Brian Acott

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Independent investigation into
the death of Mr Brian Acott,
a prisoner at HMP/YOI Lewes,
on 17 September 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. On 19 June 1995, Mr Brian Acott was sentenced to life imprisonment for murder.
On 8 June 2005 he was released from prison on a life licence. On 2 November
2015, Mr Acott was recalled to prison on his life licence for committing grievous
bodily harm, for which he was sentenced to 99 months imprisonment. On 14
September 2021, Mr Acott was released from prison. On 25 May 2022 he was
recalled to prison again for breaching his licence on 25 May 2022. On 23 February
2024, the Parole Board directed Mr Acott’s release from prison. Unfortunately, as
no suitable accommodation could be secured, he remained in prison until his death.
4. Mr Acott died of metastatic cancer of an unknown primary on 17 September 2024,
at hospital, while a resident at HMP Lewes. He was 79 years old. We offer our
condolences to Mr Acott’s family and friends.
5. The Ombudsman’s office wrote to Mr Acott’s next of kin to explain the investigation
and to ask if they had any matters they wanted us to consider. They had no
questions but asked for a copy of our report.
6. NHS England commissioned an independent clinical reviewer to review Mr Acott’s
clinical care at Lewes.
7. The clinical reviewer concluded that the clinical care Mr Acott received at Lewes
was of a reasonable standard and was equivalent to what he could have expected
to receive in the community.
8. She found that there was little to no information sharing between the prison
healthcare department and the hospital regarding Mr Acott’s healthcare and
treatment needs, which resulted in a delay to him receiving appropriate medication.
She found that there was no appropriate transport process in place to assess Mr
Acott’s suitability for transport to hospital. She also found that there were significant
delays in conducting assessments, such as mental health assessments, and no
clear recorded care and treatment plans in place for Mr Acott’s dementia, frailty,
and falls.
9. The PPO investigator investigated the non-clinical issues relating to Mr Acott’s care.
10. We did not find any non-clinical issues of concern. We make the following
recommendations related to the clinical care Mr Acott received:
The Head of Healthcare should meet with the appropriate person or
department at the Princess Royal Hospital and the Royal Sussex County
Hospital to ensure there is an understanding of the limits of nursing care that
a prison can provide, and to highlight the importance of information sharing
Prisons and Probation Ombudsman 1
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namely discharge summaries on the discharge of a patient to ensure there is
no delay to ongoing treatment.
The Head of Healthcare alongside the Governor should complete a review of
appropriate transport provided to ensure that the transport requested meets
the needs of prisoners.
Governor to note: On 16 August, having returned from hospital earlier that day,
healthcare assessed that Mr Acott needed to be transferred back to hospital. A taxi
was ordered to transport him. Mr Acott had several mobility issues and he was
unable to travel in the taxi so patient transport was then arranged. We consider that
this delay in being transported to hospital would have caused further emotional
distress to Mr Acott at an already difficult and distressing time. The Governor may
wish to consider this.
11. At the inquest held on 13 November 2024, the Coroner concluded that Mr Acott
died of natural causes.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
13. Mr Acott’s family received a copy of the draft report. They did not make any
comments.
Adrian Usher
Prisons and Probation Ombudsman May 2025
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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