The Prisons and Probation Ombudsman, Adrian Usher, has strongly criticised three prisons in reports into deaths in custody. All three reports came out in December. In each, he found that the treatment the men received in prison was unacceptable.
Wormwood Scrubs
Mehrban Hussain died in April 2022 from respiratory problems. He had been at HMP Wormwood Scrubs for eight months and had struggled to breathe throughout his time in prison.
Mr Usher’s investigation found that he was not properly monitored after he caught COVID. Nor did the prison put a proper care plan in place.
The Ombudsman concluded that Mr Hussain’s care did not match what he would have received in the community. He made several recommendations about care plans. The Ministry of Justice said Wormwood Scrubs has accepted all of them.
Northumberland
In a second report, Mr Usher heavily criticised HMP Northumberland over its treatment of Thomas Cole, aged 73.
He found that the prison had restrained Mr Cole unnecessarily. Mr Cole was elderly, immobile and in poor health, and clearly posed no risk of escape or of endangering anyone. Even so, he spent nearly three weeks in restraints.
Mr Cole had a spell in hospital, where he underwent heart surgery. He was unnecessarily put back into restraints for the return to prison. There, the Ombudsman found, he received unacceptably poor healthcare that fell short of community standards. He died in the prison on 13 May 2022.
HMP Northumberland said it had accepted the criticisms and changed its practices.
Winchester
Mr Usher also criticised HMP Winchester for failing to “follow up on the history of depression” of Thomas Goldring. Mr Goldring took his own life in the prison in 2022.
He received a referral for a mental health assessment on arrival, but nobody ever saw him in person. Mr Usher wrote that “reception staff did not properly consider Mr Goldring’s risk factors for suicide and self-harm” when he arrived.
“While we accept he took his own life several months later, we consider that this was a missed opportunity to put support in place,” the Ombudsman added.
A Ministry of Justice spokesperson said the prison had implemented all of the report’s recommendations.
The three prisons have had full inspections since the deaths. Inspectors examined Wormwood Scrubs, a Category B reception prison in London, in September 2025. They rated safety and preparation for release not sufficiently good, respect reasonably good and purposeful activity poor. Northumberland, a Category C men’s prison in the North East, received reasonably good ratings in all four areas in December 2025. Winchester, a Category B reception prison in the South East, received poor ratings for safety, respect and purposeful activity in January 2025.
