Christopher Ash

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Independent investigation
into the death of
Mr Christopher Ash,
a prisoner at HMP Birmingham,
on 26 June 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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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 Christopher Ash died of sudden unexplained death in schizophrenia on 26 June
2024, while a prisoner at HMP Birmingham. He also had a level of prescribed
antipsychotic medication in his system which may have contributed to his death. He
was 36 years old. We offer our condolences to his family and friends.
4. Mr Ash had been at Birmingham for just two days when he died, having recently
transferred from a medium secure mental health unit.
5. The clinical reviewer concluded that the clinical care Mr Ash received at
Birmingham was equivalent to that which he could have expected to receive in the
community.
6. We found that the healthcare team, residential team, and safety team did not
appropriately share information prior to Mr Ash being admitted to Birmingham. In
addition, the checks on 26 June were insufficient.
Recommendations
• The Governor should introduce a robust quality assurance process to ensure that
staff conduct routine roll checks and welfare checks in line with local and national
guidelines.
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The Investigation Process
7. HMPPS notified us of Mr Ash’s death on 26 June 2024.
8. NHS England commissioned an independent clinical reviewer to review Mr Ash’s
clinical care at HMP Birmingham.
9. The PPO investigator investigated the non-clinical issues relating to Mr Ash’s care.
She interviewed 14 members of staff from Birmingham, two probation officers and a
forensic psychologist from Reaside Clinic (a medium secure unit) between August
and September. Most interviews were conducted with Ms Judith Bird.
10. The Ombudsman’s office wrote to Mr Ash’s mother to explain the investigation and
to ask if she had any matters she wanted us to consider. She asked us to consider
why Mr Ash had not telephoned her on 25 June and what had happened to his
property. These questions have been answered in separate correspondence.
11. Mr Ash’s mother received a copy of the draft report. They did not make any
comments.
12. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Previous deaths at HMP Birmingham
13. Mr Ash was the 13th prisoner to die at HMP Birmingham since June 2021. Of the
previous deaths, eight were from natural causes and four were self-inflicted. There
are no similarities between the findings in our investigation into Mr Ash’s death and
the findings from our investigations into the previous deaths. Up to the end of
January 2025, there have been three further deaths at Birmingham since that of Mr
Ash. One was due to natural causes, one was self-inflicted, and one which is
suspected to be due to drugs.
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Key Events
14. Mr Christopher Ash had a history of substance misuse and mental health issues.
He had been in prison several times before. In November 2021, Mr Ash was
sentenced to 12 months imprisonment for an offence of arson. He was released
from HMP Dovegate on 1 November 2022 to reside at an approved premises
(accommodation provided by the Probation Service). Two days later, Mr Ash was
recalled to HMP Birmingham for displaying aggressive behaviour towards approved
premises staff.
15. Mr Ash transferred to HMP Lowdham Grange on 18 November. Staff had significant
concerns about Mr Ash’s mental health, and he was transferred to a medium secure
unit, Reaside Clinic, on 20 December 2022. While at Reaside Clinic, he was treated
for schizophrenia (a serious mental health disorder which can result in
hallucinations, delusions and disorganised thinking) and prescribed clozapine and
sodium valproate.
16. On 10 June 2024, a professionals’ meeting was held at Reaside with a psychiatrist,
a mental health nurse from HMP Birmingham, a community offender manager
(COM) and Mr Ash. A Custodial Manager (CM) was invited to the meeting but did
not attend. He told us that he had forgotten about the meeting (which was via MS
Teams). Those present agreed that Mr Ash no longer needed treatment in a secure
unit and that the nurse would recommend to the prison that Mr Ash should be
accepted for transfer there to complete his prison sentence until he was due for
release in November 2024. Mr Ash himself also said that he wanted to return to
Birmingham.
17. The Head of Residence accepted Mr Ash back to Birmingham. He had not received
minutes of the professionals’ meeting before making this decision. He had only
received an email from prison healthcare staff stating that they assessed Mr Ash as
suitable to return to the prison and that he did not need to be located in the
healthcare wing but could be on standard residential wing. He told us that even if he
had received the notes, they would not have changed his decision, since it was
healthcare staff’s assessment that Mr Ash was fit to return.
18. On 12 June, staff discussed Mr Ash at the Safety Intervention Meeting (SIM),
chaired by the Head of Safety. A mental health nurse and the mental health team
leader were also present. In interview, they could not recall what information had
been shared at the SIM. The only recorded notes were that Mr Ash would be
returning to Birmingham on 24 June.
