Mark Hayes

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Independent investigation into
the death of Mr Mark Hayes,
on 17 January 2025, following
his release from HMP Berwyn
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. Since 6 September 2021, the PPO has been investigating post-release deaths that
occur within 14 days of the person’s release from prison.
3. If my office is to best assist HMPPS in ensuring the standard of care received by
those within service remit is appropriate then our recommendations should be
focused, evidenced and viable. This is especially the case if there is evidence of
systemic process failures.
4. Mr Mark Hayes died due to idiopathic cardiac arrhythmia (an abnormal heart rhythm
with no known cause), with chronic obstructive pulmonary disease (a long-term lung
condition that makes breathing difficult) and mild fatty change of the liver (a small
amount of fat buildup in the liver) as contributing conditions on 17 January 2025,
following his release from HMP Berwyn on 3 January. He was 60 years old. We
offer our condolences to his friends and family.
5. Mr Hayes spent four very short periods in prison from 6 November 2024. He
reported no history or symptoms of heart or liver disease during this time.
Prisons and Probation Ombudsman 1
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The Investigation Process
6. We were informed of Mr Hayes’ death on 22 January 2025.
7. The PPO investigator obtained copies of relevant extracts from Mr Hayes’ prison
and probation records.
8. We informed HM Coroner for North Wales of the investigation. They gave us the
results of the post-mortem examination. We have sent the Coroner a copy of this
report.
9. The Ombudsman’s office contacted Mr Hayes’ mother to explain the investigation
and to ask if she had any matters she wanted us to consider. Mr Hayes’ mother
asked some questions that are outside the remit of our investigation, and for a copy
of our report.
10. The initial report was shared with HMP Prison and Probation Services (HMPPS).
They did not find any factual inaccuracies.
2 Prisons and Probation Ombudsman
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Background Information
HMP Berwyn
11. HMP Berwyn is category C prison, near Wrexham. Healthcare services are
provided by Betsi Cadwaladr University Health Board.
Probation Service
12. The Probation Service work with all individuals over 18 years of age subject to
custodial and community sentences. (Children under 18 are managed by the local
Youth Offending Team.) During a person’s imprisonment, they oversee their
sentence plan to assist in rehabilitation, as well as prepare reports to advise the
Parole Board and have links with local partnerships to whom, where appropriate,
they refer people for resettlement services. Post-release, the Probation Service
supervise people throughout their licence period and post-sentence supervision.
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Key Events
13. On 6 November 2024, Mr Mark Hayes was admitted to HMP Berwyn, having been
sentenced to eight weeks in prison for breach of a court order. This was his first
custodial sentence. At the time, Mr Hayes was prescribed an antidepressant, and
pain relief medication for a long standing back injury. He did not identify any other
physical health symptoms or diagnoses.
14. On 28 November, Mr Hayes was released from prison on licence.
15. On 30 November, Mr Hayes was given a 14-day fixed term recall to Berwyn when
his licence was revoked because of poor behaviour. Mr Hayes did not disclose any
new physical health symptoms during his recall. At his secondary health screen (on
2 December), he said that he had no family history of lung or heart conditions.
16. On 12 December, Mr Hayes was released on licence.
17. On 16 December, Mr Hayes was recalled to Berwyn for a second time, when his
licence was revoked due to missing an appointment with his community offender
manager (COM) and for displaying poor behaviour. As previously, Mr Hayes did not
report any new physical health symptoms. He was released on 23 December.
18. On 30 December, Mr Hayes was recalled to Berwyn for failure to attend an
appointment with his COM. He did not identify any new physical health symptoms.
He was released on 3 January 2025.
Post Release
19. On 3 January 2025, Mr Hayes did not attend his release appointment with his COM.
He also did not attend his release accommodation. As a result, Mr Hayes’ COM
made a recall application. Mr Hayes’ sentence expired on 5 January, with his
whereabouts unknown.
Circumstances of Mr Hayes’ death
20. On 17 January, Mr Hayes was found dead in a hotel in which he was staying. His
mother told us that he had fallen downstairs in the hotel two days earlier, but did not
receive any medical treatment or assessment at the time.
Post-mortem report
21. The post-mortem examination concluded that Mr Hayes’ died due to idiopathic
cardiac arrhythmia (an abnormal heart rhythm with no known cause), with chronic
obstructive pulmonary disease (a long-term lung condition that makes breathing
difficult) and mild fatty change of the liver (a small amount of fat buildup in the liver)
as contributing conditions.
22. Toxicology tests identified no illicit drugs or alcohol.
4 Prisons and Probation Ombudsman
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Findings
23. Mr Hayes died as a result of natural causes relating to heart and lung conditions.
He had no recorded history of heart or lung disease and did not report any relevant
symptoms during his time in prison. We are satisfied that there is nothing further
that prison, probation or healthcare staff could have done to prevent his death.
Adrian Usher
Prisons and Probation Ombudsman July 2025
Prisons and Probation Ombudsman 5
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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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