Carl Forrester

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Carl Forrester,
a prisoner at HMP Exeter,
on 13 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
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2025
This report is licensed under the terms of the Open Government Licence v3.0. To view this licence,
visit nationalarchives.gov.uk/doc/open-government-licence/version/3
Where we have identified any third-party copyright information you will need to obtain permission
from the copyright holders concerned.
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
1. 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 November 2024, Mr Carl Forrester was sentenced to 21 years imprisonment for
sexual offences. He died of metastatic renal carcinoma (kidney cancer that spread
to other parts of the body) on 13 November 2024, at HMP Exeter. He was 71 years
old. We offer our condolences to Mr Forrester’s family and friends.
4. The Ombudsman’s office wrote to Mr Forrester’s next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond to our communication.
5. The PPO investigator investigated the non-clinical issues relating to Mr Forrester
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr
Forrester’s clinical care at Exeter.
7. The clinical reviewer concluded that the clinical care Mr Forrester received at Exeter
was of a good standard and equivalent to that which he could have expected to
receive in the community. He found that Mr Forrester’s medical records contained
evidence of a good standard of end of life care planning. However, the clinical
reviewer also found that Mr Forrester was not referred for an ultrasound, blood or
urine tests at the earliest opportunity. He also concluded that Mr Forrester’s
persistent anaemia and raised platelet count should have been investigated.
8. We make the following recommendations:
The Head of Healthcare should ensure that appropriate referrals occur in a
timely manner and that there is a process to ensure referrals are actioned.
The Head of Healthcare should ensure that all clinical staff understand and
act on local and national guidelines regarding the significance of an elevated
platelet count in combination with unexplained anaemia.
9. The initial report was shared with HM Prison and Probation Service (HMPPS) and
Oxleas NHS Foundation Trust. They drew our attention to a name which had been
misspelled in the clinical reviewer’s report, which has now been amended, but did
not point out any other factual inaccuracies.
Adrian Usher May 2025
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
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