Christopher Randall

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Independent investigation
into the death of
Mr Christopher Randall,
a prisoner at HMP Birmingham,
on 11 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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© Crown copyright, 2026
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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.
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.
Mr Christopher Randall died from mixed drug intoxication, including use of psychoactive
substances, on 11 January 2025, at HMP Birmingham. He was 33 years old. I offer my
condolences to Mr Randall’s family and friends.
Mr Randall was withdrawing from drugs when he arrived at Birmingham on 6 January. He
should have been checked by healthcare staff during the day and night but the
investigation found that the night checks were not carried out properly. Had they been on
the night of 10/11 January, it is possible that healthcare staff would have identified that Mr
Randall was unconscious and he could have received medical intervention sooner.
The clinical reviewer found that Mr Randall’s care was not of the required standard and
was not equivalent to that which he could have expected to receive in the community.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Adrian Usher
Prisons and Probation Ombudsman January 2026
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Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 3
Background Information ................................................................................................... 4
Key Events ....................................................................................................................... 6
Findings ......................................................................................................................... 10
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Summary
Events
1. On 6 January 2025, Mr Christopher Randall was remanded in prison, charged with
theft and assault, and sent to HMP Birmingham. It was not his first time in prison.
2. Mr Randall tested positive for cocaine, benzodiazepines, opiates and cannabinoids
when he arrived at Birmingham. Healthcare staff from Birmingham Recovery Team
(BRT, the prison’s substance misuse team) placed him on a detoxification
programme and he was subject to monitoring for his first five days, which should
have consisted of daily clinical observations and nightly welfare checks. Staff
conducting the night checks were supposed to obtain a response or observe
breathing or movement.
3. During the nights of 8/9 and 9/10 January, the nurse responsible for checking Mr
Randall recorded that she could not see him because there was a towel draped
over the end of the bed. She recorded that he was in bed and “may be asleep”.
4. At 1.12am on 11 January, the nurse went to Mr Randall’s cell to carry out the night
check. Again, she recorded that she could not see Mr Randall due to the towel, that
he was in bed and “may be asleep”. She recorded that “they [the cell occupants]
were not disturbed due to the time”. At interview, she said that she did not want to
wake prisoners during the night.
5. At around 2.10am, when he got up to use the toilet, Mr Randall’s cellmate saw that
Mr Randall was on his bed with no covers over him. When he went to put a cover
on him, he realised Mr Randall was cold and not breathing. He alerted staff who
attended and started CPR. Ambulance paramedics arrived and continued with the
resuscitation attempt. However, at 3.06am, they pronounced life extinct.
6. After Mr Randall’s death, his cellmate told staff that they had been using drugs in
their cell. The post-mortem report concluded that Mr Randall died from mixed drug
intoxication which included recent use of psychoactive substances (PS).
Findings
7. The last report by HM Inspectorate of Prisons following their inspection of
Birmingham in early 2023 noted that some overnight checks of prisoners on the
drug recovery wing were not completed correctly. We found that this remained an
issue in this investigation and that the same issue occurred in the death of another
prisoner two days before Mr Randall’s death. The Head of Healthcare has since
introduced a weekly audit to check that BRT nurses are completing day and night
checks correctly.
8. The pathologist who carried out Mr Randall’s post-mortem examination said that
there were signs that Mr Randall had been deeply unconscious in the time leading
to his death. It is possible that had the nurse carried out a proper check of him at
1.12am, she would have identified he was unconscious, and he would have
received medical intervention sooner. The Head of Healthcare has taken steps to
address the quality of night checks with the nurse concerned.
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9. The clinical reviewer concluded that the clinical care Mr Randall received at
Birmingham was not equivalent to that which he could have expected to receive in
the community.
10. Mr Randall received appropriate support and harm minimisation advice from BRT.
In terms of drugs entering the prison, we are satisfied that Birmingham is taking
appropriate steps to tackle the problem.
11. We make no recommendations.
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The Investigation Process
12. HMPPS notified us of Mr Randall’s death on 13 January 2025.
13. The investigator issued notices to staff and prisoners at HMP Birmingham informing
them of the investigation and asking anyone with relevant information to contact
her. No one responded.
14. The investigator visited Birmingham on 22 January 2025. She obtained copies of
relevant extracts from Mr Randall’s prison and medical records.
15. The investigator interviewed six members of staff and Mr Randall’s cellmate at
Birmingham on 22 January and 13 February.
