Rana Khan
Natural causes
Report published
HMP Wandsworth (Prison)
Recommendations (4)
4 Accepted
Recommendation 1
The Head of Healthcare, the lead GP and the senior pharmacist should review the glyceryl trinitrate and aspirin PGDs to ensure that staff are able to use these emergency medications in all situations where they are indicated and ensure that the inclusion criteria takes account of the additional presentation of a cardiac event without pain in diabetic patients.
Response (deadline: 1 Dec 2024)
The PGDs and inclusion criteria will be reviewed.
Recommendation 2
The Head of Healthcare and the lead GP should identify if there is a need for additional guidance and training for staff to support them to escalate the requirement for senior staff to support rapid assessment of undifferentiated sudden illness.
Response (deadline: 1 Dec 2024)
The emergency response policy will be reviewed and will include additional guidance and the training/ induction program will be reviewed and will include an emphasis on the requirement for senior staff to support the rapid assessment of undifferentiated sudden illness.
Recommendation 3
The Head of Healthcare and the lead GP should issue guidance on the management of suspected acute cardiac events which makes clear the schedule of prioritisation of emergency treatment and transfer of patients to appropriate emergency care.
Response (deadline: 1 Nov 2024)
The ACS pathway will be recirculated to all staff and additional training for the management of suspected acute cardiac events is planned to be included in the ongoing training agenda.
Recommendation 4
The Head of Healthcare, lead GP and lead pharmacist should review the ‘homely remedies’ protocol to ensure that it makes reference to checking a prisoner’s prescribed medication to ensure no contraindications before the provision of a ‘homely remedy’.
Response (deadline: 1 Dec 2024)
The homely remedies protocol will be reviewed to ensure that reference to checking a prisoners prescribed medication is included and appropriate guidance will be shared with all staff administering medication.
Full Report Text
OFFICIAL - FOR PUBLIC RELEASE Independent investigation into the death of Mr Rana Khan, a prisoner at HMP Wandsworth, on 5 April 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 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 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 30 August 2023 Mr Rana Khan was remanded at HMP Wandsworth, having been charged with stalking and harassment offences. 4. Mr Khan died of ischaemic heart disease caused by hypertension, diabetes mellitus and high cholesterol on 5 April 2024 at HMP Wandsworth. He was 60 years old. We offer our condolences to Mr Khan’s family and friends. 5. The Ombudsman’s office contacted Mr Khan’s family to explain the investigation and to ask if they had any matters they wanted us to consider. We did not receive a response. 6. NHS England commissioned a clinical reviewer to review Mr Khan’s clinical care at the prison. She concluded that the clinical care Mr Khan received at Wandsworth was acceptable, but the management of his sudden illness prior to his cardiac arrest was not entirely equivalent to what he could have expected to receive in the community. 7. We make the following recommendations. The Head of Healthcare, the lead GP and the senior pharmacist should review the glyceryl trinitrate and aspirin PGDs to ensure that staff are able to use these emergency medications in all situations where they are indicated and ensure that the inclusion criteria takes account of the additional presentation of a cardiac event without pain in diabetic patients. The Head of Healthcare and the lead GP should identify if there is a need for additional guidance and training for staff to support them to escalate the requirement for senior staff to support rapid assessment of undifferentiated sudden illness. The Head of Healthcare and the lead GP should issue guidance on the management of suspected acute cardiac events which makes clear the schedule of prioritisation of emergency treatment and transfer of patients to appropriate emergency care. The Head of Healthcare, lead GP and lead pharmacist should review the ‘homely remedies’ protocol to ensure that it makes reference to checking a prisoner’s prescribed medication to ensure no contraindications before the provision of a ‘homely remedy’. Prisons and Probation Ombudsman 1 OFFICIAL - FOR PUBLIC RELEASE OFFICIAL - FOR PUBLIC RELEASE 8. The PPO investigator investigated the non-clinical issues relating to Mr Khan’s care. We did not find any non-clinical issues of concern and we make no recommendations. 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 October 2024 Inquest 10. At the inquest held on 5 June 2025, the Coroner concluded that Mr Khan died of natural causes. . 2 Prisons and Probation Ombudsman 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
Case Details
Date of Death
5 April 2024
Report Published
10 October 2025
Age
51-60
Gender
Responsible Body
HMP Wandsworth
Recommendations
4
Inquest Date
5 June 2025
Recommendation Themes
emergency_response (2)
medication (2)