Staff at HMP Exeter told the mother of the wrong prisoner that her son was dying. An independent investigation has set out how the error happened.
Michael Marsh, 33, died in hospital in November 2021 after an incident at the Devon jail. Another prisoner at Exeter at the time had the same name. The Governor broke the news to that man’s next of kin instead.
Adrian Usher, the Prisons and Probation Ombudsman (PPO), set out the mix-up in his report into Mr Marsh’s death. The report also raised concerns about the way staff monitored his risk of suicide and checked on his wellbeing. The PPO investigates every death in prison.
How the error happened
Mr Marsh went to hospital on 18 November with a brain injury. He was not expected to survive.
He had not named a next of kin. Staff therefore searched his prison record. There they “found a letter from a Mrs Marsh, who appeared to be his mother”, the report says.
The Governor went to her address to tell her in person. According to the report, “it quickly became apparent that she was the mother of the other Mr Michael Marsh”.
The Governor then asked the prison to check Mr Marsh’s phone records. Staff found a contact number there, and the Governor called the right mother to tell her. Mr Marsh died in hospital on 23 November. His mother confirmed that the family had visited him on life support to say goodbye.
The PPO accepted that the Governor contacted the right mother once he realised the mistake. But the report said informing the wrong person first was likely to have caused unnecessary distress. It urged staff to cross-check details such as a prison number. The PPO recommended that the Governor ensure staff quickly identify and tell the right next of kin. That applies whenever a prisoner dies or falls seriously ill.
Concerns over suicide monitoring
A court convicted Mr Marsh on 4 October 2021 of sending text messages causing fear or anxiety. He went on remand to HMP Exeter to await sentence. The report calls him a “troubled young man”. It says he struggled to cope in prison and isolated himself in his cell.
On 8 October, staff intercepted a letter from Mr Marsh to his mother in which he expressed suicidal intent. They opened monitoring under ACCT (Assessment, Care in Custody and Teamwork). Over the next three weeks he cut himself off and rarely left his cell. He told staff that other prisoners had threatened him.
On the evening of 18 November, an intelligence report suggested that two prisoners had assaulted him in the showers on C Wing. Staff moved him to A Wing. Mr Usher wrote: “There is no record that staff conducted a wellbeing check or spoke to Mr Marsh about the alleged assault.”
An officer checked on him at 7.45pm and found no problems. The incident came to light at 8.20pm. The report says the officer responded quickly, as did other staff.
The ombudsman noted “some positive aspects” in how staff ran ACCT procedures. But the report added: “we are concerned that some aspects were poorly managed.” It recommended that the Governor and head of healthcare make sure staff follow national instructions when managing prisoners at risk of suicide and self-harm.
HMP Exeter is a reception prison for men in the South West. Inspectors last carried out a full inspection there in March 2026. They rated safety and purposeful activity as not sufficiently good. They rated respect as reasonably good and preparation for release as good.
