Maqsood Asif

OFFICIAL - FOR PUBLIC RELEASE
Independent investigation into
the death of Mr Maqsood Asif,
a prisoner at HMP Stafford,
on 18 November 2021
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
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.
My office carries out investigations to understand what happened and identify how the
organisations whose actions we oversee can improve their work in the future.
Mr Maqsood Asif died in hospital of heart failure on 18 November 2021, while a prisoner at
HMP Stafford. He was 60 years old. I offer my condolences to Mr Asif’s family and
friends.
When Mr Asif was moved to Stafford from HMP Isle of Wight on 21 April 2021, he had
already been on the waiting list for heart surgery for six months. After Mr Asif’s transfer,
his consultant at Southampton wrote to Stafford to say Mr Asif’s surgery was now urgent.
However, Mr Asif had still not had his surgery when he died almost seven months later.
I accept that the initial delay in Mr Asif’s heart surgery was down to hospital backlogs due
to COVID-19. However, subsequent delays could have been avoided had both prisons
handled this case properly. Isle of Wight failed to consider using the clinical hold process
to prevent Mr Asif from being transferred while he was awaiting heart surgery and failed to
do a proper handover to Stafford.
Stafford then delayed referring Mr Asif to the local cardiology team and failed to provide
complete information about Mr Asif’s condition and the time he had already spent on the
surgery waiting list. This could have avoided Mr Asif going through all the same tests
again and then being told he needed surgery, a year after his Southampton consultant had
told him this.
The clinical reviewer found that the care Mr Asif received for his heart condition was not
equivalent to that which he could have expected to receive in the community. I consider
that Mr Asif was badly let down by both prisons. Had they handled this case properly, it is
highly likely that Mr Asif would have got the surgery he needed.
I am also concerned that bedwatch officers did not provide Mr Asif with a call to his family
while in hospital, despite a manager having approved it.
This version of my report, published on my website, has been amended to remove the
names of staff and prisoners involved in my investigation.
Sue McAllister, CB
Acting Prisons and Probation Ombudsman July 2022
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Contents
Summary ......................................................................................................................... 1
The Investigation Process ................................................................................................ 4
Background Information ................................................................................................... 5
Key Events ....................................................................................................................... 6
Findings ........................................................................................................................... 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Summary
Events
1. In March 2020, Mr Maqsood Asif was sentenced to 18 years imprisonment for
sexual offences. In May, he was moved to HMP Isle of Wight.
2. In October, Mr Asif was diagnosed with severe aortic stenosis (narrowing of one of
the valves in the heart) and told he needed aortic valve replacement surgery.
However, it was delayed due to the COVID-19 pandemic.
3. On 29 March 2021, a member of prison healthcare staff contacted Southampton
Hospital for an update on Mr Asif’s surgery. The hospital said there was a backlog
of appointments caused by the COVID-19 pandemic and they would ring the prison
in the next couple of weeks to book an appointment.
4. On 21 April, Mr Asif was moved to HMP Stafford.
5. On 26 April, Mr Asif’s consultant at Southampton Hospital sent Stafford a letter
saying Mr Asif’s outstanding surgery was urgent.
6. On 9 May, a prison GP at Stafford sent a referral to the local cardiology department
at Stafford Hospital.
7. On 25 May, Stafford Hospital sent the prison GP a letter requesting further
information about Mr Asif’s cardiology tests results, completed while he was at Isle
of Wight. There was no record these were sent.
8. In June, Mr Asif attended several appointments at Stafford Hospital to assess his
heart condition. In September, a consultant told him he needed aortic valve
replacement surgery.
9. On 9 November, a prison nurse saw Mr Asif, after he reported chest pain and
breathlessness which had worsened in recent weeks. Prison staff had already
called an emergency ambulance. The paramedics arrived and were concerned that
Mr Asif might have COVID-19, so took him to hospital. He tested negative for
COVID-19 but was kept in hospital for further observations.
10. On 12 November, Mr Asif asked to speak with his family. A Custodial Manager
(CM) approved a phone call for the following day. There was no record that
bedwatch officers provided Mr Asif with this call.