16. NHS England commissioned an independent clinical reviewer to review Mr
Randall’s clinical care at the prison and she conducted joint interviews with the
investigator.
17. We informed HM Coroner for Birmingham and Solihull of the investigation. The
Coroner gave us the results of the post-mortem examination. We have sent the
Coroner a copy of this report.
18. The Ombudsman’s office contacted Mr Randall’s next of kin, his mother, to explain
the investigation and to ask if she had any matters she wanted us to consider. She
wanted to know the details concerning his presentation and mood when in prison,
the events leading to his death, including when he was last seen alive. We have
addressed these issues in this report and the clinical review.
19. The investigation was suspended from 26 March until 22 August while we waited for
a copy of the post-mortem report.
20. We shared our initial report with HMPPS and the prison’s healthcare provider,
Birmingham and Solihull Mental Health NHS Foundation Trust. HMPPS pointed out
a minor factual inaccuracy which has been corrected in this report.
21. We sent a copy of our initial report to Mr Randall’s mother. She did not notify us of
any factual inaccuracies.
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Background Information
HMP Birmingham
22. HMP Birmingham is a category B adult male reception prison. It is managed by
HMPPS. Birmingham and Solihull Mental Health NHS Foundation Trust provides
healthcare services. The Birmingham Recovery Team (BRT) runs the substance
misuse service.
HM Inspectorate of Prisons
23. The most recent inspection of HMP Birmingham was in January and February
2023. Inspectors reported drug supply was far lower than at their last inspection in
2018, which may have been due to the significant investment in security
arrangements to prevent the ingress of drugs and other contraband. However, there
was no random mandatory drug testing, which meant leaders were not fully aware
of the drugs being used in the prison or the extent of the problem.
24. Inspectors also noted concerns that some night observations on prisoners on the
drug recovery wing were not performed correctly. In one case, the observation
panel was covered and others were not fully observed.
Independent Monitoring Board
25. Each prison has an Independent Monitoring Board (IMB) of unpaid volunteers from
the local community who help to ensure that prisoners are treated fairly and
decently. In its latest annual report, for the year ending 30 June 2024, the IMB
reported that the use of the X-ray body scanner had significantly reduced the
number of drugs and other illicit items being brought into the prison, but the prison
continued to be troubled by drones transporting illicit items into the establishment.
Previous deaths at HMP Birmingham
26. Mr Randall was the 18th prisoner to die at HMP Birmingham since January 2022.
Of the previous deaths, ten were from natural causes, three were self-inflicted,
three were drug related (one of these deaths occurred two days before Mr Randall
died), and one was a homicide. Up to the end of October 2025, there have been
four further deaths, three from natural causes and one where the cause of death is
currently unknown.
27. Our investigation into the drug-related death that occurred two days before Mr
Randall’s also found that the prisoner had failed to receive several doses of his
medication that had been prescribed to help with his alcohol withdrawal symptoms.
Psychoactive Substances
28. The term psychoactive substances (PS) is a broad term that refers to a drug or
other substance that affects mental process. Synthetic cannabinoids and synthetic
opioids (including nitazene) are substances that mimic the effects of traditional
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controlled drugs such as cannabis, cocaine, heroin and amphetamines. Synthetic
cannabinoids and synthetic opioids can be difficult to detect as the compounds
used in their manufacture can vary and use of these substances presents a serious
problem across the prison estate.
29. PS can affect people in a number of ways, including increasing heart rate, raising
blood pressure, reducing blood supply to the heart and vomiting. Prisoners under
the influence of these substances can present with marked levels of disinhibition,
heightened energy levels, a high tolerance of pain and a potential for violence.
Besides emerging evidence of such dangers to physical health, the use of PS is
associated with the deterioration of mental health, suicide and self-harm. Testing for
PS is in place in prisons as part of existing mandatory drug testing arrangements.
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Key Events
30. On 6 January 2025, Mr Christopher Randall was remanded in prison, charged with
theft and assault, and sent to HMP Birmingham. He arrived from court with a
suicide and self-harm (SASH) warning, which said that Mr Randall had numerous
self-harm scars on his arms and had tried to hang himself on 4 January prior to his
arrest. A custodial manager (CM) from the Safer Custody Team conducted a
welfare interview with him. Mr Randall said he had punched a wall when he was at
court as he had been frustrated about how long the court process was taking and
he wanted to get to the prison and settle into his cell. He said that he did not have
any thoughts of suicide or self-harm. The CM considered that suicide and self-harm
monitoring (known as ACCT) was not necessary.
