Brian Hayes

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Independent investigation into
the death of Mr Brian Hayes,
a prisoner at HMP High Down,
on 1 January 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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
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visit nationalarchives.gov.uk/doc/open-government-licence/version/3
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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 8 September 2023, Mr Brian Hayes was sentenced to 18 years in prison for
sexual offences. He was initially sent to HMP Wormwood Scrubs before being
transferred to HMP High Down on 14 August 2024.
4. Mr Hayes died due to advanced Chronic Obstructive Pulmonary Disease (COPD, a
progressive lung condition that makes it hard to breathe) on 1 January 2025. He
was 56 years old. We offer our condolences to Mr Hayes’ family and friends.
5. Mr Hayes did not name a next of kin and none could be identified following his
death.
6. The PPO investigator investigated the non-clinical issues relating to Mr Hayes’ care.
We did not find any non-clinical issues of concern.
7. NHS England commissioned an independent clinical reviewer to review the clinical
care Mr Hayes received at High Down. The clinical reviewer concluded that the
clinical care Mr Hayes received at High Down was of a good standard and at least
equivalent to that which would have been received in wider community.
8. The clinical reviewer noted that Mr Hayes arrived in prison with end-stage COPD.
He had regular reviews and the clinical reviewer found that the management of Mr
Hayes’ COPD was in line with national guidelines.
9. Mr Hayes had a do not attempt CPR (DNACPR) order and an advanced care plan,
which the clinical reviewer found was developed in conjunction with his wishes.
However, the clinical reviewer found that local adoption of the ReSPECT
(Recommended Summary Plan for Emergency Care and Treatment) should be
considered. This is a form developed by the Resuscitation Council UK to provide a
structured approach to recording resuscitation decisions and advanced care
planning, which the clinical reviewer noted can effectively communicate an
individual’s wishes to ambulance crews and treating clinicians if they cannot do so
themselves.
We make the following recommendation:
The Head of Healthcare should review the current documentation process for
DNACPR decisions and consider adopting the ReSPECT form.
10. The inquest into Mr Hayes’ death concluded on 4 June 2025 and returned a verdict
of natural causes.
Prisons and Probation Ombudsman 1
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Adrian Usher July 2025
Prisons and Probation Ombudsman
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
OFFICIAL - FOR PUBLIC RELEASE