Gerard Browne

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Independent investigation into
the death of Mr Gerard Browne,
a prisoner at HMP Wymott,
on 19 January 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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OFFICIAL - FOR PUBLIC RELEASE
© Crown copyright, 2024
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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. In June 2017, Mr Gerard Browne was sentenced to 14 years imprisonment for
sexual offences. He died in hospital of pneumonia and colovesical fistula (an
abnormal connection between the colon and bladder which can cause recurrent
urinary tract infections) on 19 January 2024, while a prisoner at HMP Wymott. He
was 85 years old. We offer our condolences to Mr Browne’s family and friends.
4. The Ombudsman’s office contacted Mr Browne’s niece to explain the investigation
and to ask if she had any matters she wanted us to consider. She did not respond.
5. The PPO investigator investigated the non-clinical issues relating to Mr Browne’s
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Mr
Browne’s clinical care at Wymott.
7. The clinical reviewer concluded that the clinical care Mr Browne received at Wymott
was equivalent to that which he could have expected to receive in the community.
However, she identified some areas for learning. She found that healthcare staff
missed an opportunity to discuss Mr Browne at a complex care needs
multidisciplinary meeting following his discharge from hospital in December 2023.
She also found that more could have been done to assess Mr Browne’s risk of
malnutrition and dehydration.
8. We make the following recommendations:
• The Head of Healthcare should ensure that patients with multiple
healthcare needs are discussed at the multi professional complex case
conference meeting so that the MDT has full oversight of their complex
care and multiple care needs.
• The Head of Healthcare should ensure that all healthcare staff undertake a
MUST assessment when a person is weighed and ensure any concerns are
escalated with immediate effect.
• The Head of Healthcare should ensure that all healthcare staff undertake a
risk assessment when an adult presents with risk factors that make them
at increased risk of dehydration and ensure that a plan of care is in place.
Prisons and Probation Ombudsman 1
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9. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Adrian Usher
Prisons and Probation Ombudsman July 2024
Inquest
The inquest, held on 15 November 2024, concluded that Mr Browne 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
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