Barry Rossiter

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Independent investigation into
the death of Mr Barry Rossiter,
a prisoner at HMP Northumberland,
on 23 March 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, 2025
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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 October 2022, Mr Barry Rossiter was sentenced to 26 years imprisonment for
sexual offences. He died in hospital from sepsis caused by colitis (inflamed bowel)
on 23 March 2024, while a prisoner at HMP Northumberland. He was 69 years old.
We offer our condolences to Mr Rossiter’s family and friends.
4. The Ombudsman’s office contacted Mr Rossiter’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
asked about the quality of healthcare Mr Rossiter had received and asked for a
copy of our report.
5. NHS England commissioned an independent clinical reviewer to review Mr
Rossiter’s clinical care at HMP Northumberland.
6. The clinical reviewer concluded that the clinical care Mr Rossiter received at
Northumberland was partially equivalent to that which he could have expected to
receive in the community. He found that Mr Rossiter was never physically examined
despite repeated blood tests over the course of 20 months showing that his
anaemia was getting gradually worse. He considered that Mr Rossiter should have
been physically examined and referred to general surgery once it became clear that
a FIT test result (to check for blood in the faeces) was not forthcoming. He
considered that an earlier surgical opinion may have identified colitis at an earlier
stage. We make two recommendations relating to this issue:
• The Head of Healthcare should ensure there is a robust policy for the
delivery and follow up of FIT tests and their results, and that patients
who decline to engage are offered a face-to-face appointment with a GP
to discuss.
• The Head of Healthcare should ensure that red flag symptoms are
communicated effectively between team members to ensure there is no
delay in appropriate examination and onward referral.
7. The PPO investigator investigated the non-clinical issues relating to Mr Rossiter’s
care. We did not find any non-clinical issues of concern.
8. We shared our initial report with HMPPS and with the prison’s healthcare provider,
Spectrum Community Health CIC. They found no factual inaccuracies.
Prisons and Probation Ombudsman 1
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9. We sent a copy of our initial report to Mr Rossiter’s next of kin. They made some
comments that we have addressed in separate correspondence.
Adrian Usher
Prisons and Probation Ombudsman August 2024
Inquest
The inquest, held on 9 January 2025, concluded that Mr Rossiter died from natural
causes.
2 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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