he said he had a poor appetite and significant weight loss from late
September. On 6 October, officers noted he appeared “malnourished, pale and
seemed to be on hunger strike.” Despite this, there was no food refusal care plan or
daily intake monitoring and escalation to healthcare occurred only later that
evening. On 7 October, Mr Mendoza-Sillerico was described as severely
malnourished, with ribs, hips, collarbone and spine visible through his skin.
79. In March 2025, another prisoner in his early 30s died of natural causes at Lowdham
Grange. We found that his significant weight loss had also not been investigated. It
is shocking that, despite the serious failings in Mr Mendoza-Sillerico’s care, learning
did not take place and these issues repeated themselves in the months following
his death. We issued the report into the previous death in October, recommending
improvements in investigating prisoners’ weight loss. At the time of writing this
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report, the prison has not yet responded. We do not repeat our previous
recommendation but make the following one:
The Governor and Head of Healthcare should ensure that prison and
healthcare staff are fully informed of the procedures for monitoring food and
fluid intake. This includes completing the necessary documentation and
ensuring that all relevant information is effectively communicated to
healthcare staff.
Missed healthcare appointments
80. Mr Mendoza-Sillerico did not attend a healthcare appointment on 29 August to
investigate his weight loss and this was not followed up. He also missed his
rescheduled appointment on 30 September. Mr Mendoza-Sillerico was not reviewed
by a GP before his hospital admission.
81. The clinical reviewer found no evidence of escalation or safeguarding action. She
noted that follow-up appointments and actions were not properly documented or
monitored in electronic tasks. A task created on 20 September to discuss him at the
mental health allocations meeting was not actioned. The rescheduled appointment
on 30 September was not recorded in his medical records. These delays in
communication meant that no urgent intervention occurred.
82. Following Mr Mendoza-Sillerico’s death, Lowdham Grange introduced a new
process for managing missed healthcare appointments. When a prisoner does not
attend an appointment, healthcare staff now call the prisoner in-cell to establish the
reason and confirm whether they still want the appointment. If there is no response,
healthcare staff contact the wing to check phone access and encourage
attendance. This ensures real-time follow-up rather than waiting weeks for
rebooking.
83. Following the previous death in March 2025, we also found that missed medical
appointments were not followed up. We recommended improvements to this system
which the prison has not yet responded to.
84. We acknowledge the improvements introduced at Lowdham Grange to address
missed healthcare appointments. However, robust monitoring of electronic tasks
remains crucial to prevent delays in care and ensure timely escalation of concerns.
We make the following recommendation:
The Head of Healthcare should ensure that all electronic tasks are regularly
monitored, with a documented plan in place to track actions and escalate
concerns promptly.
Recording and communication of information
85. The clinical reviewer and investigator identified a clear lack of joint working between
prison and healthcare staff, alongside poor communication about Mr Mendoza-
Sillerico’s deteriorating condition. Key information including his isolation, repeated
missed appointments and escalating vulnerabilities was not shared promptly.
Despite him being on an ACCT, there were no multi-disciplinary safety huddles,
multi-agency meetings, or documented discussions involving primary care or the
GP to address his physical and mental health needs.
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86. These were serious missed opportunities to share information which would have
allowed staff to assess, escalate and safeguard Mr Mendoza-Sillerico. This
contributed to delays in care planning, assessment and treatment. We make the
following recommendations:
The Head of Healthcare should implement structured multi-disciplinary safety
huddles and ensure all complex cases are discussed and minuted with
entries recorded in the medical records.
The Governor and Head of Healthcare should establish a formal process for
sharing information about missed appointments and safeguarding concerns
between prison and healthcare teams.
Mental capacity assessment
87. The clinical reviewer noted that there was no documented mental capacity
assessment in accordance with the Mental Capacity Act 2005, despite mental
health staff noting concerns about his delusional and paranoid presentation. We
make the following recommendation:
The Head of Healthcare should ensure that, where concerns regarding mental
capacity arise, staff undertake a formal two-stage mental capacity
assessment.
Language barriers and access to health information
88. Mr Mendoza-Sillerico’s first language was not English. While staff reported that he
could understand English, key health-related communications including a letter
about TB screenings were provided only in English. Given the complexity and
importance of this information, it is unclear whether he fully understood the content
or its implications. This may have affected his engagement with screening and
healthcare services.
89. UK Health Security Agency confirmed that they have template letters in different
languages, if needed. We make the following recommendation:
The Head of Healthcare, in collaboration with the UK Health Security Agency
(UKHSA), should ensure that translated letters are provided for all prison-
wide health concerns and screening initiatives.
