5 March 2020

Assistant Coroner Russell CallerInner West London Coroner’s Court
3 March – 4 March 2020

The inquest into the death of Osman Ali Hassan, a 45 year old man from South London, has concluded that “there was a failure to adequately manage his hypertension (high blood pressure) in prison, this made more than a minimal contribution to his death”.

The inquest jury concluded that the prison healthcare service at HMP Wandsworth lacked a clear pathway for all long-term conditions, including hypertension. They found that had this pathway been in place then Osman’s hypertension would have been managed in accordance with NICE guidelines which may have controlled his condition.

The inquest was held at London Inner West Coroner’s Court on 3 and 4 March 2020.

Osman, who was known as Ossie, died in custody at HMP Wandsworth on 10 October 2018 as a result of an aortic dissection. The cause of the dissection is unknown but high blood pressure is a risk factor. 

Osman was diagnosed with high blood pressure before entering prison. Throughout his time at HMP Wandsworth, the healthcare team recorded several blood pressure readings from him, the majority of which showed his blood pressure to be consistently high.

The inquest heard evidence from the author of an external healthcare review of Osman’s care, as well as the conclusions of a Serious Incident report and a Police and Prisons Ombudsman report. All three concluded that Osman’s blood pressure was not properly managed while in prison, that there were missed opportunities to follow up on his consistently raised blood pressure and that healthcare staff lacked clinical curiosity and a joined up approach to the care of individual prisoners.

The external healthcare review found that Osman’s care fell below the standard he could have expected to receive in the community and that he should have been prescribed additional drugs to control his blood pressure. Evidence was also given at the inquest that following Osman’s death and the recommendations in various reports, changes to procedures and practices have been made to better manage patients with long term conditions.

Since Osman’s death there have been six deaths in HMP Wandsworth, two were non-self-inflicted (or ‘natural cause’) deaths of men under 50, two deaths are yet to be classified, and one was self-inflicted.

Abide Kumyalili, sister of Osman Ali Hasssan said: “Ossie loved to make people happy. He always had a smile on his face, and I can still hear his laugh in my head. He has left a very big hole in my life and that of the family. I feel that Ossie was let down by the care he received at HMP Wandsworth. His hypertension was allowed to get out of control, but no one seemed to do anything about it. I do not think that this would have been allowed to happen had he been in the community, rather than prison.”

Jasmine Leng, Senior Caseworker at INQUEST, said: “So called natural cause deaths in prison are  too often found to be far from natural. People in prison should have the same access to to healthcare as those outside. It was paramount both for the family and the public interest that this inquest was able to bring to light the failures in Osman’s care.”

Benjamin Burrows, of Leigh Day solicitors, said: “Since his death Osman’s family have had serious concerns about the care he received at HMP Wandsworth. I hope that the inquest’s conclusion helps to give them some closure on what happened and why it happened, and that this then helps to prevent any mistakes found from happening again in the future.”


For more information please contact INQUEST Communications Team, Lucy McKay on [email protected] or 020 7263 1111.

The family are represented by INQUEST Lawyers Group member Benjamin Burrows of Leigh Day Solicitors and Hannah Noyce of 1 Crown Office Row Chambers. They are working with INQUEST caseworker Jasmine Leng.

Other interested persons represented at the inquest are the Ministry of Justice who run the prison at HMP Wandsworth, and St George’s Healthcare Trust who provided healthcare at HMP Wandsworth.

Parliament’s Health and Social Care Committee report on Prison Healthcare (November 2018), with evidence from INQUEST, found that ‘so-called natural cause deaths too often reflect serious lapses in care’. Drawing on INQUEST’s written and oral evidence, the committee makes strong recommendations to address the unacceptable number of deaths as a result of poor healthcare in prison.

INQUEST’s report on Deaths in prison: A national scandal (January 2020) offers unique insight and analysis into findings from 61 previous prison inquests in England and Wales in 2018 and 2019. The report details repeated safety failures including mental and physical healthcare, communication systems, emergency responses, and drugs and medication. It also looks at the wider statistics and historic context, showing the repetitive and persistent nature of such failings.