19. On 24 June, Mr Ash returned to Birmingham. The mental health team leader briefly
met Mr Ash in reception for him to collect his prescription for clozapine (Mr Ash had
to collect his medication from the medication hatch each day).
20. Mr Ash was located on the induction wing, and received three additional welfare
checks through the night. Staff raised no concerns during these checks.
21. On 25 June, Mr Ash had his second day induction meeting with an officer in the
wing office, and his secondary health screening with a pharmacy technician. They
both raised no concerns about Mr Ash as a result.
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22. A mental health nurse and a substance misuse worker also tried to speak to Mr Ash
that day in his cell. However, Mr Ash declined to engage with them. He remained in
his cell with his bed covers pulled over his head. Mental health staff planned to
discuss Mr Ash at the multi-disciplinary team meeting the next day and a
psychiatrist and a mental health nurse would also review him.
23. The investigator watched body worn video camera (BWVC) footage and listened to
staff radio communications from 26 June. She also obtained information from the
West Midlands Ambulance Service. CCTV was not available as it was not working
on the induction wing on 26 June. The following account has been taken from all
available sources.
24. On 26 June at approximately 5.40am, an officer completed the morning routine roll
check of all prisoners on the wing by observing them through their cell door
observation panels. She told us that Mr Ash did not appear to be medically unwell.
25. Between 6.50am and 7.30am, another officer completed the morning welfare check
on all prisoners on the landing, including Mr Ash. During interview, he described this
check as a, ‘look through the door to see if everyone’s there’. He told us that Mr Ash
appeared to be sleeping in bed and it was dark in the cell. However, he stated that
his main focus was another prisoner on the wing considered to be a risk to
themselves, and not Mr Ash.
26. Morning unlock would usually occur between 8am and 8.30am. However, because
it was a staff training day, this did not happen.
27. At 11.15am, two officers unlocked Mr Ash’s cell to allow him to collect his medicine.
They went into his cell and found Mr Ash lying fully dressed on his back, on his bed,
unresponsive. The officers were shocked by what they had seen and left the cell to
find healthcare staff. One officer radioed a code blue (emergency medical code
signalling a prisoner is having difficulty or has stopped breathing). Control room
staff immediately called an ambulance. A nurse was on the induction wing and went
straight to Mr Ash’s cell with an officer. They went into the cell, followed by another
officer. The nurse and an officer placed Mr Ash on the floor and began CPR. The
nurse told us that he believed Mr Ash had signs of rigor mortis (the stiffening of the
body after death). At 11.17am, more healthcare staff arrived with the defibrillator,
and they administered naloxone (used to reverse the effects of opioid overdose) at
11.31am. Paramedics arrived at 11.33am and took over Mr Ash’s care. They
pronounced life extinct at 11.40am.
28. At 12.10pm, the Head of Residence held a hot debrief with staff involved and
ensured staff and prisoners were appropriately supported.
29. Police removed a vape pen, wraps of paper, and a white powder from Mr Ash’s cell.
Following testing, the white powder was identified as buprenorphine (used to treat
opioid misuse and not prescribed to Mr Ash) and the vape tested positive for a
synthetic cannabinoid.
Post-mortem report
30. The pathologist concluded that Mr Ash’s cause of death was sudden unexplained
death in schizophrenia.
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31. The toxicology report concluded that the level of clozapine in Mr Ash’s blood
suggested excessive use or overdose of this drug. However, it was not clear
whether the level was high enough to cause death in isolation. The pathologist
concluded that the supratherapeutic (highly than is usually prescribed) level of
clozapine was likely a contributing factor in Mr Ash’s death, although they could not
make a definite link between the level detected and Mr Ash’s death.
32. Aside from the medications which Mr Ash was prescribed, the other medications
found in his system were buprenorphine and zuclopenthixol (antipsychotic
medication not prescribed to Mr Ash). The toxicology tests did not detect synthetic
cannabinoids.
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Findings
Clinical findings
33. The clinical reviewer concluded that the clinical care Mr Ash received was of the
required standard and therefore equivalent to that which he would have received in
the community. A nurse had attended his pre-discharge meeting at Reaside and Mr
Ash himself had said that he wanted to return to Birmingham. Mr Ash had met his
allocated nurse; Birmingham had received his discharge summary and were
prepared for the monitoring of his medication. He was scheduled to be reviewed by
a psychiatrist at the prison on the day he died.