11. Mr Asif’s condition continued to deteriorate, and he died in hospital on 18
November.
12. The post-mortem report concluded that Mr Asif died from heart failure caused by
severe aortic stenosis.
Findings
13. Despite Mr Asif being told in October 2020 that he needed heart surgery, he did not
have it before he died, over a year later. We accept that initially, the delays in
Prisons and Probation Ombudsman 1
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
surgery were due to COVID-19 backlogs, but by April 2021, Mr Asif was high
priority for surgery at Southampton Hospital. However, he was moved to Stafford,
where the process of getting his heart condition diagnosed and onto a waiting list
for surgery started all over again.
14. We consider that healthcare staff at Isle of Wight should have considered using the
clinical hold process for Mr Asif (where a prisoner is withheld from prison transfer
for medical reasons) given he was awaiting surgery for a life-threatening condition.
If holding him at Isle of Wight was not considered appropriate, then at the very
least, they should have done a proper handover to Stafford, giving full details of Mr
Asif’s condition and how long he had already been on the waiting list for surgery.
This did not happen.
15. Healthcare staff at Stafford then not only delayed making a referral to the local
cardiology team at Stafford Hospital, but also failed to set out in the referral full
details of Mr Asif’s condition and how long he had already been waiting for surgery.
They also failed to respond to a request from Stafford Hospital for further
information about Mr Asif’s cardiology tests results. Instead, Mr Asif went through a
series of tests again to then be told that he needed surgery, which he had been told
almost a year before.
16. The clinical reviewer found that the care Mr Asif received for his heart condition was
not equivalent to that which he could have expected to receive in the community.
We consider that Mr Asif was badly let down by both prisons. Had his case been
handled differently, it is highly likely he would have had the surgery he needed.
17. We are also concerned that bedwatch officers did not provide Mr Asif with a phone
call he requested to his family while in hospital, despite this being approved. We
are also concerned the family liaison officer (FLO) did not make the family aware of
financial support available for funeral expenses following his death until prompted
by the PPO investigator.
Recommendations
• The Head of Healthcare at Isle of Wight should ensure that staff consider using
clinical hold where a prisoner is awaiting surgery for a life-threatening condition
and record this in the medical records.
• The Head of Healthcare at Isle of Wight should ensure that healthcare staff
arrange a proper handover to the receiving prison where a prisoner has more
complex health care needs.
• The Head of Healthcare at Stafford should ensure that where prisoners are already
under the care of a hospital consultant when they arrive, staff:
• make hospital referrals promptly;
• include all relevant information about the stage of treatment and time spent on
the waiting list for surgery if applicable; and
• provide information requested by hospitals promptly to avoid delays in
treatment.
2 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
• The Governor of Stafford should ensure that officers taking over bedwatch
duties read the bedwatch log at the start of their shift, so they are aware of any
ongoing issues.
• The Governor of Stafford should ensure that family liaison officers make families
aware of the financial support available to them for funeral expenses following a
death in custody.
Prisons and Probation Ombudsman 3
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
The Investigation Process
18. The investigator issued notices to staff and prisoners at HMP Stafford informing
them of the investigation and asking anyone with relevant information to contact
him. No one responded.
19. The investigator obtained copies of relevant extracts from Mr Asif’s prison and
medical records.
20. NHS England commissioned a clinical reviewer to review Mr Asif’s clinical care at
the prison.
21. We informed HM Coroner for Staffordshire of the investigation. The coroner
provided the cause of death. We have sent the coroner a copy of this report.
22. The Ombudsman’s family liaison officer contacted Mr Asif’s next of kin, his wife, to
explain the investigation and to ask if she had any matters she wanted the
investigation to consider. She did not have any questions but asked for a copy of
the report.
23. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
24. Mr Asif’s wife received a copy of the initial report. She did not make any comments.
4 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Background Information
HMP Stafford
25. HMP Stafford holds approximately 750 men who have been convicted of sexual
offences. Practice Plus Group provides a 24-hour healthcare service.
