15-07-2025
Man dies within week of arriving at tough UK prison
The 37-year-old died in his cell six days after arriving in the jail.
A man died in his jail cell while he was on remand for assault.
Dean Leach, 37, passed away at HMP Forest Bank from peritonitis - inflammation of the inner abdominal wall - caused by a perforated duodenal ulcer, a report has found.
Mr Leach had been charged with assault and remanded to the Salford prison on December 29, 2022. No pre-existing physical medical conditions were listed in his medical records and his observation levels were all within normal ranges.
The Fatal Incident Report stated that on December 31, two days after being remanded, he reported to staff he was vomiting and not eating. The Prisons and Probation Ombudsman reports found he became aggressive during a medical assessment and threatened to stop eating, reports the Manchester Evening News.
Nursing staff advised that Mr Leach needed to stay hydrated and created a food refusal care plan to manage the risks, which involved him having regular GP appointments.
On January 1 2023, after discussion with officers on Mr Leach's wing, a nurse established that he had been eating biscuits and drinking tea with other prisoners in the jail.
The report says: "She considered that Mr Leach was just angry in the moment when he threatened to refuse food, so chose not to continue with the food refusal care plan. The nurse advised officers to contact the healthcare emergency responder or use the healthcare triage system if they had any concerns."
However, on January 3 2023, officers called for assistance when they saw Mr Leach "rolling around the floor of his cell in pain and holding his stomach".
Mr Leach told a nurse he was supposed to be on omeprazole (a medication taken for gastritis, inflammation of the lining of the stomach) but that he had not taken it for some time due to having been 'on the run' while resisting police arrest in the community.
Mr Leach explained that the pain worsened if he ate, so he had not eaten for a few days. The nurse assessed Mr Leach and found that he was breathing quickly and also had a fast pulse.
Nursing staff took Mr Leach to see the GP. Mr Leach told the doctor he had a history of stomach ulcers for which he had taken medication in the past. The GP completed a thorough assessment for serious illness and found that Mr Leach's observations were all within normal ranges, although he had already lost 3kg of weight since his arrival at Forest Bank.
The report says a care plan was created to manage the symptoms and Mr Leach's medication was re-prescribed. Later in the afternoon, Mr Leach was checked again by nursing staff. He said he had ongoing abdominal pain, but it was less severe.
At 6.05pm, a nurse attended Mr Leach's cell to check on him and noted that he remained fully alert and orientated, lying on his bed. Mr Leach reported ongoing abdominal pain but said it was less severe. He told her he had not vomited again.
The nurse recorded that Mr Leach had eaten a bowl of cereal and a warm drink, and administered his medication and completed a set of checks on the severity of illness and risk of deterioration, which indicated a low risk.
Shortly before 10pm, an operational support grade (OSG) completed a routine check of prisoners on Mr Leach's wing. He had a brief conversation with Mr Leach and did not raise any concerns.
But at 4.45am on January 4, a nurse contacted Mr Leach's wing to request a member of staff check on him. An officer arrived at his cell 13 minutes later and found him semi-naked on his cell floor and unresponsive.
A call was made for an ambulance but healthcare staff and other officers who responded quickly found rigor mortis was present so made the decision not to commence resuscitation. Paramedics pronounced Mr Leach's death at 5.32am.
The report says Mr Leach's father "shared that (his son) had seen a nurse and a doctor (in the community) and had a history of stomach problems which he was on medication for. He said that for his son to complain, it must have been really bad, and told us that he was supposed to be watched closely by prison staff because of mental health issues.."
In conclusion, Prisons and Probation Ombudsman, Adrian Usher, says in his report: "The clinical reviewer concluded that the clinical care Mr Leach received at Forest Bank was equivalent to that which he could have expected to receive in the community. He highlights areas of good practice and makes no recommendations.
"We found that the non-clinical care provided to Mr Leach was also of a good standard. Staff addressed Mr Leach's needs and responded swiftly and with compassion when they found him unresponsive. The outcome was unexpected and shocking for everyone involved."
The inquest into Mr Leach's death concluded on May 23 2025, returning a verdict of natural causes.
Mr Leach was the thirteenth prisoner to die at Forest Bank since January 2020. Of the previous deaths, seven were from natural causes, two were self-inflicted and three were drug related.
The report says: "There are no similarities between our findings in the investigation into Mr Leach's death and our investigation findings for the previous deaths."