Management of isolating prisoners
90. At the time of Mr Mendoza-Sillerico’s death, Lowdham Grange’s Safer Prison
Operating Policy (issued in March 2023) required prison staff to refer isolators to
Safer Custody and discuss them at weekly safety intervention meetings. However, it
did not require healthcare involvement or provide a system for proactive reviews
and there was no clinic for prisoners unwilling to leave their cell.
91. Mr Mendoza-Sillerico isolated from late August 2024, missed two healthcare
appointments for weight loss and declined a move to a wing for isolating prisoners.
Despite signs of deterioration, healthcare staff did not assess him until 6 October.
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92. Lowdham Grange has since introduced the Isolator Regime Strategy (2025), which
includes formal management plans, regular reviews, daily welfare checks and multi-
disciplinary input. The Head of Healthcare told the investigator that an isolator clinic
has been introduced to bring isolators to healthcare when other prisoners are not
around, isolators are flagged on daily briefings and care plans and in-cell checks
are now provided to prevent missed appointments.
93. During interview, the Physical Healthcare Clinical Lead told us when discussing the
new strategy for managing isolating prisoners that she is not routinely notified when
prisoners are isolating. She said healthcare involvement remains largely ad hoc,
occurring at the request of prison staff rather than through a standardised process.
This could lead to an inconsistent and uncoordinated approach to supporting
isolating individuals.
94. We found that national guidance for staff on managing isolated individuals places
significant emphasis on encouraging engagement with others and increasing
participation in the regime. However, this approach may not fully address the
healthcare needs of those in isolation.
95. Following a death at another prison, we recently made a national recommendation
to update staff guidance on isolating prisoners including a mandatory instruction to
consult prison healthcare staff when formulating individual isolator plans. HMPPS
Safety Group are currently in the process of reviewing national staff guidance on
isolated prisoners. However, in the meantime, Lowdham Grange has a clear local
strategy which we are not convinced is being consistently applied. We therefore
make the following recommendation:
The Governor and Head of Healthcare should ensure that Lowdham Grange’s
Isolator Regime Strategy (2025) is being consistently applied to all isolating
prisoners and that there is a robust quality assurance process to monitor
this.
Management of Mr Mendoza-Sillerico’s risk to himself
96. Prison Service Instruction (PSI) 64/2011, Safer Custody, (in place when Mr
Mendoza-Sillerico was in prison) lists risk factors and potential triggers for suicide
and self-harm. It says all staff should be alert to the increased risk of suicide or self-
harm posed by prisoners with these risk factors and should act appropriately to
address any concerns. Any prisoner identified as at risk of suicide and self-harm
must be managed under Assessment, Care in Custody and Teamwork (ACCT)
procedures. PSI 64/2011 also states that any information that becomes available
which may affect a prisoner’s risk of harm to self must be recorded and shared, to
inform proper decision making. In January 2025, this PSI was replaced with The
Prison Safety Framework but the guidance remains the same.
97. Staff opened an ACCT for Mr Mendoza-Sillerico on 12 September 2024 due to
concerns about his low mood and his perceived threats from other prisoners. The
ACCT remained open until his emergency transfer to hospital on 7 October 2024.
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98. We have the following concerns about the management of this ACCT:
• The first case review took place six days after the ACCT had been opened, on
18 September, rather than within the required 25 hours.
• Healthcare staff were unaware an ACCT had been opened until 18 September.
• Healthcare staff were not present at the initial ACCT case review or the review
on 18 September.
• Healthcare staff did not provide a written contribution when they were unable to
attend reviews.
• The ACCT care plan did not reflect physical health concerns or actions, even
after a referral for weight loss was made and despite Mr Mendoza-Sillerico not
being reviewed by a GP.
• Overall, the ACCT process lacked consistent multi-disciplinary involvement and
did not incorporate physical health concerns into the action plan, despite a
referral for weight loss being made by the mental health nurse on 20 September.
99. Following the internal investigation, Lowdham Grange introduced several measures
to improve ACCT management and healthcare integration. These include daily
multi-disciplinary safety huddles to ensure ACCT cases are discussed and actions
agreed, an enhanced ACCT attendance protocol requiring healthcare staff to attend
reviews or provide written input if unable to attend and improved quality assurance
processes for ACCT documentation.
100. Senior prison managers now provide additional support to ACCT case managers
and healthcare staff receive daily notifications of scheduled reviews to ensure
attendance or written contributions. Mental health staff have been reminded of the
requirement to assess and document mental capacity where concerns arise.
