Mark Richards

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Independent investigation into
the death of Mr Mark Richards,
a prisoner at HMP High Down,
on 17 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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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. On 4 March 2024, Mr Mark Richards was sentenced to two years and four months
in prison for child sex offences.
4. Mr Richards died in hospital from an infective exacerbation of interstitial lung
disease (the worsening of damaged, scarred lungs) on 17 January 2025, while a
prisoner at HMP High Down. He was 57 years old. We offer our condolences to Mr
Richards’ family and friends.
5. The Ombudsman’s office wrote to Mr Richards’ next of kin to explain the
investigation and to ask if they had any matters they wanted us to consider. They
did not respond to our letter.
6. NHS England commissioned an independent clinical reviewer to review Mr
Richards’ clinical care at HMP High Down.
7. As part of the investigation, the clinical reviewer and the PPO investigator
interviewed one member of staff on 17 March 2025.
8. The clinical reviewer concluded that the clinical care Mr Richards received at High
Down was of a good standard and was equivalent to that which he could have
expected to receive in the community. The clinical reviewer made three
recommendations which were not related to Mr Richards’ death but which the Head
of Healthcare will want to address.
9. The investigator investigated the non-clinical issues relating to Mr Richards’ care.
10. We did not identify any non-clinical learning and we make no recommendations.
11. The initial report was shared with HM Prison and Probation Service (HMPPS).
HMPPS did not find any factual inaccuracies.
Governor to note
12. On 18 December 2024, Mr Richards was restrained when he was escorted to
hospital, even though healthcare staff had objected to the use of restraints. High
Down told us that this was caused by human error. We bring this to the Governor’s
attention.
Adrian Usher
Prisons and Probation Ombudsman July 2025
Prisons and Probation Ombudsman 1
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Record of inquest
13. The inquest into Mr Richards’ death was held on 17 September 2025 and a verdict
of natural causes was recorded.
14. The coroner concluded that Mr Richards’ death was due to infective exacerbation of
interstitial lung disease. The coroner recorded that Mr Richards had ischemic heart
disease, heart failure and diabetes which were contributory factors.
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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