31. A nurse completed Mr Randall’s reception healthcare screen. She noted that Mr
Randall had a history of anxiety and depression, PTSD, bipolar disorder and
borderline personality disorder. Mr Randall said he was withdrawing from alcohol
and drugs. He tested positive for cocaine, benzodiazepines, opiates and
cannabinoids. He said that he was happy to be in prison to get the support he
needed.
32. Mr Randall was allocated to work with specialists in the Birmingham Recovery
Team (BRT - the prison’s substance misuse service). As part of the induction
reception process, a nurse completed a check at 2.09am and noted that Mr Randall
was alert and polite in their interaction.
33. The next morning, a GP prescribed Mr Randall with medication for back pain and
depression.
34. An officer completed the first key worker session with Mr Randall. He said he
wanted to detox from drugs and alcohol and had no thoughts of self-harm.
35. A BRT worker completed Mr Randall’s substance use assessment. Mr Randall said
he smoked drugs daily. Mr Randall was allocated a cell in the Integrated Drug
Treatment Strategy (IDTS) wing to begin his detoxification. He was prescribed
methadone to treat his withdrawal from opiates and diazepam for his alcohol
detoxification. Prisoners on the IDTS receive welfare checks during their first five
days. BRT nurses complete clinical observations during the day and a welfare
check at night.
36. A key worker for psychosocial support also met Mr Randall that day. Mr Randall
discussed his alcohol and drug use and accepted the support to address these.
37. Mr Randall was in a double cell with a cellmate. Mr Randall occupied the lower
bunk bed. At interview, Mr Randall’s cellmate said for most of the day they were
locked in the cell. They ate their meals in the cell, talked and watched television.
38. On 7 January at 12.18pm, a healthcare assistant recorded that she had completed
her check and had spoken to Mr Randall. She noted that he presented well and was
alert and coherent. A nurse carried out the night check and recorded at 11.50pm
that Mr Randall was asleep and she had noted movement when she switched on
the cell light. An officer recorded that she had completed well-being checks at
10.00pm, 12.20am and 6.00am on 8 January and had no concerns.
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39. The healthcare assistant recorded at 11.02am that she had spoken to Mr Randall
and checked his observations and had no concerns.
40. Nurse A carried out the night check of Mr Randall. She recorded at 12.25am on 9
January that she could not see either occupant of the cell as a towel was draped
over the end of the bed. She recorded, “He [Mr Randall] was in bed and may be
asleep. They were not disturbed due to the time.” She also recorded, “The night
officer was informed.” At interview, she said that she did not like to wake prisoners
during the night and so she would turn the light on and off to see if there was any
response and if not, she would tell an officer. There was no evidence that she told
an officer.
41. Nurse B completed the day check on 9 January and recorded at 10.45am that Mr
Randall appeared well, was happy with his treatment and had no concerns.
42. Later that morning, Mr Randall told a nurse that he had not been collecting his
diazepam as he did not know where the medications hatch was on the IDTS wing.
He had missed four doses over two days. The nurse sent a message to BRT nurses
who extended the diazepam course from five days to seven days.
43. Nurse A carried out the night check. At 11.45pm, she again recorded that she could
not see Mr Randall, that he was in bed and “may be asleep”, and that, “the officer
was informed". There was no record that she told an officer.
44. On 10 January, Nurse C completed the day checks of Mr Randall. She recorded at
10.08am that she had spoken to Mr Randall, that he was alert and orientated, and
she had no concerns.
Events of 11 January 2025
45. The investigator watched CCTV footage and body worn video camera (BWVC)
footage from 11 January. She also obtained information from West Midlands
Ambulance Service.
46. Mr Randall’s cellmate told us that they were both locked into their cell from around
4.30pm. He said he got out of his bed at approximately 10.00pm to use the toilet
and saw Mr Randall asleep.
47. CCTV shows that at 1.12am, Nurse A completed her night check. She looked
through the observation panel into Mr Randall’s cell. She recorded, as she had for
the previous two nights, that she could not see Mr Randall due to the towel draped
over the end of the bed, that he was in bed and “may be asleep” and that she did
not disturb them and told an officer. However, CCTV shows that she did not speak
to the accompanying officer. She continued walking along the landing to the next
person on her check list.