101. We are satisfied that Lowdham Grange has put clear measures in place to address
improve the management and assessment of ACCT procedures and healthcare
attendance at reviews. We therefore make no recommendation.
Restraints, security and escorts
102. 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 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.
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103. During Mr Mendoza-Sillerico’s hospital admission, he was restrained while receiving
critical care. On several occasions, staff applied restraints while Mr Mendoza-
Sillerico was sedated and physically unable to move.
104. During her interview, the Head of Security said that Lowdham Grange’s default
position was that all Category B prisoners were taken to hospital in double-cuffs as
per the External Escorts Policy Framework, unless there was a medical reason why
that should not happen. Healthcare staff were expected to complete a section of the
risk assessment to list medical conditions that might affect the level of restraint. The
Head of Security explained that decisions should balance escape risk and public
safety against medical considerations.
105. It is difficult to understand how the decision to apply restraints could be justified
when Mr Mendoza-Sillerico was critically ill, bed-bound and unable to move.
Restraints were applied while he was extremely unwell and required oxygen to
breathe. This was not proportionate to his perceived risk at the time, given his frail
and deteriorating condition. The absence of documented risk assessments
underlying some of these decisions means we do not know how they were reached.
Based on the information available, the use of restraints during his hospital
admission appears to have been excessively precautionary and inappropriate. We
therefore make the following recommendations:
The Governor and Head of Healthcare should ensure that all staff completing
and authorising risk assessments justifying the use of restraints on prisoners
taken to hospital understand the legal position and that assessments fully
consider the health of a prisoner and are based on the actual risk the prisoner
presents at the time.
The Governor and Head of Healthcare should ensure that restraint risk
assessments are documented and retained whenever there is a change in a
prisoner’s restraints.
Support for next of kin and repatriation procedures
106. After Mr Mendoza-Sillerico’s death, his sister told the family liaison officer that, in
line with their mother’s wishes, she wanted him to be repatriated to Bolivia. Over the
following weeks, Mr Mendoza-Sillerico’s sister expressed that she had no
experience with funeral arrangements and did not know what steps to take. The
family liaison officer told the investigator that communication was difficult because
she spoke very limited English and relied on a friend to interpret. The family liaison
officer told the investigator she experienced difficulties using interpreting services
over the phone when speaking with his sister.
107. Interpretation was arranged on 10 December, when an officer explained funeral and
repatriation options. During this call, conducted in Spanish, the officer advised that
funeral directors would manage the repatriation.
108. The family liaison officer provided some guidance, but Mr Mendoza-Sillerico’s sister
seemed uncertain about what was happening or what she was required to do. On
20 December, the family liaison officer noted that she had received the funeral
director’s details. The family chose a direct cremation with no service. It is unclear
whether this decision was fully informed, as she had previously expressed
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uncertainty about options and costs. The family liaison officer had not dealt with
repatriation before, did not know the prison must offer to pay repatriation costs and
lacked support and guidance.
109. PSI 64/2011 states that prisons must offer to pay reasonable repatriation costs of
the body or ashes of a foreign national prisoner. It also states that translation should
be considered. This would have helped the family understand options, costs and
the prison’s contribution in line with policy. Further support for staff in managing this
process, along with an information pack and access to translation services would
help ensure families are better supported and aware of the options available. We
make the following recommendation:
The Governor should ensure family liaison officers receive training and
guidance on bereavement procedures, including support for families with
limited English. Family liaison officers should offer repatriation and funeral
options in line with policy and use professional interpretation services where
appropriate.
Governor and Head of Healthcare to note
Delays to our investigation
110. It was incredibly difficult to arrange both prison and healthcare interviews for this
investigation. The PPO investigator and clinical reviewer offered numerous potential
dates for interviews. In addition, some staff did not attend the scheduled interviews
or assist with providing alternate dates. This impacted the timeliness of our
investigation. The Governor and Head of Healthcare will want to ensure that
sufficient priority is given to our investigations in future.
Inquest
111. The inquest into Mr Mendoza-Sillerico’s death concluded on 29 April 2026 and
returned a verdict of natural causes. It concluded that he died from sigmoid
perforation caused by disseminated tuberculosis. The Coroner found that there
were missed opportunities to identify potential medical issues that could have
enabled earlier identification and treatment for tuberculosis. The inquest found that
these missed opportunities might have contributed to Mr Mendoza-Sillerico's death.
Adrian Usher
Prisons and Probation Ombudsman April 2026
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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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