Frank Salmon

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Independent investigation into
A report by the Prisons and Probation Ombudsman
the death of Mr Frank Salmon,
a prisoner at HMP Channings
Wood, on 6 August 2023
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, 2024
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
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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. Mr Frank Salmon died of occlusion of coronary artery bypass grafts (blocking of the
blood vessel that was inserted into the coronary artery to improve blood supply to
the heart) due to atherosclerosis (narrowing of the arteries caused by fatty deposits)
on 6 August 2023 at HMP Channings Wood. He was 55 years old. We offer our
condolences to Mr Salmon’s family and friends.
4. The PPO family liaison officer wrote to Mr Salmon’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.
5. NHS England commissioned an independent clinical reviewer to review Mr
Salmon’s clinical care at Channings Wood. She concluded that the clinical care Mr
Salmon received at Channings Wood was of a reasonable standard and was at
least equivalent to that which he could have expected to receive in the community.
However, she found the management of Mr Salmon’s long-term conditions and care
plans were not of the required standard and not equivalent to that which he could
have expected to receive in the community.
6. The PPO investigator investigated the non-clinical issues relating to Mr Salmon’s
care. We did not find any non-clinical issues of concern.
Recommendation
• The Head of Healthcare should review the process for managing and monitoring
long-term conditions to ensure the development of meaningful patient-centred care
plans.
7. We shared our initial report with HMPPS. They found no factual inaccuracies. They
provided an action plan which is annexed to this report.
8. We sent a copy of our initial report to Mr Salmon’s next of kin. They did not notify us
of any factual inaccuracies.
Adrian Usher February 2024
Prisons and Probation Ombudsman
Prisons and Probation Ombudsman 1
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Inquest
The inquest, heard on 16 July 2024, concluded that Mr Salmon died from natural causes.
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