A report by the Prisons and Probation Ombudsman (PPO) has found that the standard of healthcare received by a man who died in HMP Bedford last year was not equivalent to what he would have received in the community.
Azhar Hussain, 40, died of heart failure on 27 December 2023, less than a month after being remanded in prison for breaching a restraining order. An inquest into his death, held in August and September 2025, concluded that he died from natural causes.
However, the independent investigation by the PPO, published this month, identified serious concerns with how his condition was handled while in custody.
A clinical review commissioned by NHS England concluded that Mr Hussain’s care at HMP Bedford was unsatisfactory.
On the day of his death, healthcare staff failed to use the NEWS2 scoring system, something that had already been raised in a previous investigation into a death at the prison.
Read: HMP Bedford accepts all Prison Ombudsman recommendations following inmate’s death
NEWS2 is a standardised scoring system, developed by the Royal College of Physicians, widely used in healthcare to quickly assess acutely ill adult patients and identify those at risk of deterioration or sepsis.
Staff welfare
The PPO report stated that although prison leaders had previously claimed compliance with NEWS2 was being monitored monthly, this failure raised concerns about the robustness of that monitoring process.
A recommendation has been made for the Head of Healthcare at HMP Bedford to review the system.
In addition to clinical concerns, the report highlighted issues around the prison’s emergency response and staff welfare.
Not all staff involved in the emergency response were invited to the formal debrief or signposted to support services, something the PPO had also criticised following a death at the prison in 2021.
While the protocol was followed in two deaths prior to Mr Hussain’s, it was not followed in this case.
The report also notes that Mr Hussain’s family was initially concerned about how they were informed of his death.
Good support
However, in later correspondence, they confirmed that they had received good support from the prison’s Imam, who had also acted as family liaison, though they were unaware of his formal role at the time.
The PPO said it received no factual corrections from Mr Hussain’s brother or from the prison’s healthcare provider, Northamptonshire Healthcare NHS Foundation Trust, which has submitted an action plan in response to the findings.
The report makes recommendations aimed at improving emergency response procedures, staff wellbeing after deaths in custody, and the clinical monitoring of prisoners at HMP Bedford.
The Prisons and Probation Ombudsman, Adrian Usher, said the findings would help contribute to “safer, fairer custody” and urged both prison and healthcare leaders to ensure the recommendations are fully implemented.