48. Mr Randall’s cellmate told us that at approximately 2.10am, he got out of bed to use
the toilet. He saw Mr Randall lying on his bed with no covers. He thought Mr
Randall was in the same position as when he had last seen him. As it was a cold
night, he went to put a cover on Mr Randall when he realised he was cold and not
breathing. He pressed the emergency cell bell and banged on the cell door to alert
staff. Officer A responded. In his statement he said that he immediately radioed a
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code blue (a medical emergency code used when a prisoner is unconscious that
alerts healthcare staff and tells the control room to call an ambulance immediately).
Officer B was the first person to join Officer A and they opened the cell door. Officer
B radioed a code blue again. They moved Mr Randall from the bed onto the floor as
they checked him. In Officer B’s statement he said he checked for a pulse but there
was none, and Mr Randall was very cold to touch. They began CPR as more staff
arrived. Staff asked Mr Randall’s cellmate to leave the cell and he was taken to a
cell on the healthcare win.
49. Nurse D was the first nurse to arrive at the cell. She assisted with CPR.
50. After the emergency radio code blue was called, an officer went to Nurse A and told
her she was needed at the emergency response. When she arrived, she saw
officers completing chest compressions. She helped set up the defibrillator. Staff
used the defibrillator and one shock was delivered.
51. The West Midlands Ambulance Service records noted that the emergency
telephone call was received at 2.12am. Ambulance paramedics arrived at Mr
Randall’s cell at 2.21am. The ambulance paramedics took over the resuscitation
attempt. At 3.06am, the senior paramedic declared life extinct.
52. After Mr Randall’s death, his cellmate told a prison manager that they had been
smoking illicit substances in their cell and had crashed out.
Contact with Mr Randall’s family
53. The prison appointed the Head of Business Assurance as the family liaison officer
and a prison chaplain as her deputy. They both visited Mr Randall’s mother to break
the news of his death and offer support.
54. The prison made a contribution towards the cost of Mr Randall’s funeral, in line with
national guidelines.
Support for prisoners and staff
55. Postvention is a joint HMPPS and Samaritans initiative that aims to ensure a
consistent approach to providing staff and prisoner support following all deaths in
custody. Postvention procedures should be initiated immediately after every self-
inflicted death and on a case by case basis after all other types of death. Key
elements of postvention care include a hot debrief for staff involved in the
emergency response and engaging Listeners (prisoners trained by the Samaritans
to provide confidential peer-support) to identify prisoners most affected by the
death.
56. After Mr Randall’s death, the duty governor debriefed the staff involved in the
emergency response to ensure they had the opportunity to discuss any issues
arising, and to offer support. The staff care team also offered support.
57. The prison posted notices informing other prisoners of Mr Randall’s death and
offering support. Staff reviewed all prisoners assessed as being at risk of suicide or
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self-harm in case they had been adversely affected by Mr Randall’s death.
Listeners were sent to the wing to offer support.
Post-mortem report
58. The post-mortem report concluded that Mr Randall’s cause of death was mixed
drug intoxication (MDMB-4en-PINACA, methadone, diazepam and cocaine).
Toxicology tests showed that Mr Randall had used MDMB-4en-PINACA, a synthetic
cannabinoid, at some point prior to death. The pathologist noted that synthetic
cannabinoids have been associated with fatal cardiac arrhythmias (irregular
heartbeat). Methadone and diazepam were detected at therapeutic levels. Cocaine
was also detected but at a low concentration which indicated less recent use. The
pathologist noted that the use of methadone and diazepam (which have central
nervous depressant effects) alongside cocaine (a stimulant) was an unsafe situation
with unpredictable and even fatal outcomes.
59. The pathologist noted that Mr Randall had thick mucus in his airway that suggested
he had been deeply unconscious in the time leading to his death.
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Findings
Cause of death
60. Toxicology tests showed that Mr Randall had used PS before he died and his
cellmate admitted that they had both smoked drugs that evening. Mr Randall had a
long history of drug use and was under the care of the prison’s substance misuse
team, BRT, who had provided harm minimisation advice. We consider that Mr
Randall had been warned of, and understood, the dangers of using drugs.
Drug strategy
61. The prison reported a noticeable rise in illicit drug use in January 2025. Of particular
concern were the two drug-related deaths two days apart. The drug strategy lead at
Birmingham told us that the prison used various methods to restrict the supply of
drugs. Drug detection dogs were used to search the perimeter and grounds, while
enhanced gate procedures had been introduced for all staff entering the prison. To
specifically reduce the risk of PS entering the prison, all legal visits had been made
paperless, and incoming packages were subject to X-ray screening. Additionally,
letters were photocopied before being delivered to the wings.
62. Illicit drugs remain a widespread issue across the prison estate. Birmingham has
taken steps to raise awareness among staff and prisoners and to reduce the supply
of drugs. We were told that prisoners on arrival in reception are offered an amnesty
to relinquish any illicit items before the formal searches without consequence. More
prisoners have the opportunity to engage in suitable work, activity and treatment to
reduce demand (the idea being that engaged prisoners are less likely to use drugs).
Prisoners are also encouraged to engage in peer led drug and alcohol groups for
support.
63. We understand that a major change is planned from October 2025, when the prison
will replace all current vapes with tamper-proof versions to prevent them being
modified for drug use.
64. We are satisfied that Birmingham has a comprehensive strategy for reducing
demand and supply of illicit drugs.
Clinical findings
65. The clinical reviewer concluded that the clinical care Mr Randall received at
Birmingham was not equivalent to that which he could have expected to receive in
the community. She found that the night checks were not completed properly for
three consecutive nights.
Night checks
66. The local policy on completion of night checks is outlined in the Standard Operating
Procedure (SOP) BRT 1.2. The SOP says that night checks should be completed
by looking through the cell door and checking for breathing/ movement and/or
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thumbs up and confirmation. The SOP does not include instructions on waking
prisoners at night if it has not been possible to detect movement.
67. The BRT clinical team manager told us that she would expect nurses to check for
signs of life by switching on the cell light or using a torch to check for movement. If
there was any obstruction, nurses were expected to ask the night officer to unlock
the cell and if this was refused, the nurse should record the name of the officer and
escalate to a manager.
68. In the most recent HMIP inspection in 2023, inspectors noted that healthcare staff
were not always completing night checks correctly. In response, the BRT clinical
manager issued a reminder email to staff which said that a review of medical notes
for the night checks had highlighted an issue as staff had a duty of care to ensure
the patient was visible. Staff were expected to see movement to confirm a patient
was breathing and to note that a nurse was “unable to see” was not acceptable.
Staff were asked to complete detailed documentation for confirmation of breathing.
The email attached the SOP BRT 1.2 for reference.
69. Nurse A did not complete proper night checks on Mr Randall as she noted that she
could not see him. She did not observe breathing and did not seek any response
from him. Although she noted that she had informed the night officer, no other
details were recorded and she did not escalate to a manager.
70. Nurse A went to Mr Randall’s cell at 1.12am. Had she carried out a proper check,
she might have identified that Mr Randall was unconscious, and he could have
received medical intervention sooner. (The post-mortem noted that he was likely to
have been deeply unconscious in the period leading to his death.) It was another
hour before his cellmate realised that Mr Randall was unresponsive.
71. At interview, Nurse A said she was not aware of the SOP BRT 1.2, despite working
for BRT for over 20 years. She said her practice was not to disturb sleeping
prisoners but she accepted that she was not following the required procedures and
would do so going forward.
72. The BRT clinical team manager told us that she had started a weekly audit and now
checked at least one clinical record from all BRT nurses to ensure that the
templates for day and night checks were fully completed and documented in the
clinical notes. She had also taken action to address the issues around Nurse A’s
completion of night checks. As action has already been taken to address these
issues, we make no recommendations in this report. However, the clinical reviewer
has made recommendations which the Head of Healthcare will wish to address.
Alcohol withdrawal medication
73. The clinical reviewer found that Mr Randall was appropriately prescribed medication
to support him with the management of his alcohol withdrawal symptoms. However,
he missed four doses between 7 and 9 January because he did not know where the
medications hatch was after he was moved to the IDTS wing. The missed doses
were not identified until Mr Randall told a nurse.
74. The clinical reviewer has made a recommendation on this which the Head of
Healthcare will wish to address. We made a recommendation on a similar issue
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following our investigation into the drug related death that occurred two days before
Mr Randall’s death. The Head of Healthcare accepted the recommendation and
said that templates had been amended to remind staff to check medication
compliance and discuss any non-compliance with the individual concerned.
Inquest
75. At the inquest, held from 1 to 5 December 2025, the jury concluded that Mr
Randall’s death was drug related.
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