Two men died within two months at HMP Wandsworth in early 2024, with an independent investigation finding that one received emergency care that fell below the standard he would have received in the community.
Rana Khan, 60, died of heart disease on 5 April 2024 after suffering a cardiac arrest at the prison. A Prisons and Probation Ombudsman report concluded that while his overall clinical care was acceptable, staff failed to manage his sudden illness properly before his heart stopped.
The investigation [pdf] identified serious gaps in emergency protocols that may have cost Mr Khan crucial time during his medical crisis.
Just weeks earlier, on 6 February 2024, Kevin Porter, 63, died of pneumonia related to his Parkinson’s Disease at the same prison. In his case, the ombudsman found [pdf] the clinical care was good and made no recommendations.
What went wrong
The clinical reviewer examining Mr Khan’s case identified several concerning issues with how his cardiac emergency was handled:
Staff couldn’t administer emergency heart medication. Prison protocols prevented healthcare staff from giving Mr Khan aspirin and GTN spray – standard treatments for heart attacks. The rules didn’t account for diabetic patients, who sometimes don’t experience chest pain during a cardiac event.
No clear guidance on when to escalate. Healthcare staff lacked proper training on when to call for senior medical support during sudden, serious illness.
Missing emergency protocols. There was no clear guidance on prioritising emergency treatment and hospital transfer for patients with suspected heart attacks.
Unsafe medication practices. The prison’s system for dispensing over-the-counter medicines didn’t require staff to check whether these would interact badly with a prisoner’s prescribed medications.
Four urgent recommendations
The ombudsman made four recommendations to address these failures:
- Review emergency medication protocols to ensure aspirin and GTN spray can be given in all appropriate situations, including to diabetic patients who don’t present with chest pain
- Improve escalation procedures through additional guidance and training on when to call senior support for rapid assessment of sudden illness
- Issue clear guidance on managing suspected heart attacks, including prioritisation schedules for emergency treatment and hospital transfer
- Update the homely remedies protocol to require checking for drug interactions before providing over-the-counter treatments
Oxleas NHS Foundation Trust, which provides healthcare at Wandsworth, has accepted all four recommendations [pdf] with target completion dates between November and December 2024.
Two contrasting cases
Mr Khan had been remanded at HMP Wandsworth on 30 August 2023 while facing charges of stalking and harassment. He had several risk factors for heart disease: high blood pressure, diabetes, and high cholesterol.
At an inquest on 5 June 2025, the coroner concluded Mr Khan died of natural causes.
In contrast, Mr Kevin Porter, who had been serving a 40-month sentence for sexual offences since January 2023, received care that met appropriate standards despite his complex needs from Parkinson’s Disease.
His family had raised concerns about his Parkinson’s care, which were addressed in the clinical review. The review found the care was equivalent to what he would have received in the community.
A coroner ruled on 16 January 2025 that he also died of natural causes.
Mounting concerns
These deaths add to growing worries about healthcare at HMP Wandsworth, one of Britain’s largest and most overcrowded prisons.
Adrian Usher, the Prisons and Probation Ombudsman who signed both reports, emphasised the importance of learning from deaths in custody: “If my office is to best assist His Majesty’s Prison and Probation Service 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.”
The ombudsman investigates all deaths in prisons, young offender institutions, immigration centres, and approved premises to identify failings and prevent future deaths.
Both families were offered the opportunity to comment on the draft reports but did not respond.
The cases highlight the challenges of providing adequate healthcare in prison settings, particularly for older prisoners with complex medical needs and those experiencing acute medical emergencies.
Other deaths at HMP Wandsworth
These are not isolated incidents. Many other prisoners have died at Wandsworth in recent years, with the Prisons and Probation Ombudsman investigating or having investigated these deaths:
Currently under investigation:
- Gurshinder Singh – died 27 November 2024
- Alex Boy, 30 – died 13 April 2025
Awaiting inquest results:
- Waleed Ali, 54 – died 22 October 2022
- Morgan Sullivan, 20 – died 13 November 2022
- Aleksandras Maslennikovas, 47 – died 17 July 2023
- Craig Gordon, 38 – died 31 July 2023
- Peter Honnor, 55 – died 27 June 2024
- Warren Arter, 54 – died 12 July 2024
- Sidique Govinden, 31 – died 13 January 2025
Reports published:
Self-inflicted deaths:
- Peter Tauroza – died 6 March 2020
- Przemyslaw Wozniak – died 17 February 2021
- Piotr Marszalek – died 8 June 2021
- Shahrooz Ghassemian – died 21 June 2021
- Daniel Beckford – died 23 June 2021
- Rajwinder Singh, 36 – died 25 June 2023 – father of three whose death was found to be preventable
- Damian Bugno-Swierz, 29 – died 7 November 2023
- Patryk Gladysz, 27 – died 19 January 2024 – man with schizophrenia failed by catastrophic errors
Natural causes:
- Colin Milner – died 5 July 2023
- Thanweer Asharaf, 26 – died 23 June 2024
- Rana Khan, 60 – died 5 April 2024 (subject of this report)
- Kevin Porter, 63 – died 6 February 2024 (subject of this report)
Other non-natural deaths:
- Brandon Johnson – died 12 September 2019
- David Wise, 46 – died 15 December 2021
The Prisons and Probation Ombudsman is an independent body that investigates all deaths in custody. They publish reports publicly to identify failings and prevent future deaths.