HMP Isle of Wight
26. HMP Isle of Wight is made up of two former prisons, Parkhurst and Albany. The
prison holds approximately 1,000 men, mainly convicted of sexual offences.
Practice Plus Group provides healthcare services at the prison. There is an
inpatient healthcare unit at the former Albany site, providing 24-hour care for
prisoners.
HM Inspectorate of Prisons
27. The most recent inspection of Stafford was in January 2020. Inspectors reported
that overall, the prison provided a safe environment, in which prisoners were
respected. They reported that healthcare provision had improved since their
previous inspection in February 2016.
28. The most recent inspection of Isle of Wight was in April and May 2019. Inspectors
reported that healthcare was very good at the prison and that their services were
delivered by a team who knew their patients well.
Independent Monitoring Board
29. 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.
30. In its latest annual report for Stafford, for the year to 30 April 2021, the IMB reported
that demand for cells that could be accessed without using stairs outstripped
supply. The Board were aware of two prisoners who had arrived at Stafford who
clearly could not manage stairs even though the sending prison had categorised
them as fit and well. This was unfair on the prisoner and placed unfair pressure on
staff.
31. In the IMB’s most recent report for Isle of Wight, for the year to 31 December 2020,
they reported that at least 80% of prisoners were satisfied with the healthcare
services provided.
Previous deaths at HMP Stafford
32. Mr Asif was the 13th prisoner to die at Stafford since November 2019. All the
deaths were from natural causes. There are no similarities between our findings in
this investigation and our investigation findings from the previous deaths.
Prisons and Probation Ombudsman 5
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Key Events
33. In March 2020, Mr Maqsood Asif was convicted of sexual offences and was
sentenced to 18 years imprisonment. On 20 May, Mr Asif was moved to HMP Isle
of Wight.
34. On 18 June, a prison GP made an urgent referral to Southampton University
Hospital’s Cardiology Department after Mr Asif complained of chest and back pain.
35. On 28 October, following various tests, a hospital consultant told Mr Asif he had
severe aortic stenosis (narrowing of one of the valves in the heart which restricts
blood flow) and needed aortic valve replacement surgery. The consultant told him
he should not exert himself in any way, including using stairs, until after surgery.
The prison moved Mr Asif to a ground floor cell the same day.
36. On 20 January 2021, a healthcare administrative assistant contacted the hospital
for an update on Mr Asif’s surgery. The hospital said they were only undertaking
urgent surgery due to the COVID-19 pandemic.
37. On 29 March, a healthcare administrative assistant contacted the hospital again for
an update. The hospital’s case manager said there was a backlog of appointments
and they would ring the prison in the next couple of weeks to book an appointment
for Mr Asif.
38. On 21 April, Mr Asif was moved to HMP Stafford. Stafford was unaware of Mr Asif’s
heart condition until he told them when he arrived, and they had no cells available
on the ground floor. He agreed to a cell upstairs for the night and the prison moved
Mr Asif to a ground floor cell the following day.
39. On 26 April, Southampton University Hospital’s Cardiology Department sent
Stafford a letter saying that Mr Asif required urgent aortic valve replacement and
that his priority for surgery had recently increased due to him showing symptoms of
aortic stenosis.
40. On 9 May, a prison GP sent a referral to the cardiology department at Stafford
Hospital.
41. On 25 May, Stafford Hospital sent the prison GP a letter asking for further
information about Mr Asif’s cardiology tests results, completed while at Isle of
Wight. There was no record these were sent.
42. In June, Mr Asif had several tests at Stafford Hospital to assess his heart condition.
In September, a consultant told him he needed aortic valve replacement surgery.
43. On 31 October, a prison nurse and healthcare assistant attended Mr Asif’s cell as
he was struggling to breathe and had chest pain. They completed observations and
requested an emergency ambulance. Paramedics arrived and completed an
electrocardiogram (ECG - used to check the heart’s rhythm) and found it to be
abnormal. Mr Asif was taken to hospital where a hospital doctor diagnosed him
with musculoskeletal pain and discharged him later that day.
