An independent investigation by the Prisons and Probation Ombudsman (PPO) has found that the June 2024 death of HMP Wandsworth prisoner Thanweer Asharaf was not caused by failings in his care — a rare conclusion at a jail long associated with serious safety and healthcare lapses.
The report [pdf], published this week, concludes that Mr Asharaf, 26, died from aspiration of gastric contents — inhaling vomit into his lungs — but the underlying reason for the vomiting could not be determined. While no illicit substances were detected in toxicology tests, the PPO said the circumstances “point strongly” to psychoactive substance (PS) use.
A vape pen was found beside him in his cell, and days earlier a letter sent to him had tested positive for PS — synthetic drugs often smuggled into prisons on impregnated paper. Prisoners also told investigators he had been using such substances.
However, the Ombudsman found “the care Mr Asharaf received at Wandsworth Prison was equivalent to that which he could have expected to receive in the community” and made no recommendations in this case. This stands in stark contrast to recent high-profile investigations — including the death of Patryk Gladysz, where a coroner condemned a “complete breakdown” in psychiatric care.
A Complex History of Mental Illness
Mr Asharaf, an Indian national, was on remand for grievous bodily harm and had a documented history of psychosis and drug use. Before arriving at Wandsworth in November 2023, he had been detained under the Mental Health Act at Goodmayes Hospital and was prescribed antipsychotic medication.
In prison, his mental health fluctuated. He spent time in the jail’s Addison Unit — a mental health wing — and was awaiting transfer to a secure psychiatric hospital at the time of his death. Although he sometimes refused medication, staff monitored him, adjusted dosing schedules to accommodate Ramadan fasting, and arranged regular psychiatric reviews.
By late spring 2024, his behaviour had stabilised, and he was participating in activities such as chess club and working as a wing cleaner. On 20 June, however, staff noted a sudden drop in mood. Three days later, during an early morning roll check, officers found him unresponsive with blood and vomit around his mouth. Paramedics declared him dead at 4:30am.
Drugs a Persistent Problem
While no direct fault was found in his case, the report underlines the well-documented ease of drug access at Wandsworth — a problem repeatedly criticised by HM Inspectorate of Prisons. A recent inspection triggered the Urgent Notification process, citing widespread availability of contraband, high levels of violence, and chronic overcrowding.
In surveys, over half of prisoners said it was easy to get illicit drugs. Inspectors reported the smell of cannabis throughout the prison. Random drug testing resumed in early 2024 after a five-month suspension — with 44% of prisoners testing positive.
In response to rising drug-related incidents, the prison has appointed a permanent Drug Strategy Lead, revised its anti-drug strategy, and increased search operations, including greater use of detection dogs.
The investigation also noted that Wandsworth’s “key worker” scheme — designed to give each prisoner regular, meaningful contact with a dedicated officer — has been largely suspended since the pandemic due to staffing shortages. Mr Asharaf received only four recorded sessions in seven months, mostly focused on routine matters rather than building a relationship or addressing his needs.
Inspectors have warned that the absence of key work reduces opportunities to spot warning signs and support vulnerable prisoners. While the PPO could not say whether more regular engagement would have changed the outcome in this case, it stressed that the scheme should be restored as soon as possible.
One of Many Deaths Under Scrutiny
Mr Asharaf’s case is one of 22 deaths at Wandsworth Prison since June 2021, including 13 self-inflicted and two linked to drugs. Nine other deaths remain under active PPO investigation, keeping the prison firmly under the spotlight.
The inquest into his death, held in July 2025, recorded a verdict of death from natural causes.
While this investigation did not find fault, the PPO’s office has repeatedly warned that systemic weaknesses at Wandsworth Prison — from drugs and violence to staff shortages and mental health care gaps — continue to put lives at risk.