34. Supratherapeutic levels of clozapine were found in Mr Ash’s system post-mortem.
The pathologist concluded that this may have contributed to his death. The levels of
clozapine in Mr Ash’s blood were higher than the recommended range when he
arrived at Birmingham. Reaside Clinic had been aware of and considered this but
were satisfied the prescribed dose was required to manage his mental illness and
he did not appear to have exhibited or reported any significant side effects from it.
Birmingham agreed to continue to monitor the clozapine levels once he arrived
there.
Substance misuse
35. Mr Ash had an extensive history of substance misuse both in prison and the
community. After his death, staff found buprenorphine and synthetic cannabinoids
in his cell. Post-mortem tests on Mr Ash were positive for buprenorphine and
antipsychotic medication which he had not been prescribed.
36. We do not know how Mr Ash obtained the illicit drugs in his possession. He had
been at Birmingham less than 48 hours and there is no evidence he had contact
with other prisoners, choosing to stay in his cell. It is possible he could have brought
these items into the prison himself on transfer from Reaside, suggesting searching
methods were insufficient. The Governor will want to consider this further.
Routine roll checks and welfare checks
37. Routine roll checks are primarily a visual security check to count prisoners to
ensure that they are present in their cells, but they are also an opportunity for any
concerns about a prisoner’s safety to be identified and managed. HMPPS’
Management of Internal Security Procedures Framework expects welfare checks to
take place at roll checks including that staff are able to see the prisoner’s face and
satisfy themselves that they are alive and well. Before staff unlock a prisoner’s door,
they are also required to look through the observation panel and check the welfare
of the prisoner.
38. An officer checked Mr Ash at 5.40am on 26 June. She said that there were no
obvious signs that he was unwell. She also said that the early morning roll check
was to make sure that were no major causes for concern rather than to check
whether a prisoner is alive and well. When another officer conducted the welfare
check just over an hour later, he also said he was just checking to see that Mr Ash
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was in his cell and admitted that his main focus was on another prisoner on the
landing.
39. Mr Ash had signs of rigor mortis when staff found him at 11.15am. These usually
start several hours after death. We do not know when during the night Mr Ash
became unwell. While the early morning checks did not require staff to obtain a
response from him, it is clear that staff at Birmingham did not understand that
routine roll checks and welfare checks were also intended to check the prisoner
was alive. At interview, staff continued to tell us that the checks were just to make
sure prisoners were in their cells.
40. Birmingham recognised that the welfare check by an officer was not adequate. On
28 June, the Acting Governor sent a Governor Direction informing staff that after the
morning wing briefing, they must unlock and go into every cell. Staff must ensure
that prisoners respond to them. This must occur before the regime takes place.
41. However, the officer told us that this action lasted around two weeks and then the
staff again reverted to checking prisoners through their observation panels. The
Head of Residence and the Head of Safety told us that they thought staff were
going into cells as required. Following our interviews, the investigator spoke with the
Head of Residence to inform her of the statement by the officer. She said she
believed the checks were taking place but could provide no evidence to corroborate
this. We make the following recommendation:
The Governor should introduce a robust quality assurance process to ensure
that staff conduct routine roll checks and welfare checks in line with local and
national guidelines.
Governor to note
42. We agree with the clinical reviewer that there were issues with communication
between healthcare staff and prison staff. Prison staff should have attended the
professionals’ meeting at Reaside but this did not happen. A CM was invited but
forgot to attend.
43. The Head of Residence accepted the recommendation of the mental health nurse
to accept Mr Ash to Birmingham without seeing the minutes of that meeting. Safer
custody staff were only made aware of Mr Ash’s imminent arrival on 12 June at the
SIM. Neither the nurse or the mental health team leader could recall what
information they shared in the SIM, and the Head of Safety reported receiving no
additional information other than the date Mr Ash would be returning to Birmingham.
44. While we do not think that this had any bearing on Mr Ash’s death, it is important
that all departments are aware of relevant risk information when accepting prisoners
from secure units. The Governor and Head of Healthcare will want to ensure that
there is a clear process for this.
Inquest
45. At the inquest, held from 6 May to 12 May 2025, the coroner concluded that Mr Ash
died of natural causes.
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Adrian Usher
Prisons and Probation Ombudsman April 2025
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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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