6 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
44. On 3 November, a prison nurse arranged for Mr Asif to be taken to A&E after he
reported chest pain. A hospital doctor diagnosed him with musculoskeletal pain
and discharged him the same day.
45. On 9 November, a prison nurse saw Mr Asif at the healthcare unit where he
complained of breathlessness, struggling to sleep and muscular pain. The nurse
was aware he had an appointment with the prison GP later that day and said he
should raise this with him. The GP prescribed Mr Asif pain relief.
46. That evening, a prison nurse attended the wing to see Mr Asif, as he continued to
report chest pain and breathlessness. Prison staff had already called an
emergency ambulance. The paramedics arrived and were concerned that Mr Asif
might have COVID-19, so took him to hospital. He tested negative for COVID-19
but was admitted to hospital for further observations.
47. On 12 November, Mr Asif asked to contact his family. An officer, who was on
bedwatch duty, spoke with a Custodial Manager (CM) at Stafford, who approved a
phone call for the following day. The officer recorded this in the bedwatch log.
48. The investigator asked the officer if he told officers taking over his shift about the
approved phone call. He said he did. The officers taking over the shift told the
investigator they were not aware of any approved phone calls.
49. At approximately 6.00pm on 18 November, a hospital consultant spoke with Mr Asif
and told him he was very poorly and surgery to replace his aortic valve was booked
for the following day. He explained Mr Asif’s family should be made aware of his
condition as soon as possible. An officer on bedwatch duty spoke with his family
following this.
50. At 10.10pm, Mr Asif suddenly deteriorated, and a hospital crash team came to
assist. At 10.36pm, Mr Asif was pronounced dead.
Contact with Mr Asif’s family
51. On 19 November, the prison appointed a family liaison officer (FLO).
52. At approximately 9.00am, the prison Imam contacted the family, as Mr Asif was a
Muslim. The family gave him the name of the funeral directors they had appointed,
and he provided this to the FLO. The family requested for the body to be released
that day so a funeral could be held immediately, as per Muslim practices.
53. The FLO did not explain the financial support available towards funeral expenses to
the family.
54. The investigator raised this with the FLO, and, on 11 January 2022, she sent a
letter to the family to explain the financial support available.
Support for prisoners and staff
55. After Mr Asif’s death, the Head of Operations & Security debriefed the staff that
were supervising Mr Asif in hospital at the time of his death to ensure they had the
Prisons and Probation Ombudsman 7
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
opportunity to discuss any issues arising and to offer support. They were also
signposted to the staff care team.
56. The prison posted notices informing other prisoners of Mr Asif’s death, and offering
support.
Post-mortem report
57. The Coroner accepted the cause of death provided by a hospital doctor and no
post-mortem examination was carried out. The doctor gave Mr Asif’s cause of
death as heart failure, caused by severe aortic stenosis.
8 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Findings
Clinical care
58. The clinical reviewer found that the care Mr Asif received for his heart condition was
not equivalent to that he could have expected to receive in the community.
59. Mr Asif was under the care of a consultant at Southampton University Cardiology
Department and was awaiting aortic valve replacement surgery when he was
transferred to Stafford. He had been waiting for surgery since October 2020, as it
was delayed due to the COVID-19 pandemic. We are concerned that Mr Asif’s
transfer to Stafford in April 2021 had a detrimental impact on his chances of having
the urgent surgery he needed. He did not have his surgery before he died.
60. Prison Service Order (PSO) 3050, Ensuring continuity of healthcare for prisoners,
says healthcare staff must ensure, “current healthcare needs are assessed, and
continuity of care ensured when prisoners are transferred between
establishments...”. It also says there should be a system for clinical hold, where
prisoners can be withheld from transfer for a period of time for clinical reasons. The
policy gives the example of prisoners awaiting an urgent cancer referral but also
says that it can include awaiting other appointments.
61. The investigator and clinical reviewer asked the Head of Healthcare at Isle of Wight
whether clinical hold was considered for Mr Asif. He said it was not because clinical
hold was considered only for cancer referrals, life-saving treatment and occasionally
where there had been a long wait to arrange coordinated care for a complex case.
He said Mr Asif did not meet the criteria.
62. Given that Mr Asif had a very serious and life-threatening condition, we are of the
view that clinical hold should have been considered. We recommend:
The Head of Healthcare at Isle of Wight should ensure that staff consider
using clinical hold where a prisoner is awaiting surgery for a life-threatening
condition and record this in the medical records.
63. PSO 3050 says that an up to date summary of current health concerns should be
sent with a prisoner when they transfer prisons. Where health concerns are more
complex, it says it may be appropriate for prison healthcare teams to speak directly
with each other ahead of transfer. The clinical reviewer found no evidence that Isle
of Wight did a handover to Stafford to let them know about Mr Asif’s heart condition
and outstanding surgery.
64. As Stafford were unaware of Mr Asif’s heart condition until he arrived, they did not
realise that he required a ground floor cell and were unable to provide this on his
first night. We recommend:
The Head of Healthcare at Isle of Wight should ensure that healthcare staff
arrange a proper handover to the receiving prison where a prisoner has more
complex health care needs.
65. Despite Southampton Hospital writing to Stafford on 26 April saying that Mr Asif
was awaiting urgent heart surgery, it was not until 9 May that the GP referred Mr
Prisons and Probation Ombudsman 9
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
Asif to the local cardiology team in Stafford. Also, PSO 3050 says in the clinical
hold section, “Patients may sometimes be transferred after having waited a
considerable time for hospital treatment. In these circumstances details of the wait
should be included in the referral letter from the new establishment to determine
whether this may be taken into account at the new hospital. Clinicians should
attempt to reach agreement that the waiting time will not be reset when the patient
is transferred to a new list”. The clinical reviewer found no evidence that the referral
included this information.
66. Also, she found no evidence of the GP providing the cardiology tests results
requested by Stafford Hospital on 25 May. We consider this may have further
delayed Mr Asif’s treatment. We recommend:
The Head of Healthcare at Stafford should ensure that where prisoners are
already under the care of a hospital consultant when they arrive, staff:
• make hospital referrals promptly;
• include all relevant information about the stage of treatment and
time spent on the waiting list for surgery if applicable; and
• provide information requested by hospitals promptly to avoid delays
in treatment.
Bedwatch handovers
67. On 12 November, three days after being taken to hospital, Mr Asif requested a call
to his family, which a CM approved for the following day. The officer recorded this
in the bedwatch log and said he told the oncoming shift officers about it during his
handover.
68. Both oncoming shift officers said they were unaware of an approved phone call.
This is despite one of them having signed the bedwatch log to confirm he had read
it and been given a handover. We are concerned that the oncoming shift officers
did not read the bedwatch log when starting their shift.
69. Officers should have given Mr Asif the phone call to his family, as agreed. His
family were not aware that he was in hospital until 18 November, and this may have
given them the opportunity to visit him sooner. We recommend:
The Governor of Stafford should ensure that officers taking over bedwatch
duties read the bedwatch log at the start of their shift, so they are aware of
any ongoing issues.
Liaison with Mr Asif’s family
70. Prison Service Instruction (PSI) 64/2011 on Safer Custody says that when a death
in custody occurs, the family of the deceased are entitled to financial support of up
to £3,000 towards funeral expenses from the prison. It says that any funeral
expenses should be paid directly by the prison to the funeral directors once an
original invoice is received.
10 Prisons and Probation Ombudsman
OFFICIAL - FOR PUBLIC RELEASE
OFFICIAL - FOR PUBLIC RELEASE
71. We are concerned that the FLO did not make the family aware of the financial
support available to them until prompted by the investigator. We recommend:
The Governor of Stafford should ensure that family liaison officers make
families aware of the financial support available to them for funeral expenses
following a death in custody.
Inquest
72. The inquest, held from 2 to 4 June 2025, concluded that Mr Asif died from natural
causes.
Prisons and Probation Ombudsman 11
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