Michelle Saunders

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Independent investigation into the
death of Ms Michelle Saunders,
a prisoner at HMP Littlehey,
on 9 July 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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© 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
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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 October 2007, Ms Michelle Saunders, a transgender prisoner, was given an
Imprisonment for Public Protection (IPP) sentence for sexual offences, with a
minimum term of 42 months. (IPP prisoners must serve a minimum term before the
Parole Board can consider their suitability for release.) Ms Saunders died of a heart
attack on 9 July 2024, at HMP Littlehey. She was 56 years old. We offer our
condolences to Ms Saunders’ family and friends.
4. The Ombudsman’s office contacted Ms Saunders’ partner and sister to explain the
investigation and to ask if they had any matters they wanted us to consider. Her
sister said that Ms Saunders had mentioned chest pains in a telephone call to her
mother and wanted to know whether she got help for this.
5. The PPO investigator investigated the non-clinical issues relating to Ms Saunders’
care. We did not find any non-clinical issues of concern.
6. NHS England commissioned an independent clinical reviewer to review Ms
Saunders’ clinical care at Littlehey.
7. The clinical reviewer concluded that the clinical care Ms Saunders received at
Littlehey was mainly of a good standard and equivalent to that which she could
have expected to receive in the community. However, the clinical reviewer found
that when Ms Saunders arrived at Littlehey on 28 May 2024, she had a high blood
pressure reading which was not rechecked as it should have been. We recommend:
The Head of Healthcare should ensure that prisoners with a raised blood
pressure reading at first or second stage reception screening have an
appropriate follow up arranged.
8. In response to the query from Ms Saunders’ sister, the clinical reviewer noted that
on 3 February 2023, Ms Saunders told a GP at HMP Bedford that she experienced
chest pain with her anxiety intermittently. Clinical history was in keeping with anxiety
as the cause. There were no other symptoms of a heart condition and no other
reports of chest pain in the medical record.
9. We shared our initial report with HMPPS and with the prison’s healthcare provider,
Northamptonshire Healthcare NHS Foundation Trust. They found no factual
inaccuracies. Northamptonshire Healthcare NHS Foundation Trust provided an
action plan which is annexed to this report.
Prisons and Probation Ombudsman 1
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10. We sent a copy of our initial report to Ms Saunders’ sister. She pointed out that Ms
Saunders’ previous name had been spelt incorrectly in the clinical review report.
This has been corrected.
Adrian Usher
Prisons and Probation Ombudsman November 2024
Inquest
The inquest, held on 21 January 2025, concluded that Ms Saunders